Aesthetics April 2015 by Aesthetics & CCR

VOLUME 2/ISSUE 5 - APRIL 2015

Launched in 2011, Juvéderm VOLUMA® with lidocaine is the first and only FDA approved product with VYCROSS™ technology indicated for the restoration of facial volume including cheeks, cheekbones and chin.1 Noticeable results long after treatment, up to 24 months.2 97.4% of patients reported satisfaction as “improved to very much improved” with the cosmetic effect of JUVÉDERM® VOLUMA® with lidocaine immediately after treatment.3

REFERENCES: 1. Juvéderm® VOLUMA® with lidocaine Instructions for Use (IFU). 2. Jones D, Murphy DK. Dermatol Surg. 2013: 1-11 3. Dormston W. Poster presented at 8th European Masters in Aesthetics and Anti-Aging Medicine (EMAA). 12-14 Oct 2012. Paris, France.

Allergan, Marlow International, 1st Floor, The Parkway Marlow, Buckinghamshire SL7 1YL, UK Date of Preparation: March 2015 UK/0171/2015

15367 UK VYCROSS Ad Aesthetics Journal March 2015_Front Cover.indd 1

Managing Obesity CPD

Dr Sotirios Foutsizoglou gives an overview of approaches and treatment

Advances in Lasers Dr Elizabeth Raymond Brown provides an update on lasers in aesthetics

Treating the Lips Aesthetic practitioners share their advice, methods and techniques for lip augmentation

16/03/2015 12:02

Seasonal Marketing

Charlotte Moreso on how to create a summer marketing campaign

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The ﬁller you’ll love 1. BEL-DOF3-001_1. Belotero® technology, March 2014. 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.

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Contents • April 2015 06 News The latest product and industry news 12 Production in Pringy We visit Allergan’s manufacturing and R&D facility in Pringy, France 14 Conference Reports Reports from the annual AAD meeting and Interventional Cosmetics meeting at the RSM

Special Feature Treating the Lips Page 23

16 On the Scene Out and about in the industry this month 18 News Special: Aesthetics Conference and Exhibition A review of the hugely successful ACE 2015

CLINICAL PRACTICE 23 Special Feature: Treating the Lips Aesthetic practitioners share their approaches to lip augmentation 28 CPD Clinical Article Dr Sotirios Foutsizoglou explores obesity management with an overview of treatments and approaches 35 Topical and Oral Antioxidants Ms Rozina Ali and Eva Escofet address the use of topical and oral antioxidants 41 Advances in Lasers Dr Elizabeth Raymond Brown provides an update on the latest advancements in aesthetic lasers 45 The Importance of Skin Texture Dr Sharon Crichlow discusses the importance of skin texture in aesthetic treatment 49 Case Study: Treating Filler Complications Frances Turner Traill on her experience of managing a dermal filler complication 51 Treating the Perioral Area Dr Souphiyeh Samizadeh details the treatment of perioral ageing 54 Advertorial: AestheticSource A chance to find out more about the scientific research behind NeoStrata skincare 55 Abstracts A round-up and summary of useful clinical papers

IN PRACTICE 57 Seasonal Marketing Charlotte Moreso looks at the best methods of creating a summer marketing campaign 61 Building Patient Loyalty Pam Underdown outlines useful strategies for retaining patients 64 Handling a Legal Complaint Dr Askari Townshend shares his experience of dealing with a legal complaint 66 In Profile: Constance Campion We talk to aesthetic nurse Constance Campion about her passion for the anti-ageing specialism 68 The Last Word: Photography Dr Steven Dayan argues for patient awareness around image distortion

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Marketing Creating a seasonal campaign Page 57

Clinical Contributors Dr Sotirios Foutsizoglou specialises in minor cosmetic surgery and aesthetic medicine. Founder and medical director of SFMedica, he has extensively lectured and presented at national and international conferences and meetings. Ms Rozina Ali is a consultant reconstructive and aesthetic surgeon, specialising in facial aesthetic surgery. Graduating from St Thomas’ Hospital Medical School, she now holds numerous qualifications. Eva Escofet is a highly established nutritional therapist with 12 years of clinical experience. She owns a multidisciplinary clinic in Surrey, and is also co-owner of Aneva Nutraceuticals, specialists in nutraceutical products. Dr Elizabeth Raymond Brown is a laser specialist, currently academic lead for the MSc. in Non-Surgical Facial Aesthetics (NSFA) at UCLan, Preston, and a professional trainer with an array of laser experience. Dr Sharon Crichlow works as a consultant dermatologist at the Skin to Love Clinic in St. Albans, UK. Her interests include treatment of acne scarring and pigmentary disorders commonly seen in patients with skin of colour. Frances Turner Traill is an independent nurse prescriber and runs her own aesthetic clinics in Scotland. An active board member of the British Association of Cosmetic Nurses (BACN), she leads the Scottish Regional Group’s educational meetings. Dr Souphiyeh Samizadeh is a dental surgeon with a special interest in aesthetic medicine. She is an honorary clinical teacher at King’s College London and clinical director of Revivify London clinic.

NEXT MONTH

• IN FOCUS: Lifting and Tightening • CPD: Vitamin A • Treating the Gluteus Maximus • Review of Electronic Record Keeping Systems

Entry for the Aesthetics Awards opens May 1st. Full list of categories in next month’s issue

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

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Editor’s letter The highly anticipated ACE 2015 weekend came and went, and it was brilliant. We have had the most positive feedback ever, so my thanks to all of you for attending and participating to make ACE the best conference of its type. The free education on offer proved Amanda Cameron extremely popular, with packed Expert Clinics Editor and Masterclasses featuring live demonstrations from top practitioners, while the Business Track offered imaginative and effective ways for augmenting business. Delegates also had the chance to meet with suppliers and distributors who shared exciting innovations, and the exhibition floor was a hub of activity throughout the weekend. The new format Conference programme attracted great numbers of delegates seeking thorough, interactive learning from international speakers. The four modules provided comprehensive guides to key areas of medical aesthetics, utilising novel approaches for maximising engagement, with the voting technology stimulating some interesting debates. A special thanks must go to Mr Dalvi Humzah who, as chair of the ACE Steering Committee, played a huge part in the seamless execution and high quality of the educational programme. To see packed sessions right up to the close of the event on Sunday

was truly a proud moment for us, proving that the scientific and nonclinical agendas that we had assembled succeeded in providing incredibly engaging and high-quality learning for a huge range of interests and professional needs. If you missed out this year, see pages 18-21 for a review of some of the event’s highlights. With many exhibitors booking immediately for next year’s event, and speakers already planning exciting sessions for the educational agenda, work for ACE 2016 is already underway. So what do we look forward to next? This issue features some great topics that continue our focus on high quality education – these include the second part of Dr Sotirios Foutsizoglou’s weight management CPD article. This detailed feature is relevant to all practitioners as, in caring for our patients’ health and wellbeing, we deal with weight matters and body issues on a daily basis. This month is our Smile issue, and we explore this area in a roundtable discussion from leading practitioners on their best techniques for treating the lips (p. 23) and in a detailed overview by Dr Souphiyeh Samizadeh into perioral ageing (p. 51). I would also like to remind you that entry is open for the Aesthetics Awards as of May 1, and you will be able to find all the categories and entry information in the next issue of Aesthetics. Let us know what you think of this issue by tweeting @aestheticsgroup or emailing editorial@aestheticsjournal.com

Editorial advisory board We are honoured that a number of leading figures from the medical aesthetic community have joined Aesthetics Journal’s editorial advisory board to help steer the direction of our educational, clinical and business content Dr Mike Comins is fellow and former president of the

Dr Raj Acquilla is a cosmetic dermatologist with over 11 years

British College of Aesthetic Medicine. He is part of the cosmetic interventions working group, and is on the faculty for the European College of Aesthetic Medicine. Dr Comins is also an accredited trainer for advanced Vaser liposuction, having performed over 3000 Vaser liposuction treatments.

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.

Mr Dalvi Humzah is a consultant plastic, reconstructive and

Dr Tapan Patel is the founder and medical director of VIVA

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.

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.

Sharon Bennett is chair of the British Association of

Mr Adrian Richards is a plastic and cosmetic surgeon with

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).

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 Christopher Rowland Payne is a consultant

Dr Sarah Tonks is an aesthetic doctor and previous

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.

maxillofacial surgery trainee with dual qualifications in both medicine and dentistry. Based at Beyond Medispa in Harvey Nichols, she practises cosmetic injectables and hormonalbased therapies.

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

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

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

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

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

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Awards

Talk #Aesthetics Follow us on Twitter @aestheticsgroup #Safety Good Surgeon Guide @goodsurgeon Just because he/she is a #plasticsurgeon doesn’t mean he/she is an expert in every single procedure. Do your #research well. #gsg

#Learning Dr. Ahmed Al-Qahtani @aqskinsolutions During our #AQ #growth #factor training in #Indonesia. Great turnout.

#Media Emma Bedford @MissEmmaBarlow Good to see the fabulous @drtapanp giving advice on burns treatment on tonights @BBCCrimewatch. Feel for the poor victims of acid attacks.

#Journal Medico Beauty @medicobeauty @aestheticsgroup I just got my copy! Look forward to reading all the great articles this evening. Can’t wait for #ACE2015

#Aesthetics Dr Rita Rakus @DrRitaRakus We featured in the Aesthetics magazine from a SkinCeuticals event we attended in February. #SkinCeuticals #aesthetics

#Training Luisa Scott @Nurse_Luisa Great @EllanseUK training day with @Dr_AskariT and the team

#Interview Lorna Bowes @LornaBowes With lovely Betsan of @aestheticsgroup after interviewing Leigh Ann Catlin and Cathy Mueller of NeoStrata Co. Great questions. #skinfitness

#Equality PHI Clinic @PHIclinic Let’s hear it for the girls @PHIclinic. How blessed we are to have such talented, brilliant women on board #InternationalWomensDay

#Education Dr Chrysopoulo @mchrysopoulo @cpelletiere @DrRothaus No single “best procedure” for everyone. Patient education re ALL options key to ensuring fully informed decisions

#Clinic Dr Ravi Jain @DrRaviJain Looking forward to a day of male cosmetic surgery @Riverbanks. We have #gynecomastia & Vaser all day #surgeonselfie

Entry for the Aesthetics Awards 2015 opens in May From May 1, practitioners, clinics, distributors and manufacturers are invited to submit their entry for the prestigious Aesthetics Awards ceremony, to be held in London on December 5, 2015. Last year’s event saw more than 500 members of the medical aesthetics profession celebrate the great achievements of our speciality in 2014, in an elegant ceremony and an evening of entertainment which proved a huge success amongst attendees. Consultant plastic surgeon Mr Dalvi Humzah, who won the Training Initiative of the Year award, said, “The Aesthetics Awards is one of the premier awards events for aesthetics, recognising excellence and the outstanding achievements of practitioners, surgeons and suppliers.” The Aesthetics Awards categories cover all aspects of the specialty, including awards for Medical Practitioner of the Year, Best Customer Service by a Manufacturer or Supplier, Treatment of the Year and Product Innovation. Each category submission requires a thorough and high-quality written entry that meets the criteria for submission. Entries are then judged by an expert panel or decided upon via a combination of judging and votes from industry professionals. Details for each category will be available on the Aesthetics Awards website. Dr Maria Gonzalez of the Specialist Skin Clinic in Cardiff, and winner of the Sinclair IS Pharma Award for Best Clinic Wales, said, “As the medical director of a new clinic, it was a moment of great pride to receive an Aesthetics Award. The entire process was motivating for the team of clinic staff whose work was rewarded by this success. All in all, an excellent night.” This year, two new categories have been added to the line up. Awards will be presented to the Best Clinic Group made up of three or more clinics, and the Best Clinic Group comprising ten clinics or more. Sponsors for three categories have already been announced. Sterimedix will support the Injectable Product of the Year, whilst NeoCosmedix will once again sponsor the award for Association/ Industry Body of the Year. HealthXchange will continue to support The Janeé Parsons Award for Sales Representative of Year, in memory of their colleague and her outstanding work within the industry. The eagerly anticipated event will be held at the Park Plaza Westminster Bridge Hotel in Central London. Submit your entries via www.aestheticsawards.com from May 1. Standards

BSI ‘Aesthetic NonSurgical Standard’ update A public consultation on the draft European Standard for nonsurgical aesthetic treatment has begun. Covering a wide range of non-invasive treatments, the new standard, titled, ‘Aesthetic medicine services – Non-surgical medical procedures (EN 16844)’, aims to address a variety of aesthetic procedures. Carried out across Europe, professional organisations and the general public can comment via the British Standards Institute, who are responsible for the UK consultation. Open until May 4, 2015, the public can have their say on www.bsigroup.com.

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015

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Aesthetics

LED Phototherapy

Aesthetic Technology launches Dermalux Tri-Wave Compact device Aesthetic device manufacturer Aesthetic Technology has added a new product to its Dermalux LED Phototherapy range. The Dermalux Tri-Wave Compact device uses non-thermal light energy to naturally stimulate skin rejuvenation and aid skin conditions, aiming to safely and effectively treat a wide range of indications; including ageing, acne and pigmentation. The non-invasive device delivers narrowband wavelengths at optimised intensity and dose with red 633 nm, blue 415 nm and new infra-red 830 nm. According to the company, the Dermalux Concurrent Modality Treatment feature allows for individual wavelength treatments, or simultaneous use of all wavelengths to accelerate results and reduce treatment visits. Using the latest LED technology, the manufacturer claims the device is also a significant development in the treatment of inflammatory skin conditions. Managing director of Dermalux Huw Anthony said, “With our development programme now in full swing and with more systems to come over the next 18 months, plus our recent launch into the export markets, we are excited by what the future may hold for Dermalux.” The Dermalux Tri-Wave Compact device is available in the UK from April. Patient safety

BAPRAS launches patient safety campaign The British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS) has launched a campaign to persuade patients to think carefully about aesthetic treatment. BAPRAS created the campaign ‘Think Over Before You Makeover’ in response to results of their research into cosmetic surgery choices. The major study indicated that two million people in the UK are considering or will undergo cosmetic surgery in the next year. It showed that, on average, a quarter of patients don’t check the credentials of their surgeon, while a fifth aren’t aware of the risks associated with the procedure they are undertaking. The results further suggested that a fifth aren’t clear on the potential outcomes of their procedure before going ahead. BAPRAS president and consultant plastic surgeon Nigel Mercer said, “Cosmetic surgery is not something to be taken lightly and yet thousands of people are putting themselves at serious risk by rushing into major procedures recklessly, without consideration for their own safety.” Members of BAPRAS hope that this campaign will ensure patients carry out the appropriate research on prospective treatments and prospective practitioners, before making the decision to undergo surgery. Mercer added, “‘Think Over Before You Make Over’ is not here to promote cosmetic surgery; we recognise that thousands of people will choose to have surgery this year and we want all these people to read our campaign advice so they can make informed choices and protect themselves from bad practice.” Fat reduction

New statistics reveal surge in nonsurgical fat reduction procedures The American Society for Aesthetic Plastic Surgeons (ASAPS) has announced that non-surgical fat reduction procedures rose by 43% in 2014. Since they began recording figures, it’s the first time that more than 100,000 non-surgical fat reduction procedures were performed in one year. ASAPS president Michael Edwards said, “Non-surgical fat reduction is a new frontier in the realm of cosmetic procedures. The rise in its popularity is indicative of the public’s desire for non-surgical alternatives in lieu of their invasive counterparts.” However, he added, “Not everyone is a candidate for non-surgical treatment as well. Many will still be better served from a surgical approach to include liposuction.”

News in Brief 3D-lipo opens Kuwait head office Aesthetic device manufacturer 3D-lipo has launched a new head office in Kuwait. The office, which will focus on providing support to their Middle Eastern distributors, has six 3D-lipo treatment rooms, a reception area and offices to handle distribution in the region. Managing director of 3D-lipo Roy Cowley said, “It offers a fantastic bridge to conquer expansion into the entire middle-eastern territory.” Seppic launches first cosmetic ingredient derived from their macroalgal cell culture innovations BiotechMarine, a subsidiary of specialty ingredient developer Seppic, are to launch Ephemer in April at the incosmetics trade fair in Barcelona. The new ingredient is a gametophyte extract taken from macroalgal cells, extracted at an ephemeral stage in the life cycle of Undaria Pinnatifida seaweed. Seppic claims the macroalgal cells accumulate anti-oxidant molecules, creating an ingredient that can be manipulated for use in skin protection. Jan Marini launches new face and neck creams Skincare company Jan Marini has added two anti-ageing creams to its product portfolio. The updated Age Intervention Face Cream and the new Marini Juveneck aim to reduce the signs of ageing on the face and neck. Director of Outline Skincare Clinic Mary White said, “Harnessing the use of peptides, along with Vitamin E and hyaluronic acid to deeply hydrate, Marini Juveneck is giving my ladies a noticeable lift.” Molecular-based skincare products launched Aesthetic practitioner Dr Gabriela Mercik has launched a molecular-based facial skincare line. The products include the Advanced Molecular Face Mask and Magic Beauty Face Lift, which aim to moisturise, hydrate and replenish skin. After conducting research into the indications of molecular water, Dr Mercik claims she has created a formulation that will protect the skin from ageing due to its hydrating properties.

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015

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Television

Aesthetics aestheticsjournal.com

Industry

BBC commissions series based on Harley Street The BBC has commissioned a three-part series based on Harley Street’s medical neighbourhood and history. The programmes, called ‘Inside Harley Street’, will give viewers the opportunity to learn about the world of private medicine and explore the types of treatments available today. Directed by ‘Welcome to the World of Weight Loss’ director Vanessa Engle, the programme will be broadcast on BBC Two, and each episode will feature interviews with both practitioners and patients. Episode one will look at private healthcare, the second will focus on aesthetic medicine and the final episode will address complementary and alternative medicine. Kim Shillinglaw, controller of BBC Two and BBC Four, said, “With Vanessa Engle’s trademark warmth and humour, this series takes us behind the closed doors of this very British institution to give a revealing insight into some very modern concerns, from the role of private healthcare to the lengths we’ll go to for the latest cosmetic and alternative treatments.” Prescribing

HealthXchange launches online pharmacy Medical supplier HealthXchange Pharmacy has launched an online prescribing system. The new service will allow practitioners to process prescriptions online, create and sign orders, pay online and have the ability to re-order using a one-click process. Once an order is made, it will be stored in a computer system to make future orders more efficient and build an order history. HealthXchange claim the system is suitable for sole practitioners as well as larger corporate businesses. The e-pharmacy is compliant with the Medicines and Healthcare Products Regulatory Agency (MHRA) regulations and will be available to use on any mobile device. Managing director of HealthXchange Pharmacy Karen Hill said, “For too long practitioners, clinic owners and pharmacies have had to rely on paper-based prescribing and be at the mercy of the fax, scanner or email account.” The system is available now.

Actavis completes acquisition of Allergan Allergan has announced that the pending acquisition of the company by Actavis is now complete. The news comes following the confirmed clearance by the European Commission three days earlier, which satisfied the final regulatory conditions to the closing of the pending acquisition. The confirmation of completion rounds up a $70.5 billion cash and equity deal, which began in November 2014, combining the companies to create one of the world’s top 10 pharmaceutical companies by sales revenue. The companies have predicted combined annual pro forma revenue of more than $23 billion in 2015. “The combination of Actavis and Allergan creates an exceptional global pharmaceutical company and a leader in a new industry model – Growth Pharma,” said Brent Saunders, CEO and president of Actavis. “Anchored by world-renowned brand franchises, a leading global generics business, a premier pharmaceutical development pipeline and an experienced management team committed to maintaining highly efficient operations across the organisation, we are creating an unrivaled foundation for long-term growth.” He added, “With the acquisition now complete, we will immediately begin implementing our comprehensive integration plans to ensure that we leverage our strengthened global organisation to generate sustainable organic earnings growth from our newly expanded base, and continue our ascent into the fastest-growing and most dynamic growth pharmaceutical company in global healthcare.” It has also been announced that Actavis intend to use ‘Allergan’ as their corporate name. Saunders said, “By adopting the Allergan name for the corporation we will ensure that our corporate identity reflects the dramatic evolution of our company within the pharmaceutical industry.”

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Aesthetics

Brand development

Skincare

5 Squirrels adds products to Your Signature Range

Medico Beauty launches LUNA Fusion

Private label cosmeceutical supplier 5 Squirrels has added three new products to its Your Signature Range portfolio. The additions to the existing five-product line are C-10, Refine and Protect 45. The C-10 is a Vitamin C serum containing 10% L-ascorbic acid, which the company says is essential to achieving optimal skin health. Refine is an intensive eye cream that contains Vitamin E and Lactic Acid, which aims to improve the appearance of periocular ageing. Protect 45 is an SPF 45 daily tinted moisturiser. The product includes a small amount of mineral makeup, which conceals any undesired SPF residue without making a significant change to the natural skin complexion. Co-founder of 5 Squirrels Gary Conroy explains that the products contain clinically proven and tested ingredients, which have been developed with leading UK healthcare professionals. The range can be branded specifically to your clinic, which the company claims reduces the burden of development and regulatory issues. Conroy said, “The importance of brand development in clinical practice has never been so crucial as the UK medical aesthetics market enters a more mature era. UK leading clinics have adopted this approach and have seen huge benefits in patient retention, recruitment and brand recognition.”

Skincare distribution company Medico Beauty has launched a treatment that combines the CosMedix skincare range with the Foreo Dual T-Sonic Wave. LUNA Fusion is a new skin treatment protocol aimed at the treatment of dry, sensitive and rosacea skin. The Foreo Dual T-Sonic Wave is a hand-held device that pulsates 8,000 times per second. It sends sonic waves across the body, with the purpose of cleansing the treatment area. The CosMedix formulations, used in conjunction, utilise a process called Chiral Correction to purify active ingredients and aid in the treatment of sensitive skin. Medical aesthetician Caroline McLean of La Belle Forme clinic in Glasgow offers the LUNA Fusion treatment to her patients. She said, “In our clinic we often meet patients who experience sensitive skin and rosacea. The LUNA Fusion fully integrates with all advanced services and supports the successful resolution of these conditions.”

Dermal filler

Radiofrequency

Study suggests polycaprolactonbased dermal filler induces neo-collagenesis

Viora launches V20 multi-technology platform

A new study suggests that polycaprolaction-based (PCL) dermal fillers may be able to induce neo-collagenesis when injected into human tissue. The study aimed to show that Ellansé, a novel PCL-based dermal filler by Sinclair Pharma, would be able to revive collagen in human tissue. Previous clinical studies indicated that Ellansé was capable of encouraging neocollagenesis in rabbit tissue. The new pilot study, however, published in the Journal of Cosmetic and Laser Therapy, suggested that the filler may also be capable of inducing neo-collagenesis when injected intra-dermally into human tissue. The study monitored two patients who undertook a temple-lifting procedure using Ellansé, injected intra-dermally into the tissue. Biopsies were analysed to show the improvement of collagen formation around the PCL particles, which, according to the researchers, maintained their original state 13 months post treatment, and showed that tissue migration of the PCL particles had not occurred at this stage.

Aesthetic distribution company AZTEC Services has announced the launch of the V20 multitechnology platform. The V20 consists of light and radiofrequency technologies, which enable practitioners to offer patients multiple treatment options using one system. The three handpieces on the device include the V-IPL, which aims to enhance IPL treatments, the V-ST to aid skin tightening treatments, and the V-FR, which aims to improve fractional radiofrequency treatments using Viora’s SVC technology. Board-certified plastic surgeon Dr Daniel Man uses the device in his clinic. He said, “With different technologies within one system, and Viora’s use of combination protocols, the treatment of difficult conditions such as stretch marks and scars, can be addressed with more efficacy and success.”

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015

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Events diary 10 – 12 April 2015 International Master Course on Ageing Skin – IMCAS Annual Meeting, China www.imcas.com/en/china2015/congress th

30th April – 2nd May 2015 Cosmetex 2015 Conference, Melbourne www.cosmetex.org 14th – 19th May 2015 American Society for Aesthetic Plastic Surgery (ASDS) Annual Meeting, Montréal www.surgery.org/downloads/microsite/ meeting2015/welcome.php 7th – 9th July 2015 British Association of Dermatologists (BAD) Meeting, Manchester www.bad.org.uk/events/annualmeeting Topicals

No-needle hyaluronic acid filler treatment launched A Swiss-developed topical gel filler has been launched in the UK with the aim of plumping skin without the use of needles. Fillerina comprises a blend of six hyaluronic acids, which aim to increase tissue volume in cheeks and lips. The gel also contains peptides that aim to stimulate collagen production and soften the appearance of fine lines and wrinkles. The at-home kit contains 14 doses of 2ml gel filler, 14 doses of 2ml nourishing film and two precision applicators, which can be used to aid successful application of the topical gel. According to Labo, the Fillerina manufacturers, the treatment should be used once daily for 14 days. Three different grades of gel strength are available, as well as a range of creams in lower strength doses than the gel. Dr Elisabeth Dancey of Bijoux MediSpa said, “I recommend Fillerina to my patients for two reasons. For use if they have a fear of needles, or for a skin ‘boost’ between their botulinum toxin or filler treatments.” Following a double blind, randomised clinical trial, results have been proven to be effective and last between two and a half to three months.

Aesthetics Journal

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Dermal filler

FDA recommends expanded use of Radiesse for hand augmentation The Food and Drugs Administration (FDA) Medical Devices Advisory Committee has announced a majority vote in recommending the expanded use of Merz Aesthetics’ Radiesse dermal filler to include volume correction in hand augmentation. The FDA’s General and Plastic Surgery Devices Panel of the Medical Devices Advisory Committee voted the hand treatment as safe, with a majority of 11 to three. According to clinical studies conducted by Merz over 12 months, it was indicated that Radiesse had produced a statistically significant improvement of volume loss in the hands after three months, remaining stable over time, with effectiveness after treatment similar to that seen following initial treatment. Merz further claimed that the results showed no detrimental effect on hand function post-treatment, and no new safety issues had been identified. “The data presented show Radiesse is safe, effective and non-invasive, and we support its approval process,” said Dr Lawrence Green, a board-certified dermatologist, speaking on behalf of the American Society for Dermatologic Surgery Association (ASDSA). The panel further voted that the available data was sufficient to characterise hand function post injection, though it was suggested that more hand function tests for daily living should be undertaken in future studies. They also recommended that the photographs from the study should be evaluated by unbiased, blinded healthcare professionals, rather than on-site. In addition to including long-term study data on those with severe handvolume loss, the panel advised that the study guidelines in the future should evaluate patients who receive surface treatments in order to determine where applicable time lags between treatments should exist. In 2006, Radiesse received FDA approval for the use of the dermal filler in treating indications of subdermal implantation for restoration and/or correction of the signs of facial fat loss in people with HIV, as well as for the correction of moderate-to-severe facial wrinkles and folds. Cellulite

Exilis Elite receives FDA clearance for cellulite treatment The Food and Drugs Administration (FDA) has approved Exilis Elite as a treatment for the temporary reduction of cellulite. The non-surgical radiofrequency device from BTL Aesthetics has been primarily used to reduce wrinkles and tighten skin. The device uses monopolar technology to heat the skin, which aims to remodel, tighten and firm collagen tissues. With the new FDA approval, practitioners will now also be able to use the technology as a cellulite reduction device. UK-based practitioner Dr Kannan Athreya said, “The fact that the Exilis Elite has received FDA approval as far back as 2009 for non-surgical treatment of wrinkles, and then this year for the reduction in the appearance of cellulite, is a testament to its power and reliability to provide consistent and reliable results.” Scott Mills, the US vice president of sales at BTL Aesthetics, added, “We are committed to working closely with our partners in the aesthetics community to build on the initial results and continue to improve our capabilities for treating cellulite.”

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015

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Aftercare

Episciences launches new post-procedure care kit Skincare manufacturer Episciences has launched an aftercare range for patients who have undergone moderate to deep skin rejuvenation procedures. The Essential Recovery Kit will be added to the Epionce skincare range and aims to address skin irritation post-procedure, soothe the skin to minimise stinging, boost hydration and reduce downtime. The manufacturer claims the ‘take-home’ care kit will address patients’ needs after treatments such as micro-needling, fractionated laser and mid-depth to deep chemical peel treatments. Priming Oil, Enriched Firming Mask and Medical Barrier Cream are included in the kit. CEO of Episciences Dr Carl Thornfeldt said, “After a deeper resurfacing procedure, the skin is so sensitive and vulnerable. Most of the products on the market do not fully address what the skin needs to heal quickly, completely and without negative side effects such as stinging, long-term sensitivity or even dark spots.” The Essential Recovery Kit is available in the UK now. Industry

VENN Healthcare launches Lutronic in UK VENN Healthcare has acquired the UK-distribution rights to global aesthetic device company Lutronic. The main products in the distribution company’s initial offering will include microneedling radiofrequency device Infini, long-pulsed Alexandrite and Nd:YAG laser Clarity, and dual-pulsed Q-switched Nd:YAG laser Spectra XT. Managing director of VENN Healthcare Jim Westwood said, “Lutronic is not only challenging competitors, but in some instances we believe the systems offer better results and a more versatile device for customised treatments. As we know, the aesthetic market is growing at a rapid rate and with patient demand on the rise, we enter the UK market in a strong position with a range of high quality, proven systems.” Skincare

Scandinavian Skincare Systems UK launches new skincare range Scandinavian Skincare Systems UK has launched MÖ Scandinavian Cosmeceuticals, a range of products that includes professional strength peels. According to the company, the cosmeceutical range targets skin on a molecular level, speeding up the cell renewal process. The company’s flagship product is the Stem Cell Corrector, which uses the stem cells of a Swiss apple to aim to regenerate cells in patients’ skin. CEO of Scandinavian Skincare Systems Paul Olavesen-Slabb explained that the formulations are clinically tested to reduce wrinkles, improve elasticity, enhance collagen production, balance sebum properties and smooth irritated skin. The new range is paraben-free, natural and organic, and vegan certified with no animal ingredients. The products are available to aesthetic medical professionals via the company’s online shop, which is closed to the general public.

Roy Cowley, founder and managing director of 3D-lipo Ltd: Why did you create 3D-lipo? I regard the 3D-lipo device and brand as a culmination of my 25 years of experience within the industry. I strove to create something fundamentally different, results driven and affordable to both clinic and customers. Our point of difference is that we do not stand behind a trend that would make us directly comparable to competition in the market, but created a multi-technology platform that meant that we had the ability to treat fat removal, loose skin and cellulite from one amazing machine. The key to this was also to ensure that all individual technologies were comparable or better than that of stand-alone devices. Once I had achieved all of this, we stood behind our differences, being the unique 3D approach, and embarked on a national PR awareness campaign. What do you attribute to 3D-lipo’s vast success? There are several factors that have contributed to our success, those being fantastic results, multiple treatment applications and affordability. These are the foundations. However, without a doubt the success built from these foundations is wholly down to the massive national media exposure that the brand has achieved. This has highlighted our results and point of difference, creating massive awareness not only within our industry but also to consumers nationwide. How does 3D-lipo support its customers? As a company we pride ourselves on our support, which at times has been difficult due to the vast expansion in the UK and overseas. It all starts with great training and local marketing assistance and continues with our constant efforts to gain national exposure behind our unique devices, which in turn drives patients through our customer’s doors from our clinic finder on our website. During the week that Amy Childs launched 3D-lipo in her own clinic, we were getting more than 3000 hits on our website per day from the social media activity and national media articles from customers hungry for the 3D-lipo treatment. Our branding and USP ensures that it is only 3D-lipo customers that benefit from this support. This column is written and supported by

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015

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Data

Survey indicates one in five US women intend to have cosmetic treatment A survey has suggested that one in five women are currently pursuing or intending to have cosmetic treatment. Conducted on behalf of RealSelf by Zeitgeist Research, the survey comprised 5,053 women in the US between 18 and 64 years old. It explored the trends of the US market for beyond-the-counter beauty procedures and the potential for expanding the industry. The results found that of the women surveyed, one in five are currently pursuing or planning to have cosmetic surgery. During the survey, it was also indicated that of 87% of women who were unhappy with at least one area of their body, the trend to seek cosmetic treatment has risen by more than 200%, with these women representing an estimated market of more than $75 billion. Of those who were willing to seek treatment beyond the retail floor, 62% would also consider surgery. The 24% of women who are planning for less invasive treatment represent an estimated market of $12 billion. Another area explored in the survey was motivation, which stated that 65% of women wanted to feel more comfortable with themselves, whilst one third (29%) were also considering cosmetic work due to a milestone life event. “While the total market has previously been calculated by the procedures performed in the past year, we can see that the total addressable market is actually far greater,” said Tom Seery, CEO of RealSelf. “As cosmetic procedures continue to become mainstream, millions of women are overcoming social stigma to pursue cosmetic changes they have been researching, often for years.”

R&D Report

Production at Pringy Aesthetics visit the production site and R&D hub for Allergan’s crosslinked family of hyaluronic acid dermal fillers The Allergan Medical site in Pringy, France, was acquired in 2007. Currently, it houses 240 employees, 33 of which carry out the vital research and development work that has secured Allergan’s place as one of the forerunners in the manufacturing and distribution of dermal fillers. Pringy is what Allergan employees refer to as the ‘centre of excellence’. This is because the site in France works as the base for all of Allergan’s manufacturing and R&D activity for Juvéderm – the company’s diverse range of cross-linked, hyaluronic acid dermal fillers. In its two neighbouring buildings, the site has produced around 28 million syringes

BACN announces new board member The British Association of Cosmetic Nurses (BACN) has announced that former Wigmore Medical chairperson David Hicks will take a position on their board. A pharmacist by profession, Mr Hicks actively supported nurses at Wigmore Medical, and the BACN expressed their delight at his appointment. The move has been announced among several changes currently happening at the BACN, which includes an office move to Bristol. Sharon Bennett, BACN chairperson, said, “He brings with him a pair of safe hands, a wealth of experience, and will strengthen the current committee with his knowledge of our specialist area of medicine and his business acumen.” Current BACN board members supported the move unanimously. Of his new position, Mr Hicks said, “I am honoured to be part of the BACN.”

since 2000. The approach at Pringy is a holistic one. “One of the big strengths we have in Pringy is the proximity of the R&D and manufacturing,” explains senior general director Claudie Allaire. “This proximity provides a great sense of collaboration, reactivity and flexibility.” Inspecting this notion closer, director of engineering Pascal Brice notes that, in fact, three worlds combine together at Pringy, “Here we are manufacturing a medical product, whereas the syringe is a pharmaceutical device, yet the packaging belongs to the luxury industry.” As a pharmaceutical company, Allergan has five plants across the world – in Texas, Costa Rica, Brazil, Ireland and France – and more than 10,000 employees. With the confirmation of an acquisition by Actavis in place, this network is set to expand. A theme of continual expansion is evident in Pringy, where plans are in place to increase capacity and automate processes in order to increase quality control; next year they will introduce a state-of-the-art camera system to inspect syringes. “We will be the first pharmaceutical company to inspect syringes with gel using technology,” says Brice. This type of approach aims to eliminate human error, he says, and it is this approach of careful monitoring and continual development of technologies that puts the manufacturing and development of the Juvéderm range in line with regulatory standards closer to that of the pharmaceutical requirements for prescription-onlymedicines (POMs). The mission at Pringy, emphasises Brice, is to exceed customer expectations and quality control is evidently a key term. “We are proud of our strong commitment to quality which influences everything we do,” says Allaire. “From sourcing our ingredients, to manufacturing through to our suppliers – it’s all designed to deliver the highest quality product possible.”

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015

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RSM ICG-7: International Multidisciplinary Annual Meeting, London More than 130 aesthetic medical professionals attended the Royal Society of Medicine’s Interventional Cosmetics Group’s 7th International Multidisciplinary Annual Meeting (RSM ICG-7) on February 27-28. The two-day Dr Kathryn Taylor Barnes and event featured unique presentations Dr Kate Goldie following their presentations from a range of practitioners, who discussed everything from treating filler complications to managing your online reputation. Former president of the European Society for Cosmetic and Aesthetic Dermatology (ESCAD) Dr Christopher Rowland Payne chaired a number of sessions, where he aimed to ensure the high level of scientific content was maintained. Following the meeting, he said, “It was a really great multi-disciplinary, highly scientific discussion. We had international speakers from all parts of the world and a very focused audience – comprising people from the cutting edge of aesthetics – interacting and engaging with each other and the speakers.” Each day was divided into four and five sessions, respectively, between which delegates could discuss their learning with fellow speakers and attendees. On Friday afternoon, general practitioner and aesthetic medicine specialist Dr Kathryn Taylor-Barnes presented ‘Aesthetic treatments in gynaecology – casting light “down under”’. This session invited

The American Academy of Dermatology (AAD) Annual Meeting, San Francisco Lorna Bowes offers an aesthetic glimpse of the AAD 2015 annual meeting in San Francisco San Francisco was always going to attract an impressive number of dermatologists – this year it was confirmed that the event had received more than 18,000 registrants. With this number in mind, it’s unsuprising that three distinct sites were needed for the AAD 2015 annual meeting; even then its lecture theatres and exhibition halls were full and buzzing. One aptly named ‘Hot Topics’ session addressed photoprotection, with board-certified dermatologist Dr Henry W. Lim (chairman of the department of dermatology at Henry Ford Hospital in Detroit), warning that although some authorities suggest a little sun exposure is acceptable, “There is no safe dose of ultraviolet exposure.” It was further emphasised that, “The regular use of photoprotection prevents photoageing and cancers.” Joining Dr Lim in the same session was Dr Zoe Draelos, private practitioner and consulting professor of dermatology at Duke University, North Carolina, to discuss the conundrum of cosmeceuticals; bemoaning the lack of dosage information supplied by most manufacturers. This same topic resurfaced in the session ‘The Science of Cosmeceuticals and Nutraceuticals’, with a panel including Dr Draelos looking at the

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much debate from the audience as delegates conferred both the clinical and ethical aspects of gynaecological rejuvenation treatments. Dr Taylor-Barnes said, “The audience was very receptive to my presentation and asked me challenging questions. Non-surgical rejuvenation of the female genitalia is often deemed a controversial area in aesthetic medicine development, but all agreed that it will become more mainstream and popular with the average woman in the future as there is a genuine need for these treatments.” The meeting hosted international speakers, including those from Switzerland and Morocco, and their international knowledge and perspective impressed both organisers and delegates. Dr Rowland Payne commented that Mr Alain Tenenbaum, a Swiss-based plastic surgeon, gave a particularly thought-provoking talk on intramuscular carbolic acid gluteoplasty and gluteopexy, which was supported by Dr Taylor-Barnes who said his presentation was “most memorable”. Closer to home, UK-based consultant plastic and reconstructive surgeon Mr Dalvi Humzah impressed delegates with his anatomy expertise during his ‘Essential anatomy to avoid complications from injectables’ presentation. Nurse practitioner and delegate Constance Campion said, “I am always happy to hear Mr Humzah speak as he is a specialist. Plastic surgeons aren’t always integrated enough into aesthetics, so I was glad he presented and I fully supported our plastic surgeon colleagues who were there.” Following the close of conference on the Friday, speakers were invited to a dinner in the Toynbee Mackenzie ENT Room at the RSM, which Dr Taylor-Barnes described as a “real highlight of the meeting as it took place in such a beautiful and prestigious venue”. According to Dr Rowland Payne the meeting was a huge success and the best measure of this was delegates expressing their desire to attend again next year.

science of cosmeceuticals for acne and skin lightening, as well as the science and cutaneous effects of nutraceuticals. One main theme of this session was getting to the core of the clinical evidence behind a product line – the importance of asking whether there is sciencebased, published data with reliable sources behind it – as well as reviewing ways to battle misinformation. A session by Dr Heidi Waldorf on ‘Aging gracefully’ looked at defining the parameters of ‘graceful aging’ from a consumer versus a medical perspective, making suggestions for therapeutic plans for preventions, rejuvenation and maintenance, including reviewing the choices and timings of cosmeceuticals, injectable neuromodulators, soft tissue fillers and various devices for non-invasive rejuvenation. Perhaps the hottest topic of this year’s annual meeting was robotic hair transplants from Artas, which, with 35 million men experiencing hair loss, is a growing area of commercial development. Though balding is itself not harmful, the emotional effects can be both frightening and traumatising. In discussion was a new system enabling physicians to harvest healthy follicular units in a minimally invasive procedure delivering a healthy, intact graft. Providing a wealth of topics over the five days, the AAD meeting proved yet again a crucial source of educational activity within the field of dermatology.

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015

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Lumenis ResurFX Workshop, London Aesthetic practitioners were invited to an afternoon of learning, courtesy of international energy-based medical company Lumenis, on March 19. Held at the PHI Clinic, Harley Street, the event brought together both inexperienced and well-practised laser users. First, delegates enjoyed a light lunch and networking session, followed by an introduction to the Lumenis devices and the UK sales team. Dr Tapan Patel then discussed his experience of using the new ResurFX device. For the laser beginners present, Dr Patel offered a beginner’s description of how the system should be used, whilst ensuring he also gave an advanced explanation to the more experienced attendees present. Delegates then participated in an engaging question and answer session, allowing the Lumenis team and Dr Patel to address all concerns from the audience. Questions queried patient suitability, modes of treatment, suggested anaesthesia and recommended lengths of time between ResurFX procedures. Of the meeting, aesthetic practitioner Dr Askari Townshend said, “Hearing Dr Patel talk is always a fantastic opportunity to learn about the nuances of advanced laser treatments. Seeing how he’s treating acid burn victims’ scars with the new fractional non-ablative device by Lumenis has been amazing.”

Eden Aesthetics business seminar, London Eden Aesthetics Distribution invited aesthetic practitioners to a one-day business seminar at the Academy of Medical Sciences in London, on February 26. Welcomed to the free seminar with coffee and cake, attendees were presented with a selection of talks covering various business topics. During the two-hour lunch break, they also had the opportunity to watch live demonstrations of treatments and test products being discussed. Topics covered included the importance of a clinically proven range with Epioncé, and how to market your brand for optimum results, courtesy of digital marketing agency Blow Media. In the afternoon aesthetic practitioner Dr Mervyn Patterson demonstrated how to maximise facial lifting with Voluma using a cannula. Of the demonstrations, he said, “I think there were a lot of very interested people present, and they’re seeing some cutting edge technology, new ways to combine micro-needling treatments and the very latest in quadrapolar radiofrequency skin tightening.” Reflecting on the business talks, attendee Ayse Suleyman said, “It’s quite informative to know what the next step would be for longterm retention of your patients. That’s really important for us as a business.”

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Skin Geeks Image Skincare Worldwide Launch Party, Brighton Clinic owners and aesthetic practitioners met at Stanmer House, Brighton, for the Skin Geeks Image Skincare Worldwide Launch Party on March 16. The event introduced three new Image Skincare products added to the Skin Geeks distribution portfolio, including the ILUMA Intense Brightening Eye Cream, the MAX stem cell masque and the ILUMA Intense Brightening Exfoliating Powder. Attendees were able to test the skincare, whilst education specialist Victoria Hiscock gave a thorough explanation of the science behind the ranges. One attendee, Dr Dev Patel, clinical director of Perfect Skin Solutions in Portsmouth, said, “Although I’m already familiar with Image Skincare, I’m always impressed by the clinical research that goes into creating these products and enjoy coming to these events to learn more.” At the close of the launch party, managing director of Skin Geeks Don Maree said, “Our core value at Skin Geeks is science-based education so, for us, this is a must attend industry event. We are showcasing our new technology and it’s a fantastic opportunity for us to meet our clients to update them with all the new products.”

PicoWay workshop, London Hosted by Syneron Candela, international practitioners were invited to attend a oneday workshop on the PicoWay laser at PHI Clinic, London, on March 6. The day began with an introduction, followed by a detailed discussion of the science behind PicoWay from Dr Jayant Bhawalkar, vice president of research at Syneron Candela. Attendees were invited to watch tattoo removal demonstrations in the clinic’s treatment rooms, whilst qualified practitioners had the opportunity to test the laser. Hamish Mcnair, director of clinical education EMEA at Syneron Candela, discussed clinical protocols and Food and Drugs Administration data before breaking for lunch. In the afternoon, aesthetic practitioner Dr Tapan Patel performed another live treatment demonstration, which was followed by practice marketing advice and time for questions to round up the day by 4pm. “Venues like this are really useful, because they’re so big we can communicate the benefits of this device and this technology to the physician community,” said Dr Bhawalker. “Having a forum like this, which is an all-day session, the physicians not only get to hear the science behind Pico, but really understand why those parameters are important.”

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015

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ACE 2015 in Review We look at the highlights from the Aesthetics Conference and Exhibition 2015 The Aesthetics Conference and Exhibition (ACE) 2015 has been hailed a huge success following overwhelmingly positive feedback and requests to attend next year from delegates, speakers and exhibitors alike. The conference, held on March 7 and 8 in Central London, was the perfect opportunity for aesthetic professionals to come together over one weekend and enjoy the vast range of learning and networking opportunities available at ACE. ACE attracted more than 2,500 visits to watch the 61 outstanding clinical and business sessions, delivered by 71 speakers throughout the two-day event. With such an extensive offering, ACE attracted a variety of industry specialists, statistics showing 33% to be cosmetic doctors, surgeons, dermatologists and GPs, and 26% aesthetic nurses. Of the remaining delegates, 13% were found to be dentists, while 10% made up aestheticians and 18% clinic managers. Alongside a comprehensive exhibition floor, which featured 100 top exhibitors, the weekend’s educational programme incorporated four agendas: interactive Conference modules, live demonstration Expert Clinics, Masterclasses and a Business Track. Each agenda featured respected and experienced speakers from across the aesthetics industry, who shared invaluable advice and knowledge on a variety of treatments, techniques and business insight, with more than 63 CPD points available across the weekend. Amanda Cameron, Aesthetics editor and ACE 2015 programme organiser, said, “This year we saw an increase in attendance over both days of the conference, with packed demonstration theatres and business workshops right up until the last session on the Sunday. We received overwhelmingly positive feedback from delegates, who really enjoyed the interactivity of the sessions, such as the individual voting keypads utilised in the main conference auditorium.” During sessions, delegates were able to interact with the speakers via the latest conference technology and throughout the event had free access to the Exhibition, Expert Clinics, Masterclasses and Business Track. The Conference programme featured four dynamic and interactive modules which explored the entire patient journey across different areas of aesthetics, including the role of fat, injectables and dermatology. Mr Dalvi Humzah, renowned consultant plastic surgeon and ACE 2015 Steering Committee chair, joined his fellow practitioners and friends Dr Tapan Patel and Dr Raj Acquilla, with a

guest appearance on Saturday from Canadian aesthetic doctor and international speaker Dr Arthur Swift, to present two main Conference sessions over the weekend, exploring the anatomy of the face and treatment with injectables. Reflecting on the sessions, Mr Humzah said, “It was exhilarating, we had great fun with each other and great interaction with the audience. There were questions asked on some interesting and challenging topics. I was delighted to work with Raj, Tapan and Arthur Swift, and each of us have been able to contribute a different perspective.” A key focus was facial anatomy, a concept which Mr Humzah feels is crucial to safe injection. “I am very keen on making sure people working in this area know about the anatomy and relate back to this in their practice,” he said. “I have an interest in anatomy, and I thought this way we could bring the subject to life on stage, using the videos, using the demonstration and using the models, so practitioners could see that this really is the way forward.” Dr Arthur Swift also presented on behalf of Merz Aesthetics at the Merz Aesthetics Live Demonstration Zone, where he launched the new Belotero Volume with Lidocaine filler. He noted the importance for delegates to understand the scientific background of products and techniques, while retaining a focus on the overall goal – beauty. “I think when you start to understand the science behind the product and how the product works, sometimes it’s very easy to go ahead and lose your focus on what we’re trying to achieve,” he said. “These conferences aren’t just important, they’re crucial. Conferences like this are really the fibre of how we do our work.” Alongside the injectables sessions, the Conference agenda also included ‘The role of FAT in medical aesthetics’, which drew together a vital debate about how fat should be managed in the aesthetics industry. Panellists took to the stage to discuss the latest and most effective ways of managing weight loss, and, with the use of audience interaction, found that attendees were divided 50/50 on whether plastic surgeons should be the only ones to perform liposuction. A board of industry experts were then invited to present their lipolytic technology to the audience, offering a wide overview of what is available in the industry today, allowing the audience to decide on their preferred technology. Mr Taimur Shoaib, consultant plastic surgeon and co-chair of the fat session, said, “I think the strongest point of the session was the variety of the people in the audience and on the panel.” He continued that the Conference brought together

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015

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“a multidisciplinary team of people, where we can discuss patient concerns by asking people from a variety of different backgrounds.” Sunday’s ‘Aesthetic Dermatology Clinic’ provided delegates in attendance with an insight into the newest innovations and skin treatments available in aesthetic dermatology in 2015. During the three-hour session, aesthetic nurse Anna Baker argued for the use of photodynamic therapy (PDT) for the treatment of basal cell carcinoma, which was supported by respected dermatologist Dr Stefanie Williams, who said, “In my opinion, this seems to be one of the best methods we can use.” “This conference is a very exciting, multidisciplinary one which brings together all different aspects of cosmetic practice,” said Dr Christopher Rowland Payne, who chaired the dermatology session alongside Dr Williams. “It’s the opportunity for multidisciplinary discussion and talking about different treatments and developments and has a very interactive audience who participate in everything.” Set on the busy exhibition floor, the two Expert Clinic live demonstration theatres saw consistently full benches throughout the entire event. Within the programme, which offered independent and sponsored classes, sessions were presented by Lynton Lasers, Rosmetics, AestheticSource, Medico Beauty, Fusion GT, Sinclair Pharma, HealthXchange, BTL Aesthetics, 10 Laser, Skinceuticals and NeoCosmedix, covering topics from chemical peels to lasers. Amongst the vast array of topics, debates, techniques and treatments presented by esteemed speakers, Mr Humzah was joined on stage by Dr Elizabeth Raymond Brown to address the importance of good photography within aesthetics. While highlighting ethical issues around consent of use with patient images, Dr Raymond Brown offered delegates key guidance in image taking. During the session, She said, “If you do one thing today – check your white balance. It will make a huge difference to your image results,” also reinforcing the idea that spending money on a decent camera would provide more detailed and effective images. In particular, the Vitamin Infusion Debate garnered a huge amount of interest. The Expert Clinic panel was chaired by nurse practitioner Sharron Brown and comprised Dr Martin Kinsella, Richard Sikkel, Dr Jacques Otto and Constance Campion. Though views on

the treatment were divided, all panellists agreed that thorough consultations prior to vitamin drip treatments were crucial for maintaining patient safety. Of the Expert Clinic agenda, Dr Simon Ravichandran, who presented a session on advanced injectables to a packed audience with Dr Emma Ravichandran, said, “The delegates seem to be quite interactive here, they were quite open and asking questions – and they’re asking the right questions.” He added, “Often we practice independently. It’s a very lonely industry for those of us who don’t have colleagues, friends and peers who we can turn to, but events like this not only allow people to attend lectures and get all the best advice and latest training, but find other people to discuss ideas and get their advice from.” Another popular aspect on the educational programme were the sponsored Masterclasses, a group of seminars and workshops where attendees could learn key best practice guidance for leading products from the top company KOLs. Within the broad Masterclass agenda, Mr Shoaib discussed the patient experience in a session sponsored by Allergan. He stressed the importance of asking vital questions of patients during consultation and told the audience, “We need to explore their fears and anxieties.” Other Masterclasses, sponsored by Sinclair Pharma, Medical Aesthetic Group, Institute Hyalual, Adare Aesthetics, 3D-lipo Ltd and Galderma, addressed acne treatment, the benefits of multi-platform treatment approaches, thread lifting, injectables and skin rejuvenation. For those looking to build on their non-clinical skills, the ACE Business Track, sponsored by Church Pharmacy, gave delegates the chance to enhance their clinics and provide the ultimate patient experience.

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015

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Sessions provided a broad range of learning opportunities for delegates, which included how to give a great first impression, marketing skills, using social media, and VAT and insurance guidance. US author and international commentator Wendy Lewis presented two sessions over the weekend, which highlighted the importance of social media and visual content. Reflecting on her talk, she said, “People were really engaged and interested – social media is a really hot topic right now and marketing your clinic is of utmost importance. The attendance really showed that.” Following the successful programme, co-director of Church Pharmacy Zain Bhojani said, “The delegates have been very interested in what the speakers have to say, so it’s nice to know they are getting something out of it and learning something that is a bit different to the clinical side of things. Without a doubt ACE is my favourite show.” KEY ISSUES IN 2015 The exclusive Question Time debate on Saturday evening, free to all attendees and sponsored by 3D-lipo Ltd, aimed to highlight this year’s most current and important industry issues. Former BBC presenter Peter Sissons chaired the event, with a panel that included Wendy Lewis, Mr Dalvi Humzah, plastic surgeon Mr Paul Banwell, professional body chairs Sharon Bennett and Dr Paul Charlson, and Health Education England (HEE) modality lead Andrew Rankin. The HEE recommendations for qualification requirements were first to be discussed, with Mr Humzah insisting that it is “up to us as an industry to set up official qualification courses,” while Bennett said “If Europe can agree a consensus I can’t see a problem.” Regulation and accreditation were major factors in the debate, with Dr Charlson arguing that the General Medical Coucil are interested in accreditation for cosmetic practitioners, in contrast to many opinions, while Lewis raised the importance of policing your online reputation. One audience member questioned whether the panel felt positive about the potential for change in the industry, to which Rankin said, “The commitment we all have to improving standards is inspiring.” Bennett was also adamant that the future is bright and that “the climate will change and the consumer will be looking for accredited practitioners.” To conclude Question Time, each panelist offered a final thought. Bennett told delegates, “Join an association, lone practitioners are dangerous.” LATEST INNOVATIONS The exhibition floor was the perfect opportunity for delegates to meet with the top suppliers, gain valuable business partners and discover the latest product innovations. Lorna Bowes, director of headline sponsor AestheticSource, said, “The Expert Clinics seemed packed each day with a variety of topics covered, and the format of ‘clinic sessions’ on the main agenda packed the auditorium. This was particularly impressive given that the Merz sponsored sessions with Dr Arthur Swift were also packed – there were an awful lot of delegates in

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total!” She added, “For me the highlight, as last year, was the industry debate – time for people to air views and raise contentious issues. Congratulations on providing a platform like this to our industry.” David Gower of Med-fx, registration and consumables partner of ACE 2015, also praised the quality of the exhibition, which drew in huge numbers of professional attendees. “We see this year a much more professional, much more vibrant exhibition,” he said. “I feel that there has been a lot of interest in products, not just the products that we’re offering but in general, and people who are approaching have been very business-like and professional in manner.” Among the exceptional feedback that was received during and after ACE, one of the most prominent points that delegates consistenly praised was how well the event addressed the need to keep up to date with the latest treatment techniques and new innovations. One plastic surgeon emphasised that, “We need to update ourselves and learn what is available to give the best possible service to the patient.” This was widely agreed by attendees, with a cosmetic doctor adding, “Products change, techniques change, knowledge changes and unless you’re keeping up to date you are really not being the best practitioner you can be – and you’re not really giving your patients the best. So that’s the reason you need to attend conferences like this.” Reflecting on a weekend packed with extensive, high quality education, a nurse prescriber further commented, “This is actually one of my favourite

conferences; ACE squeezes so much into the time we have, it’s been very beneficial on all levels. I’m an experienced nurse prescriber and have been injecting for 16 years, but I still learn a lot every time I come and would definitely recommend ACE to colleagues. I’ll be back again next year.” The success of this year’s event has firmly cemented ACE as the leading medical aesthetics conference and exhibition in the UK and, as such, planning for ACE 2016 is already underway. Cameron concluded, “In view of this success, we are now already working on next year’s event to ensure that delegates once again will be given the opportunity to attend a conference that perfectly complements their practice, and inspires them to push innovative boundaries within aesthetics.”

To stay up to date with the latest news and developments for ACE 2016, register at www.aestheticsjournal.com.

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015

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Treating the Lips Seldom does a week go by when we’re not subjected to media propaganda about lip enhancement procedures. Whether it’s hype about the latest celebrity to appear with a suddenly-plumper pout, or denigration of the trend when something goes publicly wrong; there is no denying that aesthetic lip procedures have received scrutiny unrivalled by other similar minimally invasive treatments. Allie Anderson talks to practitioners about the different ways to treat this area of the mouth. There has been great public awareness of lip rejuvenation non-surgical procedures, so the availability and accessibility procedures since the infamous Leslie Ash case in 2002, which means more people are having the treatment.” led to coining of the now-familiar phrase ‘trout pout’. The actress Lip treatment also appears to be particularly popular in certain had her top lip injected with permanent filler to make it appear geographical areas, as Dr Lee Walker, clinical director of Liverpoolfuller, but an allergic reaction caused permanent swelling and based B City Clinics, attests. “It’s probably the second-most resulted in the product fusing with the muscles between her lips requested treatment after botulinum toxin, because it’s a unique and nose.1 While her story is extreme, she was to be the first of demographic in Liverpool,” he says. “There’s an incredibly mediamany celebrities whose lips have made it firmly into the spotlight. driven image that’s projected with young females in the city; when Media portrayal of lip enhancement has a profound influence on I speak to colleagues around the country, none of them perform its popularity in clinics, in a number of ways. According to a 2014 the amount of lip treatments that I do.” Dr Walker explains that survey of 1,000 women, 63% would like fuller lips, yet 78% say they around 95% of the lip treatments he carries out are to introduce would avoid lip fillers due to fear of ‘trout pout’ and the health risks, as well as the cost of treatment.2 On the other side of the coin, fuller lips are constantly According to Dr Acquilla, age-related restoration commonly involves the presented as desirable and achievable, and the following points: trend for fuller, more defined lips has translated 1. Oral commissure: to correct sad mouths and give positivity to the smile. to an increase in the number of lip procedures 2. Lateral upper lip depression: often associated with previous lip filler but being carried out in clinics across the UK. “Lips are also exacerbated by ageing. incredibly popular [as a treatment area] due to the 3. Vermilion border: to promote eversion and external rotation of the lip rise of lip augmentation in the media and ‘celebrity and therefore increase mucosal culture’. The most common demographic are the show. budget-conscious young female patients (18-25), 4. Peri-oral rhytids: erasing who have £150 to spend and request lip fillers lines and wrinkles associated to give them a sexy, glamourous pout,” explains with ageing of the skin and aesthetic practitioner Dr Raj Acquilla. orbicularis oris. As demand has grown, so has supply, adds Dr 5. Glogau Klein points and Kieren Bong, clinical director of Glasgow’s Essence philtral columns: for definition Medical Cosmetic Clinic. “Unfortunately we’ve seen of the apex of the Cupid’s bow the general public trivialise medical procedures like and philtral concavity. this and underestimate the risks and the potential 6. Volumetry: precise side effects,” he comments. “It’s not helped by volumetric augmentation to an the fact there are a lot of practitioners who also upper-to-lower lip ratio of 1:1.618, underestimate the risk and fail to convey it to which is commonly distorted by the general public. The market is saturated with novice injectors. Image courtesy of Dr Raj Acquilla practitioners from all sorts of backgrounds offering

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015

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After

The clinician’s expertise and skill play a crucial part. Indeed, practitioners have a duty to guide patients on what to expect, and what outcomes can be achieved with different procedures – and there is often a mismatch between the treatment patients initially seek, and those that are recommended. “Of the 100-120 patients I treat per week, more than half request lip fillers and only 20-30% actually need and receive them,” comments Dr Acquilla. Treatment with Juvéderm Volbella. After image shows patient two weeks post treatment. For those patients who do, he uses low Images courtesy of Dr Sarah Tonks. molecular weight hyaluronic acid fillers dermal fillers for a plumper and more defined look. “owing to their excellent tissue integration and soft, natural results While lip shaping and augmentation seems to be particularly at rest and on animation of the lips,” he explains. “In addition, I popular among the under-35s, a proportion of patients undergoing also complement fillers with fractional CO2 laser resurfacing of the treatment are seeking to address or reverse the signs of ageing. perioral skin to remove pigment and fine textural lines,” says Dr “The lips are a focal point of the face, and our eyes are drawn to Acquilla. Filler containing hyaluronic acid is a popular choice among this area when we are talking. They are part of the central triangle many practitioners to enhance and plump the lips, alongside peels and can distinguish our age quite easily,” explains Sharon Bennett, and botulinum toxins in the perioral region, particularly to address independent nurse prescriber and clinical director of Harrogate ‘smokers’ lines’. However, the precise formulation and treatment Aesthetics. “As we age, and through environmental and extrinsic will depend on the patient and their desired result. Dr Bong says factors, our lips will become thinner and wrinkly, with downturned that while a large number of his patients are seeking a plumper lip corners (oral commissures), and lack the shape and support we (to varying degrees of fullness), others are increasingly seeking to once enjoyed. The Cupid’s bow drops down and is no longer reinstate hydration, which is often also a casualty of ageing. “We upright and defined, and the philtral columns flatten.” have a range of products that restore hydration and improve the texture of the lips without increasing the volume,” he explains. Dr Sarah Tonks, who practices at Omniya clinic in Knightsbridge, “We inject a product that has a concoction of ingredients such as says that lip treatments are often carried out as part of – or as a vitamins, antioxidants, and hyaluronic acid, which has a very high result of – anti-ageing procedures or treatments to the rest of the affinity for water and attracts up to 1,000 times its own molecular face. “I do a lot of whole-face rejuvenation in one appointment weight in hydration.” with my patients, and when you rejuvenate the whole face this While there are manifold topical products available over every can make the lips appear smaller, as the rest of the face has more high street counter, particularly aimed at rehydrating the lips, Dr volume. I warn my patients of this and tell them they will probably Bong suggests that these do not provide the long-term results that need to do the lips too, although they don’t often believe me injectable treatments do. “With all our technology, it still has not until they look in the mirror,” she explains. “A lot of people are advanced far enough to produce a topical substance with a small frightened of looking ‘too done’, and there is an association that if enough molecule that will penetrate the deep layers of the skin and you have your lips done, you will always look fake.” provide sustained hydration,” he says. “Hence, a moisturiser will To counter this, and to manage a patient’s expectations, it’s only work when you apply it and won’t result in any cellular changes imperative to conduct a thorough consultation and to consider that will provide sustained improvement.” Similarly, Dr Tonks says of the anatomy of the perioral area. “The skin, musculature and even topical, volumising lip treatments: “It’s like replacing missing teeth the bone structure change as part of the ageing process,” says with a denture.” It is common, however, to use a topical anaesthetic Dr Bong. “So, first I have to listen to what patients are hoping to before treating the lip area, such as LMX 4% (lidocaine). “This is achieve, before analysing the anatomy. Then, I consult with my effective at taking about 70% of the discomfort away, and makes the patients and make them aware of what’s achievable and more procedure manageable for the patient,” says Dr Walker. Alternatively, a importantly, what’s not achievable, as a result of the constraints of the anatomy.” Similarly, to achieve Before After natural and age-appropriate results when using filler, product choice is important. “We don’t use a one-size-fits-all filler; the problem with doing so is that it could be too heavy for some parts of the face, and too light for other parts of the face,” Dr Bong explains. “We only use lip filler that has been exclusively formulated for lip contouring and enhancement. Within this range, there are different grades – there’s no point giving someone a thick grade of filler who doesn’t want too much treatment. Also, if it’s an older patient, we want to emphasise contour rather than volume, so we’d use a different grade again.” Images courtesy of Dr Kieren Bong

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015

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The lips, though a focal point of a person’s face, are of course one part of the whole canvas dental block can be used to completely numb the area. The lips, though a focal point of a person’s face, are of course one part of the whole canvas. As such, it’s important that patients are made aware that treating the lips in isolation without attending to the facial and labial skin may well have inadequate results. According to Bennett, addressing the skin of the lips before undertaking a procedure is important. “If there is any evidence of ageing, [tackling the skin] can improve the lip itself greatly and reduce the need for significant work,” she says. “Also, if you only treat the lip, but the surrounding skin is aged, sagging and wrinkly, lacking support and structure, then the lip will probably look somewhat incongruous and very evident. A younglooking plump, hydrated and shapely lip surrounded by a wrinkling face and mouth can look odd. It will not make the patient look particularly younger if the lip is the only area on an ageing face to be treated.” A holistic approach should be taken to halting or reversing the effects of ageing – and that, according to Dr Bong, ought to incorporate a number of factors. “Emphasis should be on the canvas of the face, which is the skin, because it’s part of looking good that we have radiant, healthy looking skin,” he comments. “Ageing is a multi-faceted, multi-factorial process, and you need to look at ageing in its entirety. To achieve a natural result, we need to look at everything simultaneously, including hair, teeth and skin.” As such, patients who seek and undergo procedures on the lips should also be given guidance on the how the area will look against the backdrop of an untreated face, and how treating other areas around and beyond the lips could enhance the overall result. In addition, patients having lip treatments should be encouraged to support good skin health through protecting against sun damage, topical application of antioxidants, retinoids and peptides, and maintaining a good daily skincare regime. Different cultures and ethnicities have conflicting perceptions of beauty – including what is considered both attractive and undesirable in terms of the lips and mouth. Dr Walker’s mostly white European patients in Liverpool seek a very noticeably enhanced lip. Similarly, practicing in a northern spa town, Bennett treats a high proportion of Caucasian men and women. “The majority of patients are looking at a one third to two thirds [upper-to-lower lip] ratio, which we can measure,” she comments. “Younger women often want to emulate the look of a particular reality TV

Image courtesy of Dr Kieren Bong

star or celebrity – Kylie Jenner is very ‘of the moment’ – and they tend to prefer an almost 50/50 ratio. We have few men requesting lip treatments and those who do are not often wishing to have anything noticeable to others.” Dr Tonks, on the other hand, has a lot of Arabic patients, and reports that their preferences are quite different, as is their tolerance to more product and the way she approaches lip treatments. “Patients from the gulf have naturally larger lips that can absolutely eat product,” she says. “You can easily use 2ml in a patient in one sitting if they are after something glamorous. They don’t have the problem that Caucasian patients often do, with very thin, almost non-existent upper lips, which are very hard to do that with in one treatment sitting.” Bennett adds that Arabic patients don’t like a wide mouth look, which can be the result of filler injected under the oral commissures to elevate them. People from African Caribbean backgrounds also tend to have fuller lips, and often prefer treatments concentrated on definition at the corners of the lips, says Dr Bong, while in the Asian community, the perception of beauty is more focused on the shape of the face. Religion and culture also have an influence, with some patients reluctant for friends and family to know that they have had treatment due to a negative perception of cosmetic interventions. “Therefore, it’s much more common that they want treatments performed in stages and a result that is much more natural and subtle” he adds. In order to fulfil each patient’s cultural and personal requirements, a thorough understanding of both is necessary. Dr Acquilla comments, “I travel all around the world teaching injection techniques in different genetic backgrounds. There is definitely a strong link between genetics and aesthetics, such as strong lips in the Middle East and Asia with deficiencies in Caucasian populations. The key to success here lies in accurate assessment and treatment of the whole face in good balance and proportion.” Despite its share of negative press, the case evidently remains that lip treatment is growing in demand. Mass marketing has created the illusion that lip augmentation is a quick and easy way for people to conform to the latest beauty fad with few consequences. This is perpetuated by a concerning trend in such procedures being offered at discounted rates or as prizes. The Keogh Review described such advertising practices as “socially irresponsible” and recommended they be “prohibited by the professional registers’ code of practice”,3 but unless these recommendations are wholly embraced by the aesthetics industry, patients are potentially being put at risk. Practitioners must ensure they market and perform treatments ethically, embracing the Keogh recommendations rather than just paying them lip service. REFERENCES 1. Emine Saner, A brave face (The Guardian, 12 September 2008) <www.theguardian.com/lifeandstyle/2008/sep/12/ celebrity> [Accessed on 16 March 2015] 2. Naomi Greenaway, Out with the ‘trout pout’: Three quarters of women would AVOID lip fillers for fear of ending up with the fish-look recently spotted on Tulisa (MailOnline, 2 September 2014) <www.dailymail.co.uk/femail/article-2740840/ Three-quarters-women-AVOID-lip-fillers-fear-Tulisa-trout-pout.html> 3. Department of Health, Review of the Regulation of Cosmetic Interventions (London: gov.uk, 2013), page 43. <www.gov.uk/ government/uploads/system/uploads/attachment_data/file/192028/Review_of_the_Regulation_of_ Cosmetic_ Interventions.pdf>

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015

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Managing Obesity: Approaches and Treatment In the second instalment of a two-part weight loss special, Dr Sotirios Foutsizoglou looks at methods of managing and treating obesity In last month’s first instalment on managing obesity, we explored the physiology and the role of fat, looking at its function within the body, whilst also observing current obesity trends and statistics from across the globe. It has been suggested that even modest reductions in weight may be associated with health benefits, with reductions in blood pressure, cholesterol and triglycerides achievable with just a 5-10% reduction in initial body weight.1 Therefore, as healthcare professionals, it is our role to aid our patients in the understanding, management and treatment of obesity. A wide range of interventions are available for the management of weight and obesity. These include work/school/community programmes (for primary prevention), dietary modification, exercise programmes, behaviour modification programmes, pharmacological agents, commercial programmes (e.g. Weight Watchers) and alternative therapies. Surgery is usually reserved for those suffering from very severe obesity (BMI greater than 40 kg/m2), for whom less invasive methods of weight loss have failed. In this second instalment I will discuss various weight management strategies that may be used alone or in a combination. Assessment and classification When conducting an initial consultation with a patient who is overweight or obese, it is vital to assess their lifestyle, comorbidities (e.g. hypertension, diabetes, dyslipidaemia, cardiovascular disease, sleep apnoea) and their willingness to change. This can be done both verbally, and through written Figure 1: Metric BMI Formula assessment, with the aid of a questionnaire. The next step Table: Metric BMI Formula is to utilise the BMI scale, weight in kilograms BMI = referred to in the previous ———————————— ( kg/m² ) article,2 in order to classify the height in metres² degree of obesity. When carrying out this assessment, it is important to consider the following factors: • BMI may be less accurate in muscular people. Although BMI correlates with the amount of body fat, BMI does not directly measure body fat. As a result, some people, such as athletes, may have a BMI that identifies them as overweight due to their increased muscle mass, even though they do not have excess body fat. • For Asian adults, risk factors may be of concern at lower BMI as a given BMI tends to be associated with higher percentage body fat than in European populations.3 • For older patients, risk factors may be significant at higher BMIs due to a lower correlation with percentage body fat in the old than in the young, and a weaker association with cardiovascular mortality and morbidity.4 For patients with BMI less than 35kg/m2 we are able to assess health risks by using waist circumference.3 A waist circumference in men

of >102 cm, and in women >88cm, is associated with high risk to health.3 Although • Normal weight 18.5–24.9 waist circumference and • Overweight 25.0–29.9 BMI are interrelated, waist • Obesity class 1 30.0–34.9 circumference provides an • Obesity class 2 35.0–39.9 independent prediction of risk • Obesity class 3 ≥ 40.0 over and above that of BMI. It is particularly useful in patients who are categorised as normal or overweight on the BMI scale. It’s important to note here that in South Asian patients (of Pakistani, Bangladeshi and Indian origin) living in England, a large waist circumference is more likely to be associated with features of metabolic syndrome, compared to patients deriving from Europe; for example, higher triglycerides and lower high-density lipoproteins (HDLs) in female patients from South Asia, and higher serum glucose in male patients from South Asia.5 Figure 2: The National Heart, Lung, and Blood Institute Overweight and Obesity Classification by BMI (in kg/m2):

Lifestyle changes The next step in assessment is to understand the patient’s lifestyle (in terms of their relationship with food, exercise and attitude to weight and wellbeing), and to suggest interventions. Interventions should: • Always be delivered by healthcare professionals who have relevant competencies and appropriate training. • Include behaviour change strategies – such as goal setting and self-monitoring of progress – in order to increase patients’ physical activity levels, and improve eating behaviour or quality of diet. • Take into account the person’s needs, preferences, social circumstances, degree of obesity, comorbidities, physical fitness and any previous or concurrent anti-obesity over the counter (OTC) and prescribed medication. • Include exercise (preferably cardiovascular), even if this does not lead to weight loss, as it has other health benefits such as reduced risk of type II diabetes and cardiovascular disease.6 Recent studies suggest that individuals who commute to work by active means (cycling or walking) have significantly lower body mass index and percentage body fat than people who use private transport.7 Dietary advice is crucial in this process. As slow weight loss is associated with more sustainable results, aim for a maximum weekly weight loss of 0.5 -1kg.8 For this kind of approach, the National Institute for Health and Care Excellence (NICE) recommends diets that have a 600kcal/day deficit (that is, they contain 600kcal less than the person needs to stay the same weight), or it is advised to reduce calories by lowering the fat content (utilising low-fat diets).3 Depending on the patient, another consideration would be to use low-calorie diets (1000-1600kcal/day), or very-low-calorie diets (< 1000kcal/day). This approach may be used for a maximum of 12 weeks continuously,3 or intermittently with a low-calorie diet (e.g. two to four days/week), if the person is obese and has reached a plateau in weight loss. Any diet of less than 600kcal/day should be used only under clinical supervision.

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015

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Pharmacological management Current treatment of obesity consists primarily of health behaviour modification (diet, exercise and behavioural therapy) for all patients, and bariatric surgery for a minority of selected severely obese people. Because health behaviour modification can be limited in its effect in many patients, and the availability of bariatric surgery is restricted, additional adjunctive, effective and safe obesity treatments are required. To date, anti-obesity drugs have not adequately filled this therapeutic void. The serotonergic agents fenfluramine and dexfenfluramine were withdrawn in 1997 due to association with cardiac valvulopathy and pulmonary hypertension.9 After the withdrawals of rimonabant (Acomplia) in 2009 for depression and suicidal ideation,10 and silbutramine (Meridia, Reductil) in 2010 because of increased cardiovascular risk, 10 orlistat became the only agent available for long-term weight management. In 2012, two new oral agents – phentermine and extended release (ER) topiramate (Qsymia) and lorcaserin (Belviq) – were approved by the US Food and Drugs Administration (FDA) as adjuvants to health behaviour modification in patients with a BMI greater than 30, or greater than 27 with an obesity related comorbidity, such as hypertension, dyslipidaemia, or type 2 diabetes. 10 The European Medicines Agency did not approve either agent, citing toxicity concerns and a lack of morbidity and mortality data in 2012.11 NICE has advised that patients with a BMI > 30kg/ m2 should receive treatment. Therefore, pharmacological treatment of obesity should form a part of a wider assessment of a patient’s lifestyle and risk factors for cardiovascular disease. In patients who are motivated to lose weight, drug treatments can increase the amount of weight loss as part of a diet and exercise programme. Any drugs used in the treatment of obesity should be prescribed by an experienced doctor who should comply with NICE guidance on the prevention, identification, assessment and management of overweight and obese patients.3 In the UK, all anti-obesity drugs, or ‘slimming pills’, other than orlistat, are widely known to be in use off license. Anti-obesity drugs acting on the gastro-intestinal tract Orlistat Following the withdrawal of fenfluramine and dexfenfluramine, interest has focused on orlistat, currently the only licensed anti-obesity drug in the UK. • Orlistat inhibits the action of the pancreatic lipase within the gut lumen. It can be given as an adjunct to diet and exercise in the treatment of obesity when BMI > 30Kg/m2 or > 28Kg/m2 associated with other risk factors for cardiovascular disease such as diabetes, hypertension, hypercholesterolaemia, etc. • It should be taken with a well-balanced calorie-controlled diet that is rich in fruit and vegetables and contains an average 30% of the calories from fat. • Orlistat can reduce the absorption of fat-soluble vitamins, therefore long-term treatment vitamin supplementation, especially of vitamin A (β-carotene), is recommended. Other lipid-soluble vitamins include D, E and K. Most patients however, are not at risk of vitamin deficiency. • No dosage adjustment is usually required in hepatic or renal insufficiency. • Orlistat is barely absorbed, so the risk of systemic adverse effects is low. • Inhibition of fat absorption commonly causes oily stools, abdominal pain and faecal incontinence (minimised by reduced fat intake). Some patients may find them intolerable; therefore need to be warned in advance.

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• Treatment can be continued beyond three months only if weight loss since commencement of Orlistat exceeds 5% of initial body weight (target is lower in Type II diabetes patients). • Orlistat has been studied in long-term clinical studies of up to four years’ duration, hence it has a good safety profile.12 • Orlistat 120mg should be taken before, after, or up to one hour after each main meal. Dose can be omitted if the meal contains no fat. Maximum dose 360mg a day. • It is recommended that orlistat treatment should be discontinued after 12 weeks in patients who lose less than 5% of their initial body weight. 12 • European prescribing guidelines state that the duration of treatment with orlistat should not be longer than two years.13 Methylcellulose • Methylcellulose is a bulk-forming laxative. • It is claimed to reduce food intake by producing a feeling of satiety.14 However, there is very little evidence to support its use in the management of obesity. Chromium Picolinate Chromium is an essential trace mineral found in various foods. It has been used as a dietary supplement as there are claims that it can aid weight loss through regulating blood sugar levels, thus suppressing appetite and food cravings. However, studies examining a potential association between chromium and insulin concentrations have yielded mixed results.15 In 1999, following a study conducted by the University of Alabama, initial concerns were raised that chromium picolinate is more likely to cause DNA damage and mutation than other forms of trivalent chromium.16 However, in December 2004, the Committee on Mutagenicity published its findings, which stated that, “Overall it can be concluded that the balance of the data suggest that chromium picolinate should be regarded as not being mutagenic in vitro,” and that, “The available in-vivo tests in mammals with chromium picolinate were negative.”17 400μg chromium picolinate, preferably at mealtimes, can be used as a food supplement to suppress cravings and insulin spikes. Centrally Acting Appetite Suppressants (CAAS) There are hundreds of clinics in the UK that use CAAS, among other anti-obesity drugs, under ‘Specials License’. ‘Specials’ are unlicensed medicines for human use which have been specially manufactured or imported for the treatment of an individual patient after being ordered by a: • doctor • dentist • nurse prescriber • pharmacist independent prescriber • supplementary prescriber By law, private clinics who prescribe CAAS must be registered with the Healthcare Commission. Patients should be aware of any ‘Specials’ or ‘off licence’ use of their prescribed medication, be given full explanation of risks and benefits and sign a consent form. Failure to do so contravenes the General Medical Council’s (GMC) ‘Good Practice in Prescribing Medicines’.18 Phentermine • Phentermine is an amphetamine analogue that enhances satiety by increasing hypothalamic noradrenaline (norepinephrine) levels.

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015

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Pharmacokinetic data Bioavailability

Peak plasma levels occur within 1 to 4.5 hours Absorption is usually complete by 4 to 6 hours

Protein binding

Approximately 96.3%

Metabolism

Hepatic

Half life

16 to 31 hours

Excretion

Urinary elimination

• Phentermine first received approval from the FDA in 1959 as an appetite-suppressing drug. • Phentermine Hydrochloride then became available in the early 1970s. • Phentermine is an appetite suppressant. It can help reduce weight in obese patients when used short-term and combined with exercise, diet and behavioural modification. • Fen-Phen (a combination of Fenfluramine and Phentermine) was withdrawn from the market in 1997 after 24 cases of heart valve disease were attributed to the Fenfluramine component of FenPhen. There has been no strong evidence that Phentermine is also associated with cardiovascular or valvular disease.19 • Phentermine is available on prescription in most countries including the US and UK (off licence). • It is a sympathomimetic amine and works by stimulating the release of norepinephrine.20 In a very small minority of cases increments of more than 20mmHg in systolic or diastolic BP and more than 20 beats/min in pulse rate may be shown. Therefore regular monitoring of BP and heart rate is strongly advised – every two weeks for the first four months and then monthly thereafter. If large rises in BP and/or pulse rate are observed then CAAS should be discontinued. • Phentermine appears to be well-tolerated, producing mild side effects consistent with catecholamine-releasing properties through sympathomimetic pathways.21 Amfepramone • Amfepramone is commonly known as Diethylpropion in the UK. • Amfepramone is a sympathomimetic amine. • Is a stimulant drug of the phenethylamine, amphetamine, and cathinone chemical classes that is used as an appetite suppressant.22 • Is a selective norepinephrine-releasing agent (NRAs). • Is believed to have relatively low habituation potential.23 • Delivered as a regular and extended-release (long-acting) tablet. Diethylpropion is usually taken three times a day, one hour before meals (regular tablets, 25mg), or once a day in mid-morning (extended-release tablets, 75mg). Sibutramine (Reductil) • Sibutramine is an inhibitor of the reuptake of serotonin and noradrenaline. • Originally developed by Boots as an antidepressant, Sibutramine was sold as an anti-obesity drug to Knoll and then Abbott (Reductil). • An interim analysis of the SCOUT (Sibutramine Cardiovascular Outcome Trial) study found that the drug increased morbidity from cardiovascular disease.24 • SCOUT does not clarify whether the increased risk was caused by the specific properties of Sibutramine or by the modest degree of weight loss achieved.

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• The European Medicines Agency (EMA) decided in 2010 that Sibutramine must follow the example of Rimonabant (a cannabinoid receptor antagonist used as an adjunct in metabolic syndrome), which was withdrawn in 2008 because of safety concerns including severe depression and suicidal thoughts.2.5 • On 21 January 2010, the Medicines and Healthcare products Regulatory Agency (MHRA) announced the suspension of the marketing authorisation for Sibutramine (Reductil). Topiramate • Topiramate is approved for epilepsy and migraine prophylaxis. • Putatively reduces weight by decreasing food intake, decreasing lipogenesis, increasing thermogenesis, improving insulin sensitivity and increasing secretion of adiponectin.26 Lorcaserin • On 27 June 2012, the FDA approved lorcaserin as an adjunct to a reduced-calorie diet and exercise for chronic weight management with initial BMI ≥30 kg/m² (obese) or ≥27 kg/m² (overweight), with one weight-related comorbid condition (e.g. hypertension, dyslipidemia, type 2 diabetes mellitus). • Lorcaserin is a selective agonist of serotonin (5-hydroxytryptamine or 5-HT) 2c receptors. • It stimulates proopiomelanocortin (POMC), producing neurones in the hypothalamus, resulting in generation of α-melanocortin stimulating hormone which acts on melanocortin receptors to decrease food intake and enhance satiety.27 • Lorcaserin is metabolised in the liver to multiple inactive metabolites that are renally excreted. • Lorcaserin appears to be well tolerated in patients and the most common adverse events reported did not include serious complications. Common adverse effects include headache (18%), upper respiratory tract infection (15%), dizziness (8%), nausea (8%), constipation (7%), dry mouth (5%).28 • Lorcaserin has not been associated with depression or suicidal ideation. • The potential for recreational use is low.29 • The safety and efficacy of lorcaserin (10 mg twice daily) for ≥ 52 weeks has been evaluated in three separate Phase 3 trials. Lorcaserin demonstrated a satisfactory safety profile according to FDA criteria but patient outcomes in the trials failed to achieve the FDA mean benchmark of patient weight loss.30 Data examining the effect of CAAS on death and cardiovascular events is not currently available and is needed before the benefits of these drugs can be fairly assessed. Drugs with conflicting evidence Growth hormone It is believed that Growth Hormone (GH) secretion is markedly blunted in obesity.31 The role of GH in obesity is complex and somewhat controversial. Although primary GH deficiency leads to centripetal adiposity, visceral obesity per se also results in a secondary reduction in serum GH concentrations. The GH response to pharmacological (growth hormone releasing hormone, L-Dopa) and physiological stimuli, such as sleep, physical exercise, insulin-induced hypoglycaemia and corticosteroids, is impaired in obesity.31 Some of the theories on the cause of altered GH physiology in obesity involve the increased concentrations of leptin, insulin, free fatty acids (FFAs) and IGF-1.32 Recent evidence suggests that leptin, the product of adipocyte specific ob gene, exerts a stimulating effect on GH release in rodents;

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should the same hold be true in humans, the coexistence of high leptin and low GH serum levels in human obesity would fit in well with the concept of a leptin resistance.33 Concerning the influence of metabolic and nutritional factors, an impaired somatotropin response to hypoglycaemia and a failure of glucose load to inhibit spontaneous and stimulated GH release are well documented in obese patients; furthermore, drugs able to block lipolysis and, thus lowering serumfree fatty acids (NEFA), significantly improve somatotropin secretion in obesity. Caloric restriction and weight loss are followed by the restoration of a normal spontaneous and stimulated GH release. On the whole, hypothalamic, pituitary and peripheral factors appear to be involved in the GH hyposecretion of obesity. Treatment with biosynthetic GH has been shown to improve the body composition and the metabolic efficacy of lean body mass in obese patients undergoing therapeutic caloric restriction.32 According to Scacchi M et al, GH and conceivably growth hormone releasing peptides (GHRPs) might therefore have a place in the therapy of obesity.34 However, the bulk of studies indicate little or no beneficial effects of GH treatment of obesity, despite the low serum GH concentrations associated with obesity. Leptin Leptin, primarily produced in the adipocytes, acts on receptors in the hypothalamus where it inhibits appetite by counteracting the effects of neuropeptide Y and anandamide and promoting the synthesis of α-MSH (Melanocyte-Stimulating Hormone). The initial studies of leptin in obese humans suggest that absolute leptin deficiency is an extremely rare cause of obesity.35 Although leptin is a circulating appetite suppressing protein hormone, obese people have unusually high leptin concentrations – said to be resistant to leptin.36 Plasma leptin levels are elevated in obese patients, and correlate with their increased fat mass. Messenger RNA levels for leptin are increased in their adipose cells and also correlate with fat mass. Human obesity is likely to result from defects in the leptin receptor, in generation of its second messenger or effector mechanism within the leptin target cells or in other effector cells further downstream. Studies are currently underway to determine whether or not partial resistance to leptin can be overcome by sufficient exogenous leptin therapy. Surgery Bariatric surgery was first developed 50 years ago. However, in the past 20 years, a dramatic increase in the prevalence of severe obesity combined with improvements in the efficacy and safety of bariatric surgical techniques has led to a 20-fold increase in the numbers of procedures performed annually worldwide.37 Bariatric surgery has increased exponentially in UK over the past eight years with more than 10,000 bariatric surgical procedures performed in 2012.38 In the UK, surgery is considered for people with severe obesity if:39 • They have a BMI of 40kg/m2 or more, or 35kg/m2 < BMI < 40kg/m2 and other significant disease (e.g. type II diabetes, hypertension) that could be improved if they lost weight. • All appropriate non-surgical measures have failed to achieve or maintain adequate clinically beneficial weight loss for at least six months. • They are receiving or will receive intensive specialist management. • They are generally fit for anaesthesia and surgery. • They commit to the need for long-term follow-up. Surgery is considered as a first-line option for adults with a BMI of more than 50kg/m2 in whom surgical intervention is considered appropriate. Orlistat and/or CAAS (off label) can be prescribed before surgery if the waiting time is long.

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Types of bariatric procedures The first bariatric procedure in wide use, performed from the 1950s through to the 1970s, was known as the jejunoileal bypass, and it involved an intestinal bypass in which the proximal jejunum was bypassed into the distal ileum. This resulted in extreme weight loss by way of profound malabsorption and was eventually abandoned some years later after many people developed severe proteinenergy malnutrition.40 The next major bariatric procedures to be introduced were the horizontal gastroplasty and the vertical banded gastroplasty, which were thought to be purely restrictive procedures made possible through the development of surgical stapling devices. Both procedures have now been abandoned because stoma tended to enlarge, leading to weight regain.38 The gastric bypass was originally introduced in 1969 by Mason and Ito,41 and it was later modified into a Roux-en-Y gastric bypass configuration for drainage of the proximal gastric pouch to avoid bile reflux. The next major procedure to be introduced was the adjustable form of gastric banding.42 The adjustable gastric band is a silicone belt with an inflatable balloon in the lining that is buckled into a closed ring around the upper stomach. A reservoir port is placed under the skin for adjustments to the stoma size. Two procedures that use a more extreme intestinal bypass, along with some modest gastric reduction, are the biliopancreatic diversion and the biliopancreatic diversion with duodenal switch operations, which are often used for severely obese patients (BMI ≥ 50). Biliopancreatic diversion combines a subtotal distal gastrectomy and a very long Roux-en-Y anastomosis with a short common intestinal channel for nutrient absorption. Biliopancreatic diversion with duodenal switch combines a 70% greater curve gastrectomy with a long intestinal bypass, where the duodenal stump is defunctionalised or ‘switched’ to a gastroileal anastomosis. The most recent major bariatric procedure to be introduced is the vertical sleeve gastrectomy, and its popularity is rapidly increasing.43 This technique consists of a 70% vertical gastric resection, which creates a long and narrow tubular gastric reservoir with no intestinal bypass component.4 For patients who are severely obese (BMI ≥ 38 kg/m2 for women, ≥ 34 for men) surgery remains more effective than a non-surgical approach in the longer term (measured up to 10 years after surgery).45 However, bariatric surgery is not without risks. Despite the lower mortality rate associated with newer laparoscopic techniques, the perioperative mortality for the average patient varies across subgroups, ranging from 0.3% to 2% or even higher in some patient populations.46 A prognostic risk score for bariatric surgery includes:46 • • • • •

BMI 50 or greater Male sex Hypertension Known risk factor for PE Aged 45 years or more

Patients with four to five of these characteristics are at higher risk of death (4.3%) during the first 90 days postoperatively. In addition, evidence indicates that vitamin and mineral deficiencies, including deficiencies of calcium, vitamin D, iron, zinc and copper, are common after bariatric surgery.48 Interestingly, some observational studies suggest that some bariatric procedures introduce a greater long-term risk of substance misuse disorders, suicide and increased alcohol consumption.49 For instance, pharmacokinetic studies indicate

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that the gastrointestinal anatomy after Roux-en-Y gastric bypass and vertical sleeve gastrectomy leads to more rapid absorption of alcohol. This may inadvertently increase the frequency of physiological binges and subsequent alcohol misuse disorder.50 Conclusions Obesity is a chronic disease and a risk factor for many other medical conditions, affecting health and longevity. It is a hugely complex condition, and environmental factors such as automation and change in working conditions has meant that calorie output has reduced significantly over the past decades. Combined with the increased availability of cheap food and disposable income, obesity rates continue to increase. Prevention is the best public health strategy, and continued work in communicating the benefits of a healthy lifestyle is crucial for this. Doctors involved in the management of overweight and obese patients must be familiar with NICE protocols and all modalities available in order to be able to guide patients in the right direction, to ensure optimal long-term results and to minimise potential complications. Modest weight loss is achievable and undoubtedly provides health benefits.1 The major challenge, though, is to improve patients’ ability to maintain whatever weight loss that has been achieved. In order to be successful, anti-obesity treatments need to reflect the individual’s needs since methods of weight loss not only contain physical elements, but also strong psychological and emotional motivational factors. Unfortunately, clinical logic is not always REFERENCES 1. Goldstein D., ‘Beneficial effects of modest weight loss’, International Journal of Obesity, 16 (1992), pp. 397-415. 2. Foutsizoglou, S., ‘Managing Obesity: An Introduction’, Aesthetics, 3 (2015), pp. 27-33. 3. National Institute for Health and Care Excellence, Obesity: Guidance on the prevention of overweight and obesity in adults and children (nice.org.uk, 2006) < https://www.nice.org.uk/ guidance/cg43> 4. Goodman-Gruen D, Barrett-Connor E., ‘Sex differences in measures of body fat and body distribution in the elderly’, Am J Epidemiol, 143 (9) (1996), pp. 898-906. 5. McKeigue PM, Shah B, Marmot MG., ‘Relation of central obesity and insulin resistance with high diabetes prevalence and cardiovascular risk in South Asians’, Lancet 337(1991), pp. 382-386. 6. Myers, J., ‘Cardiology patient pages. Exercise and cardiovascular health’, Circulation, 107(1) (2003), e2-5. 7. Flint E et al, ‘Associations between active commuting, body fat, and body mass index: population based, cross sectional study in the United Kingdom’, BMJ, 349 (2014) p.10. 8. Nick Cavill, Louisa Ells, Treating adult obesity through lifestyle change interventions. A briefing paper for commissioners (National Obesity Observatory, www.noo.org.uk, 2010)< http://www. noo.org.uk/uploads/doc/vid_5189_Adult_weight_management_Final_220210.pdf> 9. Connolly HM, et al., ‘Valvular heart disease associated with fenfluramine-phentermine’, N Engl J Med, 337 (1997), pp. 581-8. 10. Rueda-Clausen CF and Padwal RS., ‘Pharmacotherapy for weight loss’, BMJ 348 (2014), g3526. 11. Wolfe SM., ‘When EMA and FDA decisions conflict: differences in patients or in regulation?’, BMJ, 347 (2013), f5140. 12. British Medical Association and Royal Pharmaceutical Society of Great Britain, British National Formulary No. 40, (London: British Medical Association and the Royal Pharmaceutical Society of Great Britain, 2000) 13. European Agency for the Evaluation of Medicinal Products, Committee for proprietary medicinal products European Public Assessment Report (EPAR): xenical (London: EMEA, 1998), pp. 1-39. 14. National Institute for Health and Care Excellence, Evidence search: Methylcellulose (evidence. nhs.uk)<www.evidence.nhs.uk/search?q=methylcellulose> 15. Preuss, H. G., Echard, B., Perricone, N. V., Bagchi, D., Yasmin, T., Stohs, S. J., ‘Comparing metabolic effects of six different commercial trivalent chromium compounds’, Journal of Inorganic Biochemistry, 102 (11) (2008), pp. 1986–1990. 16. Chaudhary S, Pinkston J, Rabile MM, Van Horn JD, ‘Unusual reactivity in a commercial chromium supplement compared to baseline DNA cleavage with synthetic chromium complexes’, Journal of Inorganic Biochemistry 3 (2005) p. 787-794. 17. Advisory Bodies, Statement on the mutagenicity of trivalent chromium and chromium picolinate, (COM/04/S3, 2004) <http://www.advisorybodies.doh.gov.uk/Com/chromium.htm> 18. General Medical Council, Good Practice in Prescribing Medicines, (2006)<www.gmc-uk.org/ Good_Practice_in_Prescribing_Medicines.pdf_25416575.pdf> 19. Bang WD, et al., ‘Pulmonary Hypertension associated with the use of Phentermine’, Yonsei Med J, 56(6) (2010), pp. 971-73. 20. Nelson DL, Gehlert DR, ‘Central nervous system biogenic amine targets for control of appetite and energy expenditure’ Endocrine Feb, 29 (2006) p.49-60. 21. World Public Library, Phentermine (netlibrary.net)<http://netlibrary.net/articles/Phentermine> 22. Richards D and Aronson J, ‘Oxford Handbook of Practical Drug Therapy’, Oxford University Press, (2006). 23. Caplan, J., ‘Habituation to Diethylpropion (Tenuate)’, Canadian Medical Association Journal, 88 (1963), pp. 943–944. 24. Caterson ID et al., ‘Maintained intentional weight loss reduces cardiovascular outcomes: results from the Sibutramine Cardiovascular OUTcomes (SCOUT) trial’, Diabetes, Obesity and Metabolism, 14 (6) (2012), pp. 523–530. 25. Williams G, ‘Withdrawal of Sibutramine in Europe: Another sign that there is no magic bullet to treat obesity’, BMJ, 340 (2010).

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applied in the consideration of obesity — health professionals commonly recommend the same lifestyle-based interventions to those with overweight or mild obesity as to those with more severe problems. I am of the belief that obesity should be treated in a much more protocol-driven manner. On the topic of obesity, my colleague and aesthetic doctor Dr Richard Brighton-Knight said that if we were looking at cancer interventions we would be using studies; entering everyone into follow-up studies and adapting protocols to improve results. The way obesity is currently treated is haphazard, without enough long-term population studies. Within the NHS, the focus is too much on bariatric surgery and not enough on non-surgical interventions. Non-surgical interventions can produce successful changes without the need for surgery, but they do require support from practitioners and crucially, motivation from the patient’s part. I strongly believe that the NHS should be running non-surgical programmes with standardised protocols that are monitored and reviewed; these can then link into surgical options when needed. The focus of treatment needs to be longterm weight loss, which often requires a change to eating habits and increased activity levels. Dr Sotirios Foutsizoglou specialises in minor cosmetic surgery and aesthetic medicine. He is the founder and medical director of SFMedica, based on Harley Street in London. In addition to his MBBS he also holds a BSc(Hons) in mathematics from the University of Athens and a MSc in Biostatistics and Epidemiology from the Harvard School of Public Health. 26. Verrotti A et al, ‘Topiramate-induced weight loss: a review’, Epilep Res 95 (2011), p.189-99. 27. Bays HE, ‘Lorcaserin: drug profile and illustrative model of the regulatory challenges of weigh loss drug development’, Expert Rev Cardiovasc Ther, 9 (2011) 9 p.265-67. 28. Kim GW et al., ‘Anti-Obesity Pharmacotherapy: New Drugs and Emerging Targets’, Clin Pharmacol Ther, 95(1) (2014), pp. 53-56. 29. Smith SR, Weissman NJ, Anderson CM, et al., ‘Multicentre, placebo-controlled trial of lorcaserin for weight management’, N Engl J Med 363 (2010), pp. 245-56. 30. Hess R, Cross LB, ‘The safety and efficacy of lorcaserin in the management of obesity’, Postgrad Med, 125 (6) (2013), pp. 62-72 31. Scacchi M, Pincelli AI, Cavagnini F., ‘Growth hormone in obesity’, Int J Obes Relat Metab Disord, 23 (3) (1999), pp. 260-71. 32. Shadid S and Jenssen MD, ‘Effects of Growth Hormone Administration in Human Obesity’, Obesity Research, 11 (2) (2003), pp. 170–175. 33. Münzer, T, Harman, SM, Hees P, et al, ‘Effects of GH and/or sex steroid administration on abdominal subcutaneous and visceral fat in healthy aged women and men’, J Clin Endocrinol Metab, 86 (2001), p.3604-3610. 34. Scacchi M, Pincelli A I and Cavagnini F, ‘Growth hormone in obesity’, International Journal of Obesity, 23 (1999) p.260-271. 35. Jeffrey M. Friedman, Jeffrey L. Halaas, ‘Leptin and the regulation of body weight in mammals’, Nature 395 (1998), pp. 763-770. 36. Bisht S., ‘Leptin hormone: it’s association with obesity: a review’, International Journal of Drug Formulation & Research, 1 (1) 2010, pp. 204-220. 37. Buchwald H, Oien DM., ‘Metabolic/bariatric surgery worldwide 2008’, Obes Surg 19 (2009), pp. 1605-11. 38. Arterburn D and Courcoulas A, ‘Bariatric surgery for obesity and metabolic conditions in adults’, BMJ, 349 (2014) p.28-32. 39. National Institute for Health and Care Excellence, Obesity: identification, assessment and management of overweight and obesity in children, young people and adults, (www.nice.org. uk, 2014) 40. Balsiger BM, Murr MM, Poggio JL, Sarr MG., ‘Bariatric surgery. Surgery for weight control in patients with morbid obesity’, Med Clin N Am, 84 (2000), pp. 477- 89. 41. Mason EE, Ito C., ‘Gastric bypass’, Ann Surg, 170 (1969), pp. 329-39. 42. Favretti F, Cadiere GB, Segato G, Himpens J, De Luca M, Busetto L, et al. ‘Laparoscopic banding: selection and technique in 830 patients’, Obes Surg 12 (2002), pp. 385-90. 43. Nguyen NT, Nguyen B, Gebhart A, Hohmann S., ‘Changes in the makeup of bariatric surgery: a national increase in use of laparoscopic sleeve gastrectomy’, J Am Coll Surg 216 (2013), pp. 252-7. 44. Welbourn R et al., National Bariatric Surgery Registry: first registry report to March 2010. (Dendrite Clinical Systems: www.e-dendrite.com, 2011)<www.e-dendrite.com/files/13/file/ Pages%20from%20NBSR%202010.pdf> 45. Gloy VL, Briel M, Bhatt DL, Kashyap SR, Schauer PR, Mingrone G, et al. ‘Bariatric surgery versus non-surgical treatment for obesity: a systematic review and meta-analysis of randomised controlled trials’, BMJ 347 (2013), f5934. 46. Buchwald H, Estok R, Fahrbach K, Banel D, Sledge I. ‘Trends in mortality in bariatric surgery: a systematic review and meta-analysis’, Surgery 142 (2007), pp. 621-32. 47. Anterburn DE and Courcoulas AP., ‘Bariatric Surgery for Obesity and Metabolic Conditions in Adults’, BMJ 349 (2014), g3961. 48. Gletsu-Miller N, Wright BN, ‘Mineral malnutrition following bariatric surgery’, Adv Nutr, 4 (2013) p.506-17. 49. Svensson PA, Anveden A, Romeo S, Peltonen M, Ahlin S, Burza MA, et al, ‘Alcohol consumption and alcohol problems after bariatric surgery in the Swedish Obese Subjects study’, Obesity (Silver Spring) 21 (2013) p.2444-5. 50. Maluenda F, Csendes A, De Aretxabala X, Poniachik J, Salvo K, Delgado I, et al. ‘Alcohol absorption modification after a laparoscopic sleeve gastrectomy due to obesity’, Obes Surg 20 (2010), pp. 744-8.

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The role of topical and oral antioxidants Surgeon Ms Rozina Ali and nutritional therapist Eva Escofet explore the benefits of topical and oral antioxidants in treating the signs of ageing INTRODUCTION The doctor-patient relationship is the keystone of any therapeutic interaction, and I am a great believer in patient engagement and responsibility. This makes for a more rewarding outcome for the patient, as they know just how much they have contributed to their own Ms Rozina Ali wellbeing. The true ‘transformation’ of aesthetic surgery is not just a passive change in appearance, but is in fact the end result of a process of reflection, consultation, absorption of information and what we hope is a commencement of a therapeutic doctor/patient partnership, all of which takes places in order for the patient to arrive at their ‘best self’. As a matter of course, I discuss skincare with all facial aesthetics patients that I see, regardless of the treatment, and my two therapeutic mainstays are corrective (antioxidants to neutralise free-radical damage) and protective (the use of adequate physical or chemical sun protection). Every consultation includes a medications and social history – but the best aesthetic consultations also include the documenting of a lifestyle and nutrition history. The patient’s diet, exercise regimen and overthe-counter (OTC) supplements are important components

BACKGROUND An antioxidant is any substance that delays, prevents or removes oxidative damage to a target molecule.3 Oxidation reactions produce free radicals that can start multiple chain reactions that eventually can cause damage Eva Escofet or death to the cell. Therefore, due to their action of inhibiting free radicals, antioxidants are crucial towards the prevention of ageing and disease.4 Oral antioxidants Oral antioxidants can come in the form of dietary supplements or natural food substances. Although dietary supplements are not designed to replace a healthy balanced diet, the Food and Drugs Administration (FDA) explains that supplements help to ensure that users get an adequate dietary intake of essential nutrients, such as antioxidants.3 Although a healthy diet often provides a source of vitamins and minerals, taking dietary supplements on top is, largely, essential in ensuring your body receives all the nutrients it needs each day. With a consistent decline in nutrients within food production over the past 70 years,4,5 combined with age-related decline in digestive enzymes6,7 and also a reduction in probiotic

of their overall wellbeing, as are their recreational and relaxation methods. Oral antioxidants are an essential component of a patient’s therapeutic regimen. Today’s busy lifestyles don’t always allow for fresh organic green vegetables or a wholly raw food diet, so I hunt tirelessly for the pills or solutions that provide the richest possible source of absorbable, active nutrients. I recommend all kinds of age or hormone-appropriate supplements and am always keen to try the latest active ingredients. Oral antioxidants exert a generalised benefit, usually slow, steady and subtle, but undoubtedly profound. Crucially, they allow for uncomplicated, rapid and strong wound healing.1 Topical antioxidants are much more localised and specific, making them feel more like part of the treatment. They rely on patient compliance as, after all, no cream provides benefit if it stays in its tube. I strongly encourage topical antioxidants with any facial procedure, whether surgical or non-surgical, invasive or non-invasive, since, in my opinion, it allows for better results. Tauter, tighter skin and a healthy glow2 can be felt and seen by patients and others alike. The stability, ingredients, consistency, smell and cost of the products all have an effect on how easy they are to use and, hence, their overall effectiveness.

gut microorganisms, absorption rates of nutrients post 40 years of age onwards are certainly compromised.8,9,10 Plus, with adding everyday stress into the equation, which further reduces digestive function and absorption,11 the need for dietary supplementation for all nutrients, especially antioxidants, is crucial. Whilst there are several assays currently used to assess in vitro antioxidant activity, the following two are most common. The first is the oxygen radical absorbance capacity (ORAC) assay, which measures the decrease in fluorescence decay caused by antioxidants. The second is the total oxyradical scavenging capacity (TOSC) assay, which measures the decrease in ethylene gas production, caused by the inhibition of the thermal hydrolysis of ABAP (2,2-Azobis [2-methylpropionamidine] dihydrochloride) by KMBA (alphaketo-gamma-methiolbutyric acid) in the presence of antioxidant compounds.12 There are various oral antioxidants with beneficial anti-ageing properties. For the purpose of this article, however, we will review those especially effective for dermal anti-ageing. L-Ascorbic Acid L-ascorbic acid is a water-soluble antioxidant that the body is unable to synthesize, therefore ingestion through supplements and diet is essential.13 As an antioxidant, it scavenges free radicals and

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reactive oxygen molecules, which are produced during metabolic pathways of detoxification. It also prevents formation of carcinogens from precursor compounds.14 Ascorbic acid (above other forms of vitamin C, such as ascorbates) has been shown to increase collagen synthesis in cultured skin fibroblasts by approximately eight-fold.15 It is also an essential cofactor for lysyl hydroxylase and prolyl hydroxylase, the enzymes needed for collagen biosynthesis.16 Supplementation doses of 250mg have been shown to be sufficient and effective.17

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chelate redox-active transition metals, regulate the detoxification of heavy metals and modulate various signal transduction pathways in physiological and pathological conditions.29 ALA has a high TOSC value of 3,380 µmol of trolox equivalents per mg, but a relatively low ORAC figure of 23,200 µmol of trolox equivalents per mg. ALA research on human dermal fibroblasts in vitro in cell-culture systems shows that ALA helps to prevent cellular damage via its antioxidant properties. It can protect fibroblasts, thus helping to slow down the ageing process in the dermis, whilst stimulating repair.30

Grape Seed Extract (GSE) GSE is known as a powerful antioxidant that protects the body from premature ageing, disease and decay. Grape seeds contain mainly phenols such as proanthocyanidins. Studies have shown that oral administration of GSE lowers reactive oxygen species (ROS) generation and plasma protein carbonyl groups, while enhancing the activity of the endogenous antioxidant systems.18,19,20,21 GSE has an impressive ORAC figure of approximately 63,000 µmol of trolox equivalents per mg, and also a high TOSC value of 3,200 µmol of trolox equivalents per mg. Research suggests that GSE is beneficial in many areas of skin health because of its antioxidant ability to bond with collagen, promoting youthful skin, cell health, elasticity and flexibility. Other studies have also shown that GSE helps to protect the skin from sun damage.22

Topical antioxidants It has long been understood that the skin is able to produce antioxidants. As we age, however, not only does the skin’s ability to synthesise antioxidants (such as ascorbic acid glutathione, alpha-tocopherol and superoxide dismutase) decrease, but our susceptibility to reactive oxygen species (ROS) increases.31 In 2001 Dreher stated, “Regular application of skin care products containing antioxidants may be of the utmost benefit in efficiently protecting our skin against exogenous oxidative stressors occurring during daily life. Furthermore, sunscreening agents may also benefit from combination with antioxidants resulting in increased safety and efficacy of such photoprotective products.”32 A study also showed topical application of antioxidants reduced UVA-induced dermatoses, and an increased exposure to UVA is required to induce hyperpigmentation in skin exposed to topical antioxidants.32 Green Tea Simply placing an ingredient with antioxidant capacity on to the skin Green tea polyphenols (mainly catechins) have been shown to have will not necessarily protect against ROS. Antioxidants need to be cancer preventative effects in vivo.23,24 Catechins scavenge ROS by absorbed into the skin in their active form and remain stable for long generating more stable phenolic radicals. The ORAC assay scores enough to achieve the intended antioxidant functionality. Oxidation green tea as providing an extremely high figure of approximately could be described as a flaw in topical antioxidant therapy; for 120,000 µmol of trolox equivalents per mg of dried tea leaves.25 It example vitamin C is susceptible to damage from exposure to also has a high TOSC value of 3,780 µmol of trolox equivalents per light and oxygen. This has led to a search for intelligent delivery mg. Green tea has more than five times the amount of catechins mechanisms and packaging solutions, such as airtight metallicised as black tea.26 Oral green tea catechins are shown to protect skin containers.33 Topical antioxidants can be divided into two main against harmful UV radiation, improve overall skin quality and boost categories – water soluble (eg. glutathione, silymarin, vitamin C, oxygen flow to the skin.27 resveratrol, grape seed extract) and fat soluble (eg. curcumin, coenzyme Q10, idebenone). A few antixoidant ingredients are both Alpha Lipoic Acid (ALA) water and lipid souble, such as alpha lipoic acid.34 ALA is an organosulfur compound derived from octanoic acid, Many other additional ingredients used in anti-ageing skincare essential for aerobic metabolism in the body. Naturally occurring have dual or multiple actions. For example, polyhydroxy acids lipoic acid is always covalently bound and not readily available (PHAs) and bionic PHAs are recognised as powerful antioxidants. from dietary sources, and is also only present in very low doses Gluconolactone, a PHA, has been shown to inhibit elastin promoter within dietary foods.28 Dietary or drug supplementation is therefore gene by 50%, decreasing solar elastosis by reducing the over necessary for therapeutic doses. Both in vivo and in vitro studies production of elastin.35 The Bioinc PHAs lactobionic acid and demonstrate that ALA exhibits the ability to scavenge free radicals, maltobionic acid have both shown powerful metal chelating capacity. Lactobionic acid has been used VERBASCOSIDE for many years as a component of organRosmarinic Acid preserving solutions, limiting reperfusion injury Quercetin in isolated ischaeimc organs.36 Maltobionic acid is also a powerful metal chelator, directly Ascorbic Acid reducing damage from free radicals.37 Rutin Maltobionic acid has also been shown to Alpha-tocopherol reduce the production of malondialdehyde and Trolox therefore reduce oxidative damage to lipids in Resveratrol the cell membrane and the mitochondria.38 An alpha hydroxyacid, citric acid is synergistic to 0 0,5 1 1,5 2 2,5 3 3,5 TEAC Value (mM) the known antioxidant vitamin E. It enhances Figure 1: Relative Trolamine Equivalent Absorbance Capacity of selected potential antioxidants vitamin E’s antioxidant action towards radiation-

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induced peroxidation and, as well as being an antioxidant in its own right, it inhibits lipid peroxidation and scavenges superoxide anion free radicals, which can form peroxynitrite – a known detrimental oxidant.39,40,41 Resveratrol and verbascocide are both curently attracting attention for their potent antioxidant effects. Verbascoside, a phenylpropanoid glycoside is a natural plant agent, usually derived from phytostem lilac leaf cell culture or buddleia davidii meristematic

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cells, with known antioxidant, anti-inflammatory and photoprotective actions.42 In comparison, using the trolamine equivalent absorbance capacity (TEAC) scale, verbascocide showed strong antioxidant activity in comparison to ascorbic acid, alpha tocopherol and resveratrol; verbascocide induces a dose dependent decrease of expression of pro-inflammatory chemokines on human keratinocytes, as demonstrated in Figure 1.43

CONCLUSION The effective use of oral antioxidants requires a lifestyle shift; it takes discipline and thought on the patient’s part. Using topical antioxidants can be a very enjoyable and constructive ritual every morning and night. In reality, each patient has to decide which regimen matches their personality, lifestyle or budget and is suitable to their everyday commitments. I advise all my patients that the maintenance and often even enhancemment of the results of any plastic surgery treatments requires their input. The plethora of data available regarding the effectiveness of key antioxidant ingredients Ms Rozina Ali in both skincare ingredients and supplements is indisputable. It is heartening to learn of the objective, scientific, biopsyproven benefits of these various ingredients, as well as the clinical synergies within products. The current trend towards layering various products to effect the best outcome is proven in our own clinics. My erstwhile refrain of ‘yes, but, does it work’ has been answered with a resounding yes, so I strongly believe we should all be including both oral and topical antioxidants in our treatment recommendations for our aesthetic patients, to ensure the best possible outcome of any procedures we recommend. Ms Rozina Ali is a highly trained and experienced consultant reconstructive and aesthetic surgeon with an interest in facial aesthetic surgery. REFERENCES: 1. Blass SC, Goost H, Tolba RH, Stoffel-Wagner B, Kabir K, Burger C, Stehle P, Ellinger S. ’Time to wound closure in trauma patients with disorders in wound healing is shortened by supplements containing antioxidant micronutrients and glutamine: a PRCT, Clinical Nutrition 31(4)(2012) p.469-75 2. Dreher F, Maibach H, ‘Protective effects of topical antioxidants in humans’, Curr Probl Dermatol, 29 (2001) p.157-64. 3. B Halliwell and JMC Gutteridge, ‘The Definition and Measurement of Antioxidants in Biological Systems’, Free Radical Biology and Medicine, Vol. 18, No. 1 (1995), p.125-126. 4. B Halliwell, ‘Biochemistry of Oxidative Stress’, Biochemical Society Transactions, Vol. 35, No. 5 (2007), p.1147-1150. 5. Food and Drugs Administration. Dietary Supplements: What You Need to Know (USA: Food and Drugs Administration, 2014) Available at: <http://www.fda.gov/Food/ResourcesForYou/Consumers/ ucm109760.htm> [Accessed 17 March 2015] 6. Mayer, AM, ‘Historical changes in the mineral content of fruits and vegetables: a cause for concern?’ in Agriculture Production and Nutrition: Proc, (USA: Tufts University, 1997). p 69-77 7. Long, C, ‘Is chemical farming making our food less nutritious?’ Org Gardening (1999) p.12. 8. Laugier R, Bernard JP, Berthezene P, Dupuy P, ‘Changes in pancreatic exocrine secretion with age: pancreatic exocrine secretion does decrease in the elderly’, Digestion, 50(3-4) (1991), p.202-11. 9. Morley JE, ‘The aging gut: physiology’, Clin Geriatr Med,;23(4) (2007), p.757-7. 10. Hurwitz A, Brady DA, Schaal SE, et al., ‘Gastric acidity in older adults’, JAMA, 27;278 (8) (2007), p.659-62. 11. Guslandi M, Pellegrini A, Sorghi M, ‘Gastric mucosal defences in the elderly’, Gerontology, 45 (4) (1999), p.206-8. 12. Pirlich M, Lochs H, ‘Nutrition in the elderly’, Best Pract Res Clin Gastroenterol, 15(6) (2001), p.869-84. 13. Konturek PC, Brzozowski T, Konturek SJ, ‘Stress and the Gut: Pathophysiology, Clinical consequences, diagnostic approach and treatment options’, Journal of Physiology & Pharm, 62, 6, (2011), p.591-599. 14. Garrett AR, Murray BK, Robison RA, O’Neill KL, ‘Measuring antioxidant capacity using the ORAC and TOSC assays’, Methods Mol Biol, 594 (2010), p.251-62. 15. Jialal I, Grundy SM, ‘Preservation of the endogenous antioxidants in low density lipoprotein by ascorbate but not probucol during oxidative modification’,Journal of Cl. Invest, 87 (2) (1991), p.597. 16. Block G, Menkes M, ‘Ascorbic Acid in cancer prevention, Nutrition and cancer Prevention, T.Moon eds, (1998). 17. S Murad, D Grove, K A Lindberg, G Reynolds, A Sivarajah and S R Pinnell, ‘Regulation of collagen synthesis by ascorbic acid’, Proc Natl Acad Sci, 78(5) (1978), p.2879-2882. 18. Pinnell SR, ‘Regulation of collagen biosynthesis by ascorbic acid: a review’, Yale J Biol Med, 58(6) (1985), p.553-9. 19. Woollard KJ, Loryman CJ, Meredith E, et al., ‘Effects of oral vitamin C on monocyte: endothelial cell adhesion in healthy subjects’, Biochem Biophys Res Commun, 294(5) (2002), p.1161-8. 20. M Balu, P Sangeetha, G Murali, and C Panneerselvam, ‘Age-related oxidative protein damages in central nervous system of rats: modulatory role of grape seed extract’, International Journal of Developmental Neuroscience, 23, (6) (2005), p.501–507. 21. M Balu, P Sangeetha, D Haripriya, and C Panneerselvam, ‘Rejuvenation of antioxidant system in central nervous system of aged rats by grape seed extract’, Neuroscience Letters, 383, (3) (2005), p.295–300. 22. A Devi, AB Jolitha, and N Ishii, ‘Grape seed proanthocyanidin extract (GSPE) and antioxidant defense in the brain of adult rats’, Medical Science Monitor, 12 (4) (2006). p.124-129. 23. Busserolles, E Gueux, B Balasińska et al., ‘In vivo antioxidant activity of procyanidin-rich extracts from grape seed and pine (Pinus maritima) bark in rats’, International Journal for Vitamin and Nutrition Research, 76, (1), (2006) p. 22-27. 24. Shi J, Yu J, Pohorly JE, Kakuda Y, ‘Polyphenolics in grape seeds-biochemistry and functionality’, J Med Food, 6(4) (2004) p.291-9.

Eva Escofet is a highly established nutritional therapist with 12 years of clinical experience. She owns a busy multidisciplinary clinic, where she mentors a team of nutritionists. 25. Cui Y, Morgenstern H, Greenland S, Tashkin DP, Mao JT, Cai L, Cozen W, Mack TM, Lu QY, Zhang ZF, ‘Dietary flavonoid intake and lung cancer’, Cancer, 112 (2008), p.2241-2248. 26. Uan JM, Koh WP, Sun CL, Lee HP, Yu MC, ‘Green Tea intake, ACE gene polymorphism and breast cancer risk among Chinese women in Singapore’, Carcinogensis, 26 (2005), p.1389-1394. 27. Chandra S, de Mejia EG, ‘Polyphenolic compounds, antioxidant capacity, and quinone reductase activity of an aqueous extract of Ardisia compressa in comparison to mate (Ilex paraguariensis) and green (Camellia sinensis) teas’, J Agric Food Chem, 52 (2004) p.3583–3589. 28. Lu QY, Jin YS, Pantuck A, Zhang ZF, Heber D, Belldegrun A, Brooks M, Figlin R, Rao J, ‘Green tea extract modulates actin remodeling via Rho activity in an in vitro multistep carcinogenic model’, Clin Cancer Res, 11(4) (2005), p.1675-83. 29. Heinrich U, Moore CE, De Spirt S, Tronnier H, Stahl W, ‘Green tea polyphenols provide photoprotection, increase microcirculation, and modulate skin properties of women’, J Nutr. 141(6) (2011) p.1202-8. 30. Reed, LJ, ‘A trail of research from lipoic acid to alpha-keto acid dehydrogenase complexes’, Journal of Biological Chemistry, 276 (42) (2001) p.38329-36. 31. Salinthone S, Yadav V, Bourdette DN, Carr DW, ‘Lipoic acid: a novel therapeutic approach for multiple sclerosis and other chronic inflammatory diseases of the CNS’, Endocr Metab Immune Disord Drug Targets, 8(2) (2008), p.132-142. 32. Annals of the New York Academy of Sciences, (2002) p.133-166. 33. Fuchs J, Huflejt ME, ‘Acute effects of near ultraviolet and visible light on the cutaneous antioxidant defense system’, Photochem Photobiol, 50:739 (1989). 34. Dreher F, Maibach H, ‘Protective effects of topical antioxidants in humans’, Curr Probl Dermatol, 29 (2001) p.157-64. 35. Bauman L, Allemann IB, ‘Cosmetic Dermatology: Principles and Practice’, 2nd edn. McGraw, 34:298 (2008). 36. Cliff S, PRIME International Journal of Aesthetic and Anti-Ageing Medicine, December 2013. 37. Briden ME, Green BA, ‘The Next Generation Hydroxyacids’, Draelos Z, Dover J, Alam M, eds. ‘Procedures in Cosmetic Dermatology: Cosmeceuticals’, Philadelphia, PA: Elsevier Saunders (2005) p.205-212. 38. Charloux C, Paul M, Loisance D, Astier A, ‘Inhibition of Hydroxyl Radical Production By Lactobionate, Adenine and Tempol’, Free Radical Biology & Medicin, 19 (5) p.699-704 39. Brouda I, Edison BL, Weinkauf RL, Green BA, ‘Maltobionic acid, a powerful yet gentle skincare ingredient with multiple benefits to protect and reverse the visible signs of agin’, Am Acad of Dermatol Poster Exhibit: Chicago, (2010). 40. Brouda I, Edison BL, Weinkauf RL, Green BA, ‘Maltobionic acid, a powerful yet gentle skincare ingredient with multiple benefits to protect and reverse the visible signs of aging’, Am Acad of Dermatol Poster Exhibit: Chicago, (2010). 41. Wills ED, ‘Effects of antioxidants on lipid peroxide formation in irradiated synthetic diets’, Journal Int J Radiat Biol Relat Stud Phys Chem Med. 37(4) (1980) p.403-14. 42. Van den Berg AJ, Halkes SB, van Ufford HC, Hoekstra MJ, Beukelman CJ, ‘A novel formulation of metal ions and citric acid reduces reactive oxygen species in vitro’, J Wound Care, 12(10) (2003), p.413-8. 43. Higashi-Okai K, Ishikawa A, Yasumoto S, Okai Y, ‘Potent antioxidant and radical-scavenging activity of Chenpi – compensatory and cooperative actions of ascorbic acid and citric acid’, J UOEH 31(4) (2009) p.311-24. 44. Vertuani S, Beghelli E, Scalambra E, Malisardi G, Copetti S, Dal Toso R, Baldisserrotto A, Manfredini S, ‘Activity and stability studies of verbascocid, a novel antioxidant, in dermocosmetic and pharmaceutical topical formulations’, Moleculs, 16(8) (2011), p.7068-80. 45. Data on file: Resources Of Nature, 801 Montrose Avenue, South Plainfield, NJ 07080.

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The latest advancements in laser Laser specialist Dr Elizabeth Raymond Brown gives an overview of the latest technological advancements in the field of aesthetic lasers Introduction The concept of the laser traces back to the theory of stimulated emission proposed by Albert Einstein in 1917.1 The first experimental laser, using a synthetic ruby crystal, was demonstrated in 1960 by Theodore Maiman.1 According to Hecht,2 the development of the laser was ‘neither simple nor easy’, but in the intervening 55 years, lasers impacted every aspect of life, including surgical and non-surgical cosmetic interventions. The UK market for cosmetic interventions (consumer value) was worth £2.3bn in 2013, and it is estimated to rise to £3.6bn by 2015. Non-surgical procedures (injectables, laser/light therapies) are estimated to account for 90% of procedures and 75% of the market value.3 Rarely can medical aesthetic clinics afford to invest in laser technology unless it offers a wide range of treatment modalities or unique features, with superior performance and benefits over other modalities and devices. What could be considered good examples of customisable laser and intense light devices for multi-applications include: the Alma Harmony XL, the Lumenis M22, Lynton Lumina and the Cutera Xeo (Figure 1). These systems offer versatile and expandable ‘platforms’ with as many as 24 different treatment modalities from a single platform, helping to grow practice treatments and revenue. Devices offering fewer, but more specific applications, such as body contouring or treatment of hyperhidrosis include; the 10600 nm output of the Syneron-Candela CO2RE for ablative rejuvenation or the 1565 nm fibre laser of the Lumenis ResurFX (Figure 2), offering fractional nonablative skin rejuvenation.

Figure 1. Cutera Xeo treatment hand-pieces

Figure 2. Lumenis ResurFX

An established marketplace The economic downturn and subtle changes in customer demands resulted in some key mergers and acquisitions, which has brought benefits to companies, investors and consumers alike. With companies extending their product portfolios, research and development (R&D) bases, and customer support services, practitioners expect suppliers to offer reliable, high performance devices, limited or zero consumable costs, on-going clinical education and ‘on-call’ service support. Lasers are designated as ‘Medical Devices’, and thus must be CE marked and comply with applicable European Medical Device Directives (within the EU).4 Unlike the United States, the UK is not required to

register laser products, but it is a legal requirement to meet the ‘Essential Safety Requirements’ of the applicable European Directives, ie. BS EN 60601-222:2013.5 Laser products are classified according to the accessible laser emission, and if this exceeds limits defined in BS EN 60825-1,6 the product must be accurately labelled and must incorporate engineering features such as key switches and interlocks. Manufacturers must also provide adequate instructions for safe and appropriate use. Laser eye protection has to be CE marked and comply with BS EN 207:2009,7 the ‘European Directive on Personal Protective Equipment’. As a certified laser protection advisor (LPA), I would strongly advise those purchasing equipment directly from non-European websites, or pre-used devices to seek independent advice on product safety compliance, output calibration and suitability of treatment protocols and protective eyewear. Extending treatment opportunities All aesthetic laser and light-based therapies exploit the concept of selective absorption of incident radiation by a given chromophore or target, as described by the theory of Selective Photothermolysis.8 To achieve an efficacious and safe clinical outcome, specific device variables must be selected and controlled according to the presenting condition to be treated and patient factors such as skin type, hair colour etc. These variables include: Wavelength (nm / µm) – determining absorption by a given chromophore, and depth of penetration into tissues. Pulse duration (ms / µs / ns / ps) – determining rate of heating of target tissues and thus interaction mechanism, eg. photochemical, photothermal, photomechanical.

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Energy, power, fluence (J, W, J cm-2 according to output) – determining amount of energy/power delivered to the tissues.

Treatment area (mm, cm-2) – affecting depth of penetration into tissues, thermal diffusion of heat and treatment time. It is the subtle but significant refinement of these variables that offer further opportunities to improve clinical efficacy, reduce treatment times and enhance patient comfort. For example, the introduction of ‘fractional’ technology – delivering energy in microspots rather than over a full beam area – had a significant impact on extending both ablative and non-ablative treatments.9 Other innovative advances are outlined below: Wavelengths – adding more and ‘mixing’ them up A number of devices offer multiple wavelengths and interesting ways of delivering them: · ·

Independent wavelength delivery – eg. Syneron-Candela GentleMax Pro, offers an Alexandrite (755 nm) and an Nd:YAG (1064 nm) output for hair reduction, allowing treatment of all skin types and pigmented and vascular lesions. Sequential wavelength delivery – eg. Cynosure Cynergy Multiplex technology emits a pulsed dye (585 nm) beam milliseconds before the Nd:YAG (1064 nm) output for increased absorption by methemoglobin and enhanced treatment of vascular lesions.

Rarely can medical aesthetic clinics afford to invest in laser technology unless it offers a wide range of treatment modalities

Figure 3 Quanta Duetto MT Laser

Figure 4 SyneronCandela PicoWay

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Simultaneous wavelength delivery – eg. The Quanta System Duetto MT laser (Figure 3), distributed by Lynton Lasers, can emit Alexandrite (755 nm) and Nd:YAG (1064 nm) wavelengths in a single emission in varying proportions. Mixing the efficacy of the Alexandrite with the safety of the Nd:YAG offers treatment for challenging conditions such as reducing fine hair in darker skin types.

Pulse durations – ever shorter Some of the most recent product advances have come from the ability to produce reliable and repeatable ultra-short picosecond (ps, 10-15 s) pulses of energy, previously the reserve of the research laboratories. Picosecond pulses induce photodisruption – a physical effect associated with optical breakdown that results in plasma formation and shock wave generation.10 Photodisruption is a well-known tool of minimally invasive surgery such as posterior capsulotomy and laserinduced lithotripsy of urinary calculi. The nanosecond pulses (ns, 10-9 s) of Q-switched lasers are successfully used for tattoo removal and treatment of pigmented lesions. However, picosecond pulses can produce incredibly high peak powers from lower pulse energies – still causing optical breakdown but with less disruptive effects to surrounding tissue.10 Devices exploiting this technology include: ·

· ·

Cynosure PicoSure, dual wavelength (755 nm / 532 nm) laser: Cynosure has exploited the laser-induced optical breakdown in tissues via their FOCUS lens array to include treatment of acne scars and wrinkles. Brauer et al11 have shown new collagen and elastin production, similar to fractional ablative lasers, but without the side effects and downtime. Syneron-Candela PicoWay (Figure 4), dual wavelength (1064 nm / 532 nm) laser: claimed to remove multi-coloured tattoos, recalcitrant tattoos and pigmented lesions. Cutera enlighten: This is a dual wavelength (1064 nm / 532 nm) laser offering both nanosecond and picosecond pulse durations (fixed), in one device, which with their variable spot sizes claimed to offer removal of both epidermal and dermal pigmented lesions.

Treatment areas – bigger, faster, cooler Patients not only expect great results, but also want fast and comfortable treatments, especially with hair reduction. Increasing

Figure 5 Alma Lasers Soprano

Figure 6. GME Linscan 808 Diode laser

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To achieve an efficacious and safe clinical outcome, specific device variables must be selected and controlled according to the presenting condition to be treated and patient factors such as skin type, hair colour etc. treated area, scanned beams and comfort cooling are the industry’s response to these demands. For example: ·

Soprano from Alma Lasers (Figure 5) is well known for its SHR hair removal (high repetition of short pulses to achieve high average power) and their in-motion treatment technique. Extending this technology further is the Soprano Ice diode laser, with large spot size and ICE contact cooling designed to enhance patient comfort. A new device, recently available in the UK via Aster International Ltd, is the German Medical Engineering Linscan 808 diode laser (Figure 6). A novel method of linear scanning across a treatment area of 50 x 15 mm offers high efficacy and reduced treatment times. Combined with contact cooling, Motion Control Technology (MCT) and menu driven presets, this compact laser offers all the important features for safe treatment delivery. Interestingly it also offers treatment settings for Onychomycosis, as a less painful alternative to the Nd:YAG 1064 nm wavelength. Building on the well established Lightsheer technology for hair reduction is the Lightsheer INFINITY, from Lumenis, offering diode wavelengths of 805 nm and 1060 nm, with a unique active pain reduction mechanism using vacuum assisted (HIT) technology and the ChillTip handpiece for effective epidermal protection. The INFINITY is a good example of the enhanced features that manufacturers need to include for both patient and practitioner with an advanced graphical interface, intuitive pre-sets and treatment defaults, benefiting the users and reducing the likelihood of inappropriate treatment settings.

Going the extra mile – customer support Aside from the technological advances and refinements, it is notable that manufacturers now strive to enhance the customer experience of buying and using a laser. It is no longer acceptable to take delivery with a half day training session and being left to ‘get on with it’. With such a range of devices available from an increasing number of suppliers, it can be hard to differentiate between them, and the decision on system purchase often comes down to the rapport developed with an individual sales person.

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Whilst perhaps understandable, this can be risky and it is wiser to focus on company pedigree, product portfolio and customer support. Reputable and trust-worthy companies offer information on compliance with safety and licensing requirements, advice on premises and room layouts, dedicated clinical trainers, workshops and educational events, webinars and learning resources, ‘user’ groups, training and business development support and rapid response to equipment service or break-down. Companies can also support their customers with contacts for finance companies, laser protection advisers (LPA) and expert medical practitioners (EMP). Conclusion From the first medical treatment of a retinal tumour with a ruby laser in 1961,12 to the surgical and non-surgical interventions available today, lasers have proven themselves as precision tools for an incredibly extensive range of treatments. Pushing the boundaries with mid and far infrared wavelengths, beam delivery methods, faster treatments over bigger areas and enhanced comfort, will continue to raise expectations of both patients and users. A word of caution however, advancing the technology without advancing practitioner education is dangerous. Just because a laser can remove our wrinkles, reduce our hair growth and banish our brown spots, it should not mean that the technology becomes so readily accessible that anyone can perform such treatments. In my opinion, this is where manufacturers and distributors have a wider role to play than just selling the latest technology. But thanks to significant R&D and investment, it is now possible to deliver medical grade treatments from the most reliable, efficient and technically-advanced devices than ever before. Dr Elizabeth Raymond Brown is an RPA2000 accredited laser protection advisor and academic lead for the MSc. in non-surgical facial aesthetics (NSFA) at the University of Central Lancashire in Preston. She has previously worked as a laser safety lecturer at Loughborough University and was head of lasers at Loughborough College.

REFERENCES 1. Hecht, J. (1992) The Laser Guidebook. 2nd edn. USA: McGraw-Hill 2. Hecht, J. Beam: The Race to Make the Laser, (USA: Oxford University Press, 2005) 3. Department of Health (2013) Review of the Regulation of Cosmetic Interventions – Final Report (UK: Department of Health, 2013) Available at: <https://www.gov.uk/government/uploads/system/ uploads/attachment_data/file/192028/Review_of_the_Regulation_of_Cosmetic_Interventions.pdf> [Accessed 17 March 2015] 4. British Standards Institute. European Medical Device Directives (UK: British Standards Institute, 2015) Available at: <http://medicaldevices.bsigroup.com/en-GB/our-services/european- mdd)> [Accessed 17 March 2015] 5. British Standard Institute. BS EN 60601-2-22:2013: Medical electrical equipment: Particular requirements for basic safety and essential performance of surgical, cosmetic, therapeutic and diagnostic laser equipment (UK: British Standards Institute, 2013) 6. British Standards Institute. BS EN60825-1:2014: Safety of laser products - Part 1: Equipment classification & requirements (UK: British Standards Institute, 2014) 7. British Standards Institute. BS EN 207:2009: Personal eye-protection equipment. Filters and eye- protectors against laser radiation (laser eye-protectors) (UK: British Standards Institute) 8. Anderson R, Parish J. (1983) ‘Selective photothermolysis: Precise Microsurgery by Selective Absorption of Pulsed Radiation’. Science 220 (1983). p 524-527. 9. Gold, M.H Ed. (2010) ‘Update on Fractional Laser Technology’ J Clin Aesth Dermatol, 3(1): pp.42-50 10. Niemz, M.H. Laser-Tissue Interactions: Fundamentals and Applications. (Berlin Heidelberg: Springer-Verlag, 1996). 11. Brauer, J, Kazlouskaya, V, Alabdulrazzaq, H, Bae, Y, Bernstein, L, Anolik, R, Heller, P, and Geronemus, R. ‘Use of a picosecond pulse duration laser with specialized optic for treatment of facial acne scarring’, JAMA Dermatology, 151(3) (2015) p 278-284 12. Institute of Medicine (US) Committee on Technological Innovation in Medicine; Rosenberg N, Gelijns AC, Dawkins H, editors. Sources of Medical Technology: Universities and Industry. Washington (DC): National Academies Press (US); 1995. PART II, Medical Device Innovation. 3, pp 7.

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The importance of skin texture Dr Sharon Crichlow analyses the role and importance of skin texture in treating the signs of ageing The Oxford English dictionary defines texture as ‘the feel, appearance or consistency of a surface or substance’. Is it dry, rough, smooth, grainy, irregular? Does it reflect light evenly? For practical purposes, Ichibori1 states that ‘skin texture represents the degree of uniformity of the surface of skin’. It can be argued that, as it relates to the overall skin surface, anything which affects the skin either directly or indirectly will affect skin texture. There are many factors involved in the perception of skin ageing; these include spots, uneven pigmentation, wrinkles, loss of volume, pore size, erythema and texture.1 Skin texture is hugely important in skin ageing and in fact, in one Japanese study, visible skin firmness and texture was found to be the first skin parameter to decline with age, occurring in participants’ 20s; whereas hyper-pigmented spots appeared in the 30s and wrinkles in the 40s.2 Therefore if we wish to prevent the earliest signs of ageing, we must focus on optimising skin texture first. Historically the focus has predominantly rested on treating wrinkles and volume loss with muscle relaxing injections, fillers and surgery; treatments that provide the instant wow-factor that patients crave. Patients, however, are no longer satisfied with having tightened, plumped-up faces free from wrinkles. In my experience, patients are now requesting the ‘no makeup, makeup’ look. The rise of celebrities with flawless looking skin in popular culture, many of whom now acknowledge the procedures that they have had, has fuelled the demand for perfection. Skin resurfacing and rejuvenation techniques have experienced significant advances in the last few decades and new devices are continuously being introduced.3 This has been facilitated by developments in science and skin culture laboratories, which have allowed us to test both the safety and efficacy of anti-ageing treatments on human skin equivalent culture models.4 As a result, we have been able to develop a wide range of both preventative and corrective products which are proven to improve skin texture.4 Healthy skin texture should be smooth, evenly pigmented, well hydrated and overlying a well supported dermis. Unfortunately there is no quick fix to achieving optimal skin texture; a patient must be committed to an ongoing skincare regime tailored to their individual skin needs. This starts from the initial consultation. Practitioners first and foremost need to know the patient’s desires, and assess whether they are realistic or not. Factors influencing the choice of treatment for each patient would include their age, skin colour and Fitzpatrick type, whether

their skin is oily/acne-prone or dry/sensitive, and whether they have undertaken previous treatments, as well as their medical conditions and medications. In Ichibori R et al’s study of ageing in monozygotic twins, it was shown that facial texture ‘is influenced by environmental factors rather than solely by genetic factors’.1 In other words, extrinsic factors play a bigger role than intrinsic ones. This is great news for those of us not naturally blessed with flawless skin – it can be nurtured! The two factors that have been shown to have the greatest impact on skin texture over time are the use of sun protection and the avoidance of smoking.1,4 Therefore, it is imperative to advise the patient of the importance of these lifestyle choices. Achieving good skin texture starts with a good skincare regime and diet. Numerous studies have demonstrated that Ultra Violet (UV) damage is the single biggest factor in skin ageing.1,5 The ‘Sunscreen Fact Sheet’ published by the British Association of Dermatologists in 20136 recommends the use of a sunscreen of at least SPF 30 and with UVA rating of 4 or 5 stars as providing adequate protection against UV damage. We would therefore advise the same. The use of creams containing the antioxidants vitamin C (at pH <4 and concentrations up to 20%) and the vitamin E isomer Tocopherol potentiates the effect of a sun-block by scavenging free radicals generated both by body metabolism as well as by UV damage.1,4 Vitamin C levels are high in normal epidermis and dermis but the levels fall with natural ageing as well as environmental and sun damage.7 Although both of these vitamins should feature in a healthy balanced diet, significant levels are often not reached in the epidermis and topical application of these vitamins may be a more efficient targeted method for supplying nutrients to the skin, especially to the epidermis.7 Regular cleansing and exfoliation with fruit enzymes, alpha- or beta- hydroxy acids and the use of retinoic acid (the active form of vitamin A in the skin), increase the turnover of new skin cells and keep the skin looking luminous. Vitamin A preparations such as retinol, retinaldehyde or retinyl-propionate, as well as newer formulations of vitamin A, for example, nano-particulate tretinoin, optimise topical retinoid therapy while reducing the skin irritation that often limits its use.8 A well-hydrated skin ages more slowly.2 The regular use of moisturisers containing hyaluronic acid, glycerine and other compounds which help to retain water in the dermis and reduce trans-epidermal water loss is therefore essential. Chronic inflammation leads to the production of free radicals which damage cell components and contribute to disease and ageing.4 The role of inflammation in both skin and body ageing is becoming increasingly recognised and with it, the importance of a diet high in essential fatty acids, which help to reduce skin inflammation.9

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015

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If the skin texture is not specifically addressed, the patient will not get the best outcome from their treatment and their skin will remain looking aged Other products which have been shown to deliver texture benefits to the skin include Panthenol (which increases skin hydration), N-acetyl glucosamine (NAG) and Niacinamide, a water soluble derivative of vitamin B3 which has been shown to reduce pore size. More recently interest has grown in investigating the role of epidermal growth factors and peptides – synthetic or naturally occurring dermal proteins which are involved in wound healing and have been proven to stimulate proliferation of collagen and elastin in skin cultures. The palmitoyl derivative of one such peptide (lysinethreonine-threonine-lysine-serine (pal-KTTKS) has demonstrated significant reductions in wrinkles and general skin appearance.4 Once the patient’s skincare regime, diet and lifestyle are optimised, more targeted treatments can be added. As mentioned earlier, all cosmetic skin treatments will affect skin texture, whether directly or indirectly. Skin peels, wrinkle relaxing injections, fillers, dermarolling, skin tightening devices and laser treatments will all influence the skin texture. In general, most patients attending an aesthetic clinic are initially more concerned with volume loss and wrinkles and so appreciate the instant gratification produced by fillers and toxins. However, if the skin texture is not specifically addressed, the patient will not get the best outcome from their treatment and their skin will remain looking aged. Sometimes the improvement in the wrinkles and facial profile paradoxically makes the abnormal skin texture even more conspicuous. I would therefore recommend offering a suitable skincare regime alongside toxins and fillers, with more targeted treatments at follow up. This kind of approach will gain the patient’s trust as they see the immediate results with the injectable treatment and therefore, they will hopefully be encouraged to continue with the valuable skincare regime you have recommended. It is worth emphasising to the patient that while the results of a good skincare programme take longer to achieve, they are well worth the wait and the benefits accumulate over time.

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

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Specific treatments could include fractional laser devices, which can work to refine pores and improve skin texture, and can be used regularly as part of a prophylactic or maintenance regime. Dermarolling is another widely used rejuvenating treatment which also enhances the absorption of topical product. Carbon dioxide and fractional laser can also be used as resurfacing tools, and are usually reserved for deeper scarring or more intensive rejuvenation. A series of chemical peels using salicylic acid 20-30%, glycolic acid 40-70% or trichloroacetic acid 20-30% depending on skin type and indication will also enhance skin texture and tone.10 Complications of all of these treatments include scarring, infection and in darker skin types, the potential for pigmentary problems. Side effects are minimised by careful patient selection, adequate preparation as necessary (e.g. reduction of melanocyte activity) and the skill of the practitioner. The patient will choose a treatment modality that suits their own personal preference and skin needs, taking account of price, time commitment for the procedure and the ‘down-time’ required afterward. In summary, changes in skin texture represent the first signs of ageing and hence must be targeted at an early age, ideally whilst patients are still in their 20s. Modern advances in bio-science are making it increasingly possible to study the ageing process and to keep it at bay. A good everyday skincare regime, with regular specific treatments as per patient need, is the basis of achieving a healthy texture in all types of skin. Dr. Sharon Crichlow works as a consultant dermatologist at the Skin to Love Clinic in St. Albans, UK. Her interests include the treatment of acne scarring and the pigmentary disorders commonly seen in patients with skin of colour. REFERENCES: 1. Ichibori R, Fujiwara T, Taniqawa T et al., ‘Objective assessment of facial skin ageing and the associated environmental factors in Japanese monozygotic twins’, Journal of Cosmetic Dermatology, 13 (2) (2014), pp. 158-63. 2. Kukizo Miyamoto, Yasuko Inoue, Kesyin Hsueh et al., 10 year longitudinal Japanese study tracking facial skin ageing for wrinkles, texture, hyperpigmented spots, radiance and firmness (UK: P&G Beauty and Grooming) <http://pgbeautyscience.com/assets/files/10%20Year%20Longitudinal%20 Japanese%20Study%20Tracking%20Facial%20Skin%20Ageing.pdf> 3. Kirkland EB, Gladstone HB, Hantash BM, ‘What’s new in skin resurfacing and rejuvenation?’ Giornale Italiano Di Dermatologia e Venereologia, 145 (5) (2010), pp. 583-96. 4. P&G beauty and grooming, Innovations in Technology and Clinical testing (UK: P&G Beauty and Grooming)< http://pgbeautyscience.com/fine-lines-wrinkles-texture-influence-self-perception1.php> 5. Maria Celia B, Gail M Williams, Peter Baker and Adele Green, ‘Sunscreen and prevention of skin ageing’, Annals of Internal Medicine, 158 (11) (2013), pp. 781-790. 6. British Association of Dermatologists, Sunscreen Fact Sheet (www.bad.org.uk)<www.bad.org.uk/ for-the-public/skin-cancer/sunscreen-fact-sheet> 7. Alexander J Michels PhD. Vitamin C and skin health (US: Linus Pauling Institute, 2011)<http:lpi. oregonstateedu/infocenter/skin/vitamin/> 8. Siddharth Mukherjee, Abhijit Date, Vandana Patravale et al., ‘Retinoids in the treatment of skin ageing: an overview of clinical efficacy and safety’, Clinical Interventions in Ageing, 1(4) (2006), pp. 327-348. 9. Giana Angelo PhD., Essential fatty acids and skin health (US: Linus Pauling Institute, 2012)<http:lpi. oregonstate.edu/infocenter/skin/EFA/> 10. Marta I Rendon, Diane S Berson, Joel L Cohen et al., ‘Evidence and Considerations in the Application of Chemcial Peels in Skin Disorders and Aesthetic Resurfacing’, The Journal of Clinical and Aesthetic Dermatology, 3(7) (2010), pp. 32-43.

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Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015

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Teaching Initiative’ at The Aesthetic Awards 2013-14 & 2014-15. In addition, Mr Humzah provides teaching to focus upon ‘The Management of Non-Surgical Complications Through Anatomy’ to further explore the concept of safe injecting and increase awareness surrounding complications encountered through botulinum toxin and dermal fillers.

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Aesthetics Journal

Aesthetics

Case Study: Treating Filler Complications Frances Turner Traill shares her experience of managing a filler complication, and advises practitioners on how to handle adverse events As an independent nurse prescriber, I have been treating aesthetic patients since 2008. In June 2014, a long-standing 36-yearold patient visited my clinic for dermal filler treatment. The patient had been treated with botulinum toxin and dermal filler in my clinic annually for the past four years. She had not undergone any previous aesthetic treatments prior to this. I had injected less than 0.5ml of hyaluronic acid filler into her glabella area four times previously but with a lower viscosity HA filler, with no adverse reaction. During consultation I had followed usual protocol and outlined the risks associated with treatment, which I checked were understood by my patient. A full medical history was also taken, which indicated that the patient would be suitable for treatment on this day. To begin treatment, I first identified the supratrocheal artery by the medial crease on contraction. I adopted an aseptic, standard technique in which I insert the needle, stop, aspirate the needle and watch both the skin and patient’s reaction. I injected slowly, performing retrograde linear threading whilst continually observing for signs of vascular occlusion. I injected 0.5ml medium viscosity filler into the patient’s glabella area using the manufacturer’s syringe and needle. As expected, the treatment went smoothly – the patient did not complain of any unexpected discomfort and was happy with the immediate outcome. There was no analgesia used, the patient did not experience any pain at the time of injection, there was no evidence of bruising or blanching and the vascular return was excellent. Three days post treatment, however, the patient called the clinic to say that she had developed a “significant bruise

Figure 1: Three days post injection

in the injected area” and was becoming extremely distressed as a result (Figure 1). I was acutely aware that I could be dealing with a potentially delayed skin necrosis. I managed the distress and psychological issues the patient was experiencing holistically, using my general nursing, diagnostic prescribing and psychiatric nursing skills. It is essential that, following a complication, patients receive both verbal and written advice quickly and clearly. I contacted the patient via telephone, explained what an impending necrosis was, and reassured her that I would do my utmost to control this unexpected reaction. As an immediate treatment, I instructed her to take 75mg of Aspirin for two weeks, as well as over the counter antihistamines. She was also instructed to use heat pads on the affected area to encourage the blood vessels to dilate, resulting in improved blood flow. I explained to the patient how to test her blood circulation, which we found was not compromised. She was then asked to attend the clinic as soon as possible. After a face-to-face assessment (Figure 2), I prescribed 500mg of Clarithromycin tablets BD for 14 days, and 400mg Moxifloxacin OD for 14 days as a precautionary measure against acute infection. My original plan was to use 1500iu of Hyaluronidase dissolved with 2.5ml of normal saline for rapid degradation of the HA dermal filler. The patient, however, had reported a significant improvement since she had started taking the Aspirin and antihistamines. Taking this into account, we decided to adopt a ‘watchful waiting’ approach, during which she would send me regular photographs of the skin’s developments. Fifteen days post injection, the complication had significantly improved

Figure 2: Four days post injection

Figure 3: 15 days post injection

and was much less noticeable with make-up (Figure 3 – no make-up). By September it had completely subsided but the patient was left with a deep line on hard expression in the glabella area (Figure 4). In November, the area had completely recovered so I treated it with botulinum toxin, which improved the appearance of the deep line – making the patient, once again, a satisfied patient (Figure 5). As soon as the patient reported the complication, I asked her to take good, clear photographs of her face and send them to me immediately. I also took my own photographs when she came to the clinic. Taking well-lit, well-positioned photographs regularly is essential for the successful management of complications. It allows practitioners to conduct thorough patient assessment and enable accurate treatment of the complication in a timely and visual manner. I ensured that the patient continued to take her medication and kept in touch with her regularly. With new research and innovation presented to us each day, it is vital that we ensure our patients are offered the very best levels of competence available. Reading journals, attending conferences and communicating with fellow aesthetic professionals will help ensure you are confident to deal with and support patients when faced with any complication in your practice. To that end, I presented this case study at the Edinburgh BACN meeting in November 2014. The main question asked was why I didn’t use Hyaluronidase to degrade the HA dermal filler. My diagnosis was that the patient had post-injection swelling, causing some compromise of her supratrocheal artery, which had reduced significantly following Aspirin, heat, massage and antihistamine use. I would have injected Hyalronidase if there had been no improvement, a deterioration or if necrosis was impending. Independent nurse prescriber Frances Turner Traill runs her own medical aesthetic clinics in Glasgow and the Highlands. She is an active board member of the British Association of Cosmetic Nurses (BACN) and continues to lead the Scottish Regional Group’s educational meetings.

Figure 4: 106 days post injection

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015

Figure 5: 156 days post injection

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INDICATION

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

dry eye. General disorders and administration site conditions; Common: injection site haemotoma. Post-Marketing Experience; Flu-like symptoms and hypersensitivity reactions like swelling, oedema (also apart from injection site), erythema, pruritus, rash (local and generalised) and breathlessness have been reported. Overdose May result in pronounced neuromuscular paralysis distant from the injection site. Symptoms are not immediately apparent post-injection. Bocouture® may only be used by physicians with suitable qualiﬁcations and proven experience in the application of Botulinum toxin. Legal Category: POM. List Price 50 U/vial £72.00 Product Licence Number: PL 29978/0002 Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer Landstraße 100, 60318 Frankfurt/Main, Germany. Date of revision of text: August 2014. Further information available from: Merz Pharma UK Ltd., 260 Centennial Park, Elstree Hill South, Elstree, Hertfordshire WD6 3SR.Tel: +44 (0) 333 200 4143 Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard Adverse events should also be reported to Merz Pharma UK Ltd at the address above or by email to medical.information@merz.com or on +44 (0) 333 200 4143. 1. Bocouture 50U Summary of Product Characteristics. Bocouture SPC 2014 August available from: URL: http://www.medicines. org.uk/emc/medicine/23251. 2. Prager, W et al. Onset, longevity, and patient satisfaction with incobotulinumtoxinA for the treatment of glabellar frown lines: a single-arm prospective clinical study. Clin. Interventions in Aging 2013; 8: 449-456. 3. Sattler, G et al. Noninferiority of IncobotulinumtoxinA, free from complexing proteins, compared with another botulinum toxin type A in the treatment of glabelllar frown lines. Dermatol Surg 2010; 36: 2146-2154. 4. Prager W, et al. Botulinum toxin type A treatment to the upper face: retrospective analysis of daily practice. Clin. Cosmetic Invest Dermatol 2012; 4: 53-58. 5. Data on File: BOC-DOF-11-001_01 Bocouture® is a registered trademark of Merz Pharma GmbH & Co, KGaA. 1180/BOC/OCT/2014/LD Date of preparation: October 2014

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Botulinum toxin type A free from complexing proteins

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Aesthetics Journal

Aesthetics

Perioral Ageing Dr Souphiyeh Samizadeh outlines how to create an aesthetically pleasing smile through awareness of perioral ageing and dental structure When we start our training to become aesthetic practitioners, the first things we learn are to fill the nasolabial folds and marionette lines. But how much do we actually know about perioral ageing? The lips and the perioral soft tissues play a key role in facial attractiveness. Lips have physiological functions (protection, eating, speaking and position of teeth) and are central to non-verbal and psychological communication. Plump and well-defined lips represent youth, attractiveness, sexuality and beauty.1,2 Teeth are an integral part of a beautiful smile, and the dentition and smile are significant features in determining facial attractiveness.3 Healthy and wellaligned teeth have been shown to have a positive effect on an individual’s confidence and psychosocial wellbeing.3,4,5 From my own findings, as well as media reports, ageing of the perioral region (e.g. thin lips, mouth furrows, and downward corners of mouth) seems to be amongst the main reasons people seek surgical or non-surgical aesthetic treatments.6 Understanding the components of facial ageing will result in a better understanding of the patient’s individual needs and therefore better-tailored treatment plans. The perioral region is defined as the lower third of the face, extending from the subnasale to mentum (Figure 1). The key perioral landmarks are: · The philtrum · Cupid’s bow · Lips and vermillion border · Nasolabial folds · Labiomental folds (Marionette lines)

Skeletal structure and relationships, soft tissue contours, the dentition and gingival contour, and the lip framework determine a patient’s lower face aesthetic. Skin ageing, subcutaneous fat atrophy and skeletal remodelling are the key factors that contribute to facial ageing. Other factors include smoking, stress, lifestyle, work habits and diet.7,8,9 Treatment and rejuvenation of this region without an in-depth understanding of the anatomy and the ageing process can produce undesirable results. For example, as we age lower facial volume increases, thus, the desired ‘inverted triangle’ facial aesthetic decreases. I also find patients lose fine lip

movement and sometimes require additional dental or surgical treatment. Dentition and dental treatment play a significant role in restoring the perioral complex. Conversely, rejuvenation of the perioral complex will further enhance the aesthetic outcome of cosmetic or restorative dentistry. When treating perioral ageing, it is important to bear in mind that facial characteristics are different in men and women. Men have larger philtrum widths, and total lip height, wider mouth width, and their pogonion (the most forwardprojecting point on the anterior surface of the chin) is located more inferiorly than in women.10,11,12 Figure 1 – The perioral region: Lower third of the face (indicated by dark blue line). The width of oral commissures is equal to the distance between the medial limbi (light blue lines). The lips should be parallel to interpupillary line (green lines).

Characteristics of ideal lips · The width of the lips: approximately 40% of width of the lower face16,17 · The ideal lip ratio on the frontal view is 1:1:6; 40% the upper lip and 60% the lower lip18 · The lips are parallel to the interpupillary line19 · The length of the upper lip from subnasale is approximately half the length of the lower lip from the chin10,19 · The width of oral commissures is equal to the distance between the medial limbi17 · Subnasale to the vermilion border of the lip is curved · There are specific break points on the lips · There is an anterior projection of the central cutaneous lip10 · The upper lip: well-defined Cupid’s bow with the apexes at the inferior aspect of the philtral columns20,21 · The lower lip: fuller than the upper lip, with slight eversion and more vermillion border show · On profile, the upper lip will extend beyond the lower lip by a couple of millimetres21 Figure 2: Youthful lip, full volume, slight eversion of the lower lip, vertical rhytides are preserved and the ‘wet-dry junction’ of the lower lip is visible. A: Cupid’s Bow B: anterior projection of the central cutaneous lip

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015

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The lip framework When discussing ideal aesthetics and treatment planning for patients, it is important to recognise the differences in races, genders, cultures and aesthetic ideas. The position of lips is affected by the skeletal make up of an individual and the underlying dental support.13,14,15 Abnormal dental-skeletal relationships should be recognised. These patients may need orthognathic surgery or orthodontic treatment, which is beyond the scope of this article. Regardless of cultural and ethnic differences, youthful lips are characterised by fullness and well-defined curvatures. Lip-teeth relationships The position and alignment of the dentition influence position of lips, smile, phonetics and functional balance. The maxillary incisal edge curvature would be parallel to the curvature of the lower lip in an ideal smile arc (Figure 4). At rest, there should be 2-4mm vertical exposure of the maxillary incisors in relation to the upper lip.21,22,23 Evaluation of anterior smile aesthetics must include both static and dynamic evaluations of profile, frontal and 45° views to optimise both dental and facial appearance.23,24 Position of the upper and lower teeth, crowding, lost dentition, discoloured teeth or different coloured restorations and tooth wear, all affect the aesthetic of a smile. During advanced facial and smile analysis, tooth proportions and symmetry, the dental midline, gingival aesthetics, the smile arc, width of the smile, buccal corridors (the negative space between buccal surface of upper first premolars and the commissure of lips when patients smile), contacts, embrasures, and incisal and gingival display should be taken into consideration.21,25 Figure 4: The ideal aesthetic smile arc has the maxillary incisal edge curvature parallel to the curvature of the lower lip

Changes with ageing: the hard tissue structures The hard tissue structures that shape the perioral complex include the mandible, the maxillary bone and the dentition. These bony components are central to the overall facial threedimensional contour of the face and suspension of the soft tissues. The ageing process affects all of these structures. Genetics, occlusal relationship (the relationship between upper and lower teeth), dental integrity, midface development and skeletal maturity are some of the factors that influence skeletal ageing. Therefore, the rate of skeletal ageing varies in different individuals.7,26,27 The maxilla Studies have shown that ageing results in: · Maxillary retrusion in both dentate and edentulous individuals, in both men and women16,28 · Changes in the bony contour of maxilla: The maxilla rotates clockwise26 Decrease in the maxillary angle and height may play a role in the malar fat pad moving down and forward. This results in a posterior positioning of the upper lip and deepening of the nasolabial folds.28 The mandible The mandible is the structural foundation of the lower face. Any changes in the dimensions of the mandible will affect the overall

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aesthetic of a patient’s face. Studies have shown that with ageing:9,16,26,29 · The ramus height and mandibular body length decreases significantly as both Figure 5 – Perioral ageing: Volume loss, loss of skin elasticity, soft-tissue men and women get older, atrophy, loss of bony support and therefore decreasing chin projection. Loss of mandibular volume also means decreased support of the projection soft tissues and may contribute to laxity · The bigonial width does not of platysma. change significantly · The mandibular angle increases in both genders, this may result in blunting or the loss of jawline definition · Loss of mandibular volume contributes towards laxity of platysma and soft tissues of the neck The dentition Chronological tooth wear may result in flattening of the incisal edges, and consequently adversely affect the smile arc. Tooth loss affects the thickness of cortical bone; edentulous patients suffer from significant cortical bone loss and maxillary and mandibular alveolar ridge resorption. This is more pronounced in the mandible than maxilla, and more in women than men, and results in reduced lower face height.30 Tooth loss from the lateral areas of the jaw can result in narrowing of the face and hollowing of the cheeks, whilst loss of anterior teeth will produce a concave profile.31 Severe tooth wear can also reduce the vertical dimension of the lower face. Dentures affect the position of soft tissues and lips, and have a direct effect on the lower face height.27,29 Changes with ageing: the soft tissue structures Skin The most important environmental insult that contributes to the agerelated clinical changes in skin (changes in colour, surface texture, and functional capacity) is chronic solar exposure. Photoageing is distinct from intrinsic or chronologic ageing. Chronologically aged skin shows epidermal thinning, with flattening of the dermalepidermal junction and loss of collagen, which results in increased water loss and decreased elasticity of the skin. Drier skin is also the result of reduced water binding capacity and sebaceous gland activity.9 Loss of skin elasticity and volume, in addition to repeated perioral muscle activity, contributes to perioral rhytides.5 Fat compartments and the perioral muscles Facial fat is divided into deep and superficial compartments and planes. With ageing, the perioral fat compartments become lipodystrophic and ptotic.8 There is a superficial fat compartment characterising the philtrum, which has a particular vascular anatomy.32 With ageing, the malar fat pad descends and overlaps medially and inferiorly over the firmly attached retaining ligament and creates a fold.8 Ptosis of the chin pad, mandibular resorption and lip depressor muscle function, contribute to a prominent labiomental crease.9 The mandibular septum separates the jowl from the submental fat and is adherent to the body of the mandible. The recession of this septum with the ageing mandible results in soft tissue rolling over the border of the mandible.23 Orbicularis oris atrophy, in combination with thinning of the overlying skin, results in formation of vertical rhytides above the vermilion border. This is made worse by smoking.18

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015

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Ageing of the lip framework Structural changes with age Changes in lip morphology during ageing include the position of the lip Figure 6 – Perioral ageing: The upper lip lines, a decrease in lip loses its volume, lengthens and inverts; the lower becomes thinner and rolls inward. The volume and thickness intercommissural width becomes longer and (degeneration of elastic commissures droop. The vermilion border and philtral columns become thinner; there and collagen fibres), lip is flattening of the vermillion border and tonicity, changes in lip partial loss of Cupid’s bow; perioral rhytids become apparent and the nasolabial folds and length and retraction labiomental folds become more noticeable. of the lips. On average, there is 2-4mm increase in upper lip length with age.2 It has been observed that the natural curves of the lips are lost through ageing and lip dryness is shown to be statistically more marked in aged women. The lower lip becomes dominant over the upper lip and is more noticeable in women. Vertical wrinkle lines start to appear during the fourth decade of life but become more visible during the fifth decade (there have been some suggestions that this corresponds to menopause).11 The commissures descend and inter-commissural distance increases with age.11 Changes in dynamic of lip movement with age In a youthful and harmonious smile, the maxillary incisors should be visible and exposed by the upper lip by 2-4mm at rest. On smiling, the entire crown of the maxillary incisors and up to 2mm of associated gingiva should be exposed.

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therefore less display of incisors · We see increased intercommissural width at rest · The buccal corridor increases

Figure 7: The images depict how, with ageing, the smile becomes wider transversely and narrower vertically, showing less maxillary teeth. In addition, the buccal corridor space increases. Older individuals tend to smile with the lower lip covering the maxillary anterior incisal edges.

Conclusion The focus of human communication is the face, thus it is key to social interaction and the perception of attractiveness. The correct soft-hard tissue balance is important for achieving and maintaining a pleasing aesthetic appearance and function. Better understanding of facial ageing leads us towards a threefold facial rejuvenation technique: restoring volume (loss of bony volume), lifting and reducing the soft-tissues and skin rejuvenation. Advanced rejuvenation involves multidisciplinary treatment and may necessitate dental restorations or plastic surgery. Overfilling and volumising where there is advanced bone resorption or dental problems may lead to undesirable aesthetic results. Likewise, perioral rejuvenation without midface correction is not recommended as this can result in an unnatural look. Dr Souphiyeh Samizadeh is a dental surgeon with a special interest in aesthetic medicine. She is an honorary clinical teacher at King’s College London and the clinical director of the Revivify London clinic. She has presented at both national and international conferences, and is actively involved with research into aesthetic medicine.

As a result of ageing:11,32,33 · The smile gets narrower vertically and wider across · There is a decreased display of maxillary anterior teeth · Exposure of mandibular anterior teeth increases · There is a reduction in the muscles’ ability to raise the upper lip,

REFERENCES 1. Wollina, U., ‘Perioral rejuvenation: restoration of attractiveness in aging females by minimally invasive procedures’. Clin Interv Aging, 2013. 8: p. 1149-55. 2. Van der Geld, P., P. Oosterveld, and A.M. Kuijpers-Jagtman, ‘Age-related changes of the dental aesthetic zone at rest and during spontaneous smiling and speech’. The European Journal of Orthodontics, 2008. 30(4): p. 366-373. 3. Robinson, P.G., ‘Summary of: The influence of tooth colour on the perceptions of personal characteristics among female dental patients: comparisons of unmodified, decayed and ‘whitened’ teeth’. Br Dent J, 2008. 204(5): p. 256-257. 4. AL-DREES, A.M., ‘Oral and perioral physiological changes with ageing’. Pakistan Oral & Dental Journal, 2010. 30(1): p. 26-30. 5. Desai, S., M. Upadhyay, and R. Nanda, ‘Dynamic smile analysis: changes with age’. American Journal of Orthodontics and Dentofacial Orthopedics, 2009. 136(3): p. 310. e1-310. e10. 6. Ferrario, V.F., et al., ‘Sexual dimorphism in the human face assessed by euclidean distance matrix analysis’. Journal of Anatomy, 1993. 183(Pt 3): p. 593-600. 7. Coleman, S.R. and R. Grover, ‘The anatomy of the aging face: volume loss and changes in 3-dimensional topography’. Aesthet Surg J, 2006. 26(1s): p. S4-9. 8. Rohrich, R.J. and J.E. Pessa, ‘The fat compartments of the face: anatomy and clinical implications for cosmetic surgery’. Plastic and reconstructive surgery, 2007. 119(7): p. 2219-2227. 9. Zimbler, M., M. Kokoska, and J. Thomas, ‘Anatomy and pathophysiology of facial aging’. Facial plastic surgery clinics of North America, 2001. 9(2): p. 179-87, vii. 10. Klein, A.W., ‘In search of the perfect lip: 2005’. Dermatologic surgery, 2005. 31(s4): p. 1599- 1603. 11. Leveque, J.L. and E. Goubanova, ‘Influence of age on the lips and perioral skin’. Dermatology, 2004. 208(4): p. 307-13. 12. Masood, Y., et al., ‘Impact of malocclusion on oral health related quality of life in young people’. Health Qual Life Outcomes, 2013. 11: p. 25. 13. Naini, F.B. and D. Gill, ‘Facial aesthetics: 2. Clinical assessment’. DENTAL UPDATE-LONDON-, 2008. 35(3): p. 159. 14. Ahmad, I., ‘Anterior dental aesthetics: Dental perspective’. Br Dent J, 2005. 199(3): p. 135-141. 15. Ahmad, I., ‘Anterior dental aesthetics: Dentofacial perspective’. Br Dent J, 2005. 199(2): p. 81-88. 16. Mendelson, B. and C.H. Wong, ‘Changes in the facial skeleton with aging: implications and clinical applications in facial rejuvenation’. Aesthetic Plast Surg, 2012. 36(4): p. 753-60.

17. Prendergast, P., ‘Facial Proportions’, in Advanced Surgical Facial Rejuvenation, A. Erian and M.A. Shiffman, Editors. 2012, Springer Berlin Heidelberg. p. 15-22. 18. Penna, V., et al., ‘The aging lip: a comparative histological analysis of age-related changes in the upper lip complex’. Plastic and reconstructive surgery, 2009. 124(2): p. 624-628. 19. Perkins, S.W. and H.D.t. Sandel, ‘Anatomic considerations, analysis, and the aging process of the perioral region’. Facial Plast Surg Clin North Am, 2007. 15(4): p. 403-7, v. 20. Klein, A.W., ‘In Search of the Perfect Lip: 2005’. Dermatologic Surgery, 2005. 31: p. 1599-1603. 21. Naini, F.B. and D.S. Gill, ‘Facial aesthetics: 2. Clinical assessment’. Dent Update, 2008. 35(3): p. 159-62, 164-6, 169-70. 22. Sarver, D.M., ‘The importance of incisor positioning in the esthetic smile: the smile arc’. Am J Orthod Dentofacial Orthop, 2001. 120(2): p. 98-111. 23. Frese, C., H.J. Staehle, and D. Wolff, ‘The assessment of dentofacial esthetics in restorative dentistry: a review of the literature’. J Am Dent Assoc, 2012. 143(5): p. 461-6. 24. Sarver, D.M., ‘The importance of incisor positioning in the esthetic smile: The smile arc’. American Journal of Orthodontics and Dentofacial Orthopedics, 2001. 120(2): p. 98-111. 25. Ahmad, I., ‘Anterior dental aesthetics: Facial perspective’. British dental journal, 2005. 199(1): p. 15-21. 26. Shaw, R.B., Jr., et al., ‘Aging of the mandible and its aesthetic implications’. Plast Reconstr Surg, 2010. 125(1): p. 332-42. 27. Wulc, A.E., P. Sharma, and C.N. Czyz, ‘The anatomic basis of midfacial aging’, in Midfacial Rejuvenation. 2012, Springer. p. 15-28. 28. Shaw Jr, R.B. and D.M. Kahn, ‘Aging of the midface bony elements: a three-dimensional computed tomographic study’. Plastic and reconstructive surgery, 2007. 119(2): p. 675-681. 29. Bartlett, S.P., R. Grossman, and L.A. Whitaker, ‘Age-related changes of the craniofacial skeleton: an anthropometric and histologic analysis’. Plast Reconstr Surg, 1992. 90(4): p. 592-600. 30. Bodic, F., et al., ‘Bone loss and teeth’. Joint Bone Spine, 2005. 72(3): p. 215-221. 31. Sveikata, K., I. Balciuniene, and J. Tutkuviene, ‘Factors influencing face aging. Literature review’. Stomatologija, 2011. 13(4): p. 113-6. 32. Garcia de Mitchell, C.A., et al., The philtrum: ‘anatomical observations from a new perspective’. Plast Reconstr Surg, 2008. 122(6): p. 1756-60. 33. Van der Geld, P., P. Oosterveld, and A.M. Kuijpers-Jagtman, ‘Age-related changes of the dental aesthetic zone at rest and during spontaneous smiling and speech’. Vol. 30. 2008. 366-373.

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015

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“Our research goes on in our labs for ingredients we plan to use for the next five, ten, fifteen years”

Leigh Ann Catlin

Catherine Mueller

NeoStrata’s Vice President of International Business Development Leigh Ann Catlin, and Executive Director of International Markets Catherine Mueller, explain why an evidence-based approach is central to the skincare company’s ethos

What makes NeoStrata stand out as a skincare company? Leigh Ann Catlin (LC): NeoStrata is totally unique as a cosmetic company for a couple of reasons. One is that we have several laboratories in our offices. We have a cell culture lab where we screen for various ingredients to measure their efficacy in treating the conditions that we want them to treat – this is where we actually grow and foster cells. We also have a standard research lab, where we do research on ingredients that we’re interested in using. We also have our own formulation research and development laboratory, with a full team of scientists that carry out research on our formulations. So although a small cosmetic company, we research the active ingredients that we want to use and we also develop our own formulations. NeoStrata is also unique in the way that we do extensive testing on our products. A doctor recommending our product, or a consumer using our product, can feel very confident that the claims that we make about our products and the things that we say that they do, they do. And we have the clinical studies, the data, and the before and after pictures to back up and support the claims that we make. How important is continuous research and development for NeoStrata? Catherine Mueller (CM): That’s extremely important. Historically we are known worldwide as the AHA (Alpha Hydroxy Acid) brand, but although we continue to use AHAs in our formulations, we have researched other new compounds. We’ve gone from AHAs to Poly Hydroxy Acids, and, specifically, Gluconolactone. We then went to Complex Poly Hydroxy Acids, later using Lactobionic Acid and now Maltobionic Acid. In the past five years, we’ve started to use NeoGlucosamine, which is a non-acid anti-ageing ingredient with great plumping and pigment-evening properties. In our latest technologies, we’ve used the amino acid Amino Fill, which is a non-acid technology – we’ve used this in our latest Skin Active Line Lift for targeted treatments to further enhance the plumping, the collagen building and the production of GAGs (Glycosaminoglycans) in the skin. And these are just the ingredients we’ve commercialised over the past 27 years as a company; our research goes on in our cell culture lab and our 54

standard lab for ingredients we plan to use for the next five, ten, fifteen plus years. LC: Research is really the heritage of NeoStrata. It’s really important to Dr Van Scott and Dr Yu (NeoStrata founders Dr Eugene J. Van Scott and Dr Ruey J. Yu, who discovered AHAs back in the 1970s) to continue researching and to discover new ingredients that can help people’s skin. Why does NeoStrata appeal to aesthetic professionals? LC: I think aesthetic professionals can see that NeoStrata has a base of clinical studies and effective products that really work. We have a lot of doctors that say they use the products themselves, so they feel very comfortable recommending them to their patients. CM: They embrace the science that’s behind it. When the doctors ask the questions, we have the answers, and we can prove it. They also then feel confident that if they’re going to use our products and recommend them to somebody, they fully understand them as well. What’s the future for NeoStrata? CM: Dr Van Scott always says that we have great formulations and they do great things, but he says the best is always yet to come. And he’s so excited about that! Helping people improve whatever condition they’re trying to improve in their skin, helping them feel more confident in themselves, that’s a great place to be in. What’s great is that our brand really does cross all ages, all generations and all conditions, from pigmentation, acne, fine lines and wrinkles, to dry skin, sensitive skin and rosacea. LC: The one thing that’s for sure is that NeoStrata Company will continue its research. There are many things in the pipeline; there are lots of ingredients and substances that we are researching now that will be used in future products. NeoStrata Company is a really exciting thing to be a part of.

NeoStrata is distributed in the UK by AestheticSource. For more information contact info@aestheticsource.com / 01234 313130

Aesthetics | April 2015

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A summary of the latest clinical studies Title: Evolving Perspectives on the Etiology and Pathogenesis of Acne Vulgaris Authors: LF Eichenfield, JQ Del Rosso, AJ Mancini, F Cook-Bolden, L Stein Gold, S Desai, J Weiss, D Pariser, J Zeichner, N Bhatia, L Kircik Published: Journal of Drugs in Dermatology, March 2015 Keywords: Acne, development, topical/oral antibiotics Abstract: As the pathophysiology of acne is complex and multifactorial, the continued influx of new basic science and clinical information requires careful analysis before drawing conclusions about what truly contributes to the development and progression of this chronic disease. Our objective is to review the latest evidence and highlight a number of important perspectives on the pathophysiology of acne. An improved understanding of acne pathogenesis should lead to more rational therapy and a better understanding of the role of P acnes opens new perspectives for the development of new treatments and management. Further research may be directed at targeting receptors, adhesion molecules, cytokines, chemokines or other pro-inflammatory targets implicated in the activation of immune detection and response (i.e., toll-like receptors [TLRs], proteaseactivated receptors [PARs]) that appear to contribute to the pathophysiology of acne. Therapeutic options that reduce the need for topical and/or oral antibiotic therapy for acne are welcome as bacterial resistance to antibiotics is a clinically relevant concern both in the United States and globally. Title: Laser treatment of periocular skin conditions Authors: B Yates, SK Que, L Dâ&#x20AC;&#x2122;Souza, J Suchecki, JJ Finch Published: Clinics in Dermatology, March 2015 Keywords: Lasers, lesions, periocular, resurfacing Abstract: Advances in laser technology in recent decades have increased the options for the treatment of dermatologic conditions of the eye and eyelid. Benign tumors can be laser-ablated with relative ease, and vascular and melanocytic lesions can be precisely targeted with modern lasers. In this contribution, we review treatment of periocular pigmented lesions, including melanocytic nevi and nevus of Ota; vascular lesions including telangiectasias, port wine stains, and infantile hemangiomas; hair removal; eyeliner tattoo removal; laser ablation of common benign periocular tumors, such as syringomas, xanthelasma, milia, and seborrheic keratoses; and laser resurfacing. The recent advent of fractionated laser technology has resulted in dramatically decreased healing times for periocular skin resurfacing and fewer adverse effects. Fractionated laser resurfacing has now nearly supplanted traditional full-field laser resurfacing, and safe treatment of rhytides on the thin skin of the eyelids is possible. Proper eye protection is, of course, essential when using lasers near the eye. Patient preparation, safety precautions, and risks-intraocular and extraocular-are discussed herein. As laser technology

continues to advance, we are sure to see improvements in current treatments, as well as development of new applications of cutaneous lasers. Title: Fractionated carbon dioxide laser therapy as treatment of mild rhinophyma: report of three cases Authors: AA Meesters, MM van der Linden, MA De Rie, A Wolkerstorfer Published: Dermatology and Therapy, March 2015 Keywords: Rhinophyma, rosacea, laser therapy Abstract: Rhinophyma is a bothersome condition of the nose that is regarded as a manifestation of rosacea (subtype 3). Whereas the efficacy of medical treatments, including antibiotics and retinoids, is often dissatisfying, conventional invasive procedures are limited by their unfavorable side effect profile. We present three patients who were treated by a minimally invasive approach using fractionated carbon dioxide (CO2 ) laser therapy, showing variable response. We observed that fractionated CO2 laser therapy may improve patient-reported outcome in some patients with mild rhinophyma and is associated with a relatively favorable side effect profile compared with conventional surgical techniques. Title: A randomized, controlled clinical study to investigate the safety and efficacy of acoustic wave therapy in body contouring Authors: AH Nassar, AS Dorizas, A Shafai, NS Sadick Published: Dermatologic Surgery, March 2015 Keywords: Body contouring, acoustic wave therapy, lateral thigh Abstract: There is an increased demand for the reduction of localized adipose tissue by noninvasive methods. The objective of this study was to determine the safety and efficacy of noninvasive lipolysis of excess adiposities overlying the lateral thigh region using acoustic wave therapy (AWT). This study incorporates 2 mechanical waves with varying properties in the same session: radial and planar AWT. The treatment was performed using AWT on the lateral thigh areas of 15 female patients. The study was performed using the planar and radial pulse handpieces, with 8 sessions performed within 4 weeks. Follow-up visits were performed 1, 4, and 12 weeks after the last treatment. Reduction in both thigh circumference and subcutaneous fat layer thickness, measured through ultrasound, was observed. This study demonstrates that AWT is safe and efficacious for the treatment of localized adiposities in the saddlebag area. However, the results obtained were not statistically significant. Larger studies will be needed to further access the effects of AWT on thigh circumference reduction. Furthermore, the authors also found an improvement in the appearance of both cellulite and skin firmness after the treatments.

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015

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other clinics and capture the consumer’s attention. The simplest way to do this is through package names and creatively named treatments or treatment zones. For example, if you simply say, “Get in Shape for Summer with the Latest Body Contouring Treatments” it’s bland, but if you created a ‘Bikini Beach Body Menu’ of treatments, it engages readers and suddenly comes to life. For example:

Creating a Summer Marketing Campaign Charlotte Moreso explores the benefits of seasonal marketing and shares practical tips on how to entice patients into your clinic during the summer months Summer provides a huge opportunity to enhance your aesthetic practice, but your marketing must be planned well in advance. Miss the season by a week or two and your competitor might just snatch up your potential business. Methods of marketing are boundless, and it’s often a minefield to decipher which of these might work best for your business and within your budget. This guide aims to help you decide which avenues might be best for enticing new patients to your clinic, whilst capturing the attention of your current patient base and extending their treatment preferences. Above all, though, your communication methods must be creative. Patients respond best to interesting tag lines, innovative treatments and eye-catching imagery as much as if they were exploring the latest fashion. Marketing preparation Timing: Forward planning is critical in order to capture business. Reach patients with your messaging and offers in the spring, when they are starting to think about ‘bikini-body’ season, then consistently target them with updated information and messaging. The Science: You may respond to the intricacies of the latest aesthetic technology, but the average patient will not. They will want to know how it works, how long until they see results, whether it will it hurt, and prices – so don’t blind them with science. Think of those beauty adverts that proclaim, ‘The Science Bit’ at the end of the advert and aim for the same level of information when marketing to your patients. The First Steps: Before you do anything, look at your treatments and list what aspects of the body patients will be hoping to improve this summer. Your list will usually include laser hair removal, sun protection, body contouring, fat reduction, cellulite treatments, stretch mark treatments and facial treatments to even out the complexion so that they can ‘go bare-faced’ on the beach. Once you have your definitive treatment list, it’s time to get creative. You need to stand out from the

The Bikini Bottom Treatment: Let us sculpt your derriere into the perfect beach peach with just six pain-free radio frequency treatments The Bikini Belly Treatment: Just two fat freezing treatments will have you ditching your swimming costume and dusting off your favourite bikini The Beachy Bingo Wing treatment: Wave without the wobble in just six weeks Lovely Lasered Legs: Want to be smooth and fuzz free this summer? Ditch the razor and love the laser! Being creative with language does not undermine the seriousness of the treatments; it’s a way of capturing attention and enticing patients to enter your clinic, where they will then receive thorough consultation and can be provided with any relevant literature on the treatment in question. Create a consistent campaign Create the strap line for your summer treatment campaign and stick to it. Use this throughout all communication. A strap line is the title of the campaign that would be used in press releases and in all marketing materials. This could be something like, ‘xx Clinic Beach Body Beautiful Treatments’. Public Relations (PR) and marketing tools could comprise: • A window sticker for your clinic • Posters • Leaflets that display the treatment menu • Roll-up banners • Press releases for journalists How to reach new patients Post office mailings, a marketing service provided by the Royal Mail that sees your marketing materials delivered to the door of selected recipients, can offer a very good return on investment and are straightforward to carry out. You are able to pick exact postal drop zones, targeting people in exactly the area you wish, for what is essentially a nominal amount of money. Once you have selected the area it is critical that the promotional material looks good and stands out from other free post. Make it beautiful and something patients will want to pick up and not just throw away. An aesthetically pleasing image one side and treatment menu on the reverse with your clinic details is sufficient. Offer a free taster treatment and the phones will start ringing. You can send materials in envelopes or alone, but placing it in a good quality coloured envelope could become more enticing to the recipient, and is a unique idea if the budget allows. Summer treatment open days I have witnessed immense success from open days, with patients queueing to pay for bookings – but open days only work if you get them right. Here’s the magic formula for filling the diary with bookings: What: Open your clinic for a day or afternoon and evening to all your patients and potential new patients, offering free taster treatments from your summer treatment menu. Also ensure you have a few ‘models’ to perform demonstrations on in quieter spells, as this often attracts an audience. When conducting these tasters, leave treatment doors open so people can see what is going on inside. It soon draws a crowd.

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015

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When: April or May is a good time, but avoid school holidays as potential patients who are also busy parents may be unable to attend. Deals: Create good value package offerings, redeemable only if they book on the day. This ensures immediate booking without the risk of losing their interest once they have walked away. Of course, it is vital that you adhere to Keogh’s recommendations when marketing these clinic ‘deals’. It was stated in the Keogh Review that, “advertising and marketing practices should not trivialise the seriousness of procedures or encourage people to undergo them hastily.”1 Offering time-limited deals, financial inducements, cosmetic procedures as competition prizes and package deals such as ‘buy one get one free’ or ‘refer a friend’ should be avoided. Goody Bag: Contact the suppliers of your brands and ask them to donate some mini-samples to the goody bag – everyone loves a freebie! Adding Luxury: Serve canapés, sparkling wine when appropriate and healthy juices. How: Create a postcard-sized flyer with details of the event on the front, and treatment menu on the reverse, that can be mailed out to homes in your local area. Go online and buy a stock image (from a stock photography website) of a good bikini body to capture attention, and ensure your flyer contains the following information: • Invitation to preview/experience the Must-Have Summer Bikini Body Menu at your clinic • Menu of Taster Treatments • Complimentary Taster Treatments • When and where • Special Offers • Goody Bag for every attendee • RSVP to reserve your place Press Reviews: Use the same menu of treatments to invite your local press to try out full-length versions for reviews in the local magazines and newspapers. If possible, avoid inviting them to the consumer open day, as they like to be treated on a one-on-one basis and expect the full treatment or a course of treatments in order to write a thorough review. If you advertise with local magazines or newspapers you should try and use this to your advantage in order to secure editorial reviews. Depending on the publication, try and negotiate editorial reviews when you book any advertising; alternatively, develop a good relationship with the editorial team at the publication and they will naturally be more inclined to write about your event and the treatments you provide.

What not to do When creating your summer marketing campaign, don’t… Sell too hard: We all know when we are being sold to, so keep it subtle and targeted towards what patients really need Do a press launch: Unless you have something 100% unique to tell journalists about. They are time-poor and getting them out of the office can be tricky. One-to-one invites set at a time that is convenient for them often work better Devalue your clinic: Too many offers might actually work against you. You want to be seen as the more advanced clinic, not necessarily the cheapest Overwhelm patients with too much science: Just because it’s a technical device doesn’t mean they want to read all the techy information

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Successful summer campaigns A recent summer campaign I was involved with was for a worldleading aesthetic beauty company where we promoted all their body devices, both existing and new, at a press event in London. The campaign, entitled ‘Body Beautiful’, was divided into two clear areas: Skin Perfecting and Body Perfecting. Skin Perfecting included treatments for stretch marks, veins, tattoo removal and body scars and Body Perfecting included treatments for fat, cellulite and skin laxity. My team enlisted leading UK aesthetic doctors and experts to present both the ‘Facts & Fix’ for each issue at the press event. A Little Black Book of Body Beautiful was written, detailing each presenter’s topic, and this was given to the UK’s top 500 health and beauty writers as a resource for their articles. The event took place mid-January, when editors and journalists were working on their early summer issues. To add theatre to the event we had a male and female model spray painted gold and silver to signify the concept of ‘Body Beautiful’. This doubled up as a social media tool, where journalists tweeted novelty shots of themselves with the models. The most successful summer-themed PR and marketing campaign we have created was for a leading laser hair removal device. Their Unique Selling Point (USP) was that all skin colours and most hair colours could be treated. We therefore created a consumer-focused campaign called, ‘No Shades Barred’. Creative marketing materials were developed using a block of facial images illustrating all the different skin and hair colours on their laser spectrum. This eye-catching image was placed onto roll-up banners, posters, leaflets and window stickers. A press pack was created and included in a marketing guide sent to all the clinics using the laser. This enabled the clinics to send the pre-written press releases to their local newspapers and magazines, and refer to our guide on how to best communicate with journalists. The pack also detailed how to order the different marketing materials. The campaign materials were up-taken by many clinics and the campaign images were used online as well. This campaign won Best Consumer Campaign 2013 at the Aesthetic Awards. And don’t forget… Use any press coverage you receive to best effect. Consumers love to see your name in the media, so scan it and post on Facebook, Twitter and your website or if the piece is particularly good, produce an e-mail flyer and send to your patient list. Many clinics also produce coverage books or create montages of their coverage as a poster or postcard, which can be displayed in reception. Also see what support the PR agencies that represent the aesthetic device companies can offer you. They may provide you with press releases or ideas on how to market the treatment to patients. The three C’s In summary, be creative, consistent and think consumer, consumer, consumer. Tell patients what they’d want to know, rather than what you’d want to know. Charlotte Moreso is managing director of True Grace PR. Charlotte has worked as a PR and marketing consultant in the health and beauty industry for more than 20 years, running highly successful campaigns for global commercial brands, smaller UK beauty brands and in more recent years, creating news for the UK’s leading aesthetic treatments, doctors and clinics. Her work has won several industry awards. REFERENCES 1. Department of Health, Review of the Regulation of Cosmetic Intervention (England: GOV.UK, 2013) https://www.gov.uk/government/publications/regulation-of-cosmetic-interventions-government- response [accessed 23 March 2015].

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015

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went, but you can rectify the situation. Use marketing strategies to attract them back to your clinic: an exclusive, limited-time offer with free taster sessions that showcase treatments needing regular clinic visits for optimum results. Provide results-driven treatments that patients can see and feel instantly – this will keep them coming back for more, and encourage them to book a course of treatments. Provide these ‘taster treatments’ on a usually quieter day, give it an appealing name and encourage them to bring friends to your new, say, ‘Love Your Skin Days’.

Maintaining Patient Loyalty Pam Underdown extols the value of offering VIP service to encourage patients back into your clinic

“You are the best and I will recommend you to everyone!” These are the words practitioners should want to hear from every patient. To achieve such acclaim, it is vital that you put the time and effort into making sure your patient experience is beyond compare from beginning to end. This patient has chosen you and your clinic because, in an increasingly busy, stressful world where time is precious, you are able to connect with them simply by listening and caring enough to give them what they really want – a treatment and service that makes them feel valued and special. The aesthetic patient that feels a bond with you and your clinic is your walking, talking testimonial. Retaining this bond is crucial. This can be done in a multitude of ways, primarily through rewarding existing patients for their continued loyalty, providing unparalleled service and reconnecting with past patients. The best way to maintain this relationship is by enhancing the patient experience; giving them the ‘wow’ factor that keeps them coming back for more. Are you a one hit wonder? If you spend all of your time, money and effort attracting a new patient and then never see them again, you are doing them and your business a disservice. If the patient felt confident enough in you to say yes initially, the hard part is done. The least you can do is reciprocate by staying in touch and following up with how they are. It’s always faster, cheaper and easier to reconnect with previous patients than it is to attract new patients, so do your best to maintain connections. You are never going to know why you lost patients, unless you reach out to them Chances are you lost some patients last year. Perhaps you can’t say for sure how many you lost, why you lost them or where they

Get all your basics right There’s a big difference between a ‘need’ and a ‘want’. A need is just what must be done, and your patient has very little emotional attachment to it. Meeting his or her needs won’t necessarily turn the individual into a long-term loyal patient. A want is different. There’s a reason why your patient desires something and this is often loaded with emotion. Explore their real reasons for seeking aesthetic consultations and reflect their own use of emotional words when presenting their individualised treatment plan. This way, your patient will know that you have listened and are now offering a personalised answer and treatment tailored to their wants. Another way of providing an individualised solution that suits the patient’s needs is to offer an annual treatment plan with monthly affordable payments, perhaps using a monthly online recurring direct debit system. Patients benefit in terms of spreading the cost of treatment, but to use this type of system your business needs to already be profitable. You must decide if this is of real value to your particular patient base and makes business sense for your clinic. However, ensuring return business is not about doing one or two big things; it’s doing a hundred little things with care and consistency, with every single patient and every single visit. Anything that is meaningful, memorable, fun, unusual or unexpected will influence how patients feel about you and your clinic. Train your team to give outstanding service. Don’t accept mediocre results from your team and before long you’ll be attracting the staff that don’t want mediocre results either. Motivate your team through regular meetings, training and team building sessions to keep morale high and reach your targets, thereby ensuring patients are consistently satisfied. Training should not just cover the clinical aspects of an aesthetic practice, but also brush up on business and customer service skills; skills that guarantee your patients leave your clinic in high spirits.

Ensuring return business is not about doing one or two big things, it’s doing a hundred little things with care and consistency, with every single patient and every single visit

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015

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Communicate and live by your ‘Patient Promise’ Your promise doesn’t need to be long; it just needs to explain what patients can consistently expect, why you’re different and how you keep your promises. Testimonials from existing, loyal patients that relate to your promise can be used as marketing material for new patients and reinforce your clinic’s positive image. For consistent results you need effective systems and processes in place, as well as the standards and measurements so you know whether your patient promise is being delivered every single time – regardless of which staff member your patients sees, what day they have had or their mood. In order to implement effective systems and processes (aka protocols) you must first ask yourself what your goal is with your new ‘Patient Promise’, the vision you are pursuing, your patients’ expectations, your team’s expectations, what you do (the system), why you do this and how you do it (the process). Document each element of your ‘Patient Promise’ using a stepby-step approach and decide which areas need monitoring and improving (the standards) and how you are going to measure each one. Will you measure based on emotional benchmarks (so you know the impact your clinic has emotionally on every patient)? Or will you measure it by performance (i.e. how quickly your phone is answered)? Will you measure by financial targets or by patient feedback? Once fully documented, you can train your team to

The best way to retain patient loyalty is not to cut back on costs when times are tough, but to invest in the right areas of your business implement each standard and ensure that the appropriate team member is accountable for on-going measurements, improvements and feedback. You must also include each one in your operations manual and staff handbook. A simple example of a standard is the measurement of incoming calls: perhaps your Patient Promise states that all calls will be answered within two to three rings – in order to measure that you must carry out the appropriate checks, either manually or by using call handling software to ensure this standard is met constantly. Remember, your job as the business owner is to ensure your team knows what’s expected of them. You must provide the training, measurement and support to guarantee each standard is consistently achieved. By sticking to your promise, your business will reap the benefits. Satisfied patients will not only come back regularly, but will also be more open to giving back, which may be in the form of providing consent for their treatment images to be used within your marketing, or offering honest feedback on your clinical services. Discovering your VIP patients Divide your patient database into those who are loyal, those who visited and never booked, and those who you treated but never saw again. People can be inconsistent – things change and people change. I’m sure you’ve heard that 80% of your profits come from

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20% of your patients. It’s called the Pareto Principle (named after the Italian economist Vilfredo Pareto) and it works just as well today as it did decades ago.1 The Pareto Principle is very simple, yet very important, particularly in business. What was most important about Pareto’s finding was that this 80/20 distribution occurs extremely frequently. In addition, the principle also suggests that 20% of your time produces 80% of your results. Your top 20% of patients provide a consistent revenue stream, and because of their frequent custom, they require less set-up time. Look for those who have spent more with you, visited most frequently, referred more patients than others or those who are very connected in the community. Then put a ‘fence’ around them to keep them happy, loyal, returning and referring. With these select number of patients, you should market to them in a different way, enhance their experience and reward them so that they feel appreciated. Make them part of your exclusive VIP Club so they receive extra perks that other patients don’t. Give them value-added extras such as: same day appointments, regular VIP patient appreciation events, or a free makeover after every procedure so they can go right back to their everyday activities. Another effective way of rewarding these patients could be by offering them a free monthly skin treatment, a free skin analysis or a retail discount card. Be creative; you have many options, just ensure that whatever you are offering is feasible and realistic; you don’t want to end up disappointing your best customers by failing to deliver on a promise. The end goal of this marketing activity is to make these patients feel special because they are part of your inner circle. The notion of a ‘VIP club’ has a very similar feel to the airline frequent-flyer clubs. You have a very different flying experience as part of the club – you get on first, there’s plenty of room for your luggage and you get more leg-room. It’s a different industry, but the same concepts apply. People like to feel special and will invest in that feeling. When a patient feels like they have been rushed through a treatment to make room for the next patient, they are less likely to feel special and will probably visit a clinic elsewhere. Capitalise on the idea of VIP service to ensure your patients are more than satisfied when they leave your clinic. This will guarantee verbal recommendations and ensure their return for their future treatments. If you look after your patients – they will look after your profits Return patients and referrals are what make a business successful. Your loyal patients are your brand advocates and should be treated like gold. Don’t take them for granted. Acknowledge and appreciate them for what they are – your positive spokespeople who keep coming back to you again and again, and bring their friends, family and colleagues. In simple terms, the best way to retain patient loyalty is not to cut back on costs when times are tough, but to invest in the right areas of your business; your patients, staff, marketing, education and continuous improvements to your patient journey. Do this well and watch your loyal patient base grow. Pam Underdown is a business growth specialist and the owner of Aesthetic Business Transformations. She works exclusively to help medical aesthetic business owners improve their marketing, increase their profits, reduce their costs and build a long term sustainable business asset. Pam has more than 25 years of business development, sales and marketing experience, including nine years in the aesthetics marketplace. REFERENCES 1. Lavinsky D, Pareto Principle: How to use it to dramatically grow your business, (Forbes, 2014) < http://www.forbes.com/sites/davelavinsky/2014/01/20/pareto-principle-how-to-use-it-to-dramatically- grow-your-business/> Last accessed 19 February 2015.

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015

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Handling a Legal Complaint In the January issue of Aesthetics, Dr Askari Townshend argued the importance of a skilful and thorough approach to handling potential litigation. This month, he shares his personal experience of managing a legal complaint Hamilton Fraser, the UK’s largest cosmetic insurer, include ‘top tips on how to avoid a potential claim’ in the knowledge centre1 on its website: 1. Keep detailed patient notes 2. Keep hold of your patient notes 3. Assess your clients carefully 4. Obtain a full medical history from the patient 5. Patient consent 6. Follow product guidelines 7. Record settings 8. Encourage patient to follow guidance 9. Patient literature 10. Take before and after photos All of these are important to follow and will reduce your chance of facing a claim, but bear in mind that they will not eliminate the risk – as I have found out to my cost. After opening my own clinic in 2008, patients that I had previously treated followed me. One lady was happy to travel a more than 100 mile-round trip for injectable treatments, which I felt was a compliment to my skills. After a thorough consultation with this particular patient, we agreed on Intense Pulsed Light (IPL) treatment for her mild rosacea. Before conducting the procedure I discussed each aspect of the consent form with the patient,

which she signed, took good photographs of her condition and performed a test patch. When she attended the clinic for her rosacea treatments, photographs were taken on each occasion and a questionnaire on change in medical history was completed. The first four treatments with incremental increases in energy produced excellent results. A very small blister did appear after the second treatment, but this resolved without consequence. For the fifth treatment, I increased the energy by one joule (the smallest increment) – this is normal practice as the target chromophore is reduced by the success of previous treatments. The next day, my patient contacted me to report that, after treatment, her face had felt hotter than usual and had developed blisters, also experiencing a significant amount of swelling. Without my knowledge, she had attended her local A&E department where she was treated with prednisolone and a topical antibiotic. Treating patients that are not local is challenging when there are complications. Although using modern technology, such as smart phones, to send and receive photographs or video calls are useful, digital communication is no replacement for face-to-face assessment, being able to support and provide necessary treatment

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or prescriptions. In addition, it is less likely that you will have colleagues that you can call upon or refer to. I gave my patient lengthy advice over the phone and asked her to keep me informed of her progress. The next day things had not settled and were, perhaps, even worse. She visited her GP and was referred to a dermatologist who saw her twice in two days and prescribed oral antibiotics to treat the complication. During this time I tried to keep in touch by phone, text and email, however, after a few days, she stopped responding to me completely. Never before (or since) have I come across such a violent reaction to a light-based treatment from such a small change in settings. It was especially unexpected as my patient had received several previous treatments, at greater energies than the one that had caused her blister, with no significant problems. My patient was adamant that there had been no recent sun exposure, changes in medical history or medication that could have contributed to the abnormal response. I immediately stopped using my IPL system and cancelled all booked treatments. The self-test used to diagnose any problems with the device was uneventful and the company engineer found no faults after conducting a full service. I contacted the company’s trainer and two other national experts who used the same system but none could shed any light on why this had happened. Once my device received the all clear I started using it again, very cautiously to begin with, and found no problem with any other treatments. I informed the Health Care Commission (as the Care Quality Commission (CQC) was known then) and my insurer. With no channels of communication, there was nothing more that I could do to help my patient, which meant I could only wait and hope that all was healing well. I received a formal letter of complaint four months later, to which I replied expressing my regret at what had happened and enquired what outcome she hoped for in order to resolve the complaint. The patient had seen a dermatologist who had recommended a course of laser treatment to correct minor scarring. She had also discussed the case with a solicitor and asked for £9,000 in compensation. Even if I had wanted to, I didn’t have the money to pay this. Having discussed this with my insurer I offered a fraction of this amount, which was declined. The

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015

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excess on my insurance was £1,500, so offering significantly more than this wasn’t practical. After the first flurry of solicitor letters encouraging me to admit liability (something you must not do without discussing with your insurer first as it may be against the policy requirements) we didn’t hear anything for more than a year. I thought that perhaps the solicitors had recognised the quality of my notes and consent process and had decided not to pursue the case. This was optimistic as three years after the procedure had taken place, her solicitors were in touch once again. My solicitors felt that there was a weakness in our case as I had increased the energy of the treatment without a prior test patch. Some practitioners advocate test patches at the end of each treatment, though, in reality, this is not a good verification of treatment response. A single shot is not comparable to the heat generated from a full treatment – of course this is not to be confused with test patches before the first treatment, or after a significant change in settings, which are vital. This issue

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had been discussed at a British Medical Laser Association (BMLA) meeting I had attended after the incident, which found that the majority of members – if not all – did not routinely test patch before every minor change of settings. Despite this, my solicitor felt that a judge may rule that a test patch could have avoided the injuries caused – especially as judges are not always sympathetic towards our speciality. This was a disappointment as I felt that I had done all that I could to ensure a safe treatment, and had not been able to find any practitioner that felt otherwise. The result of the process, drawn out across four years, was a payout to my patient of £7,000, with an additional £16,000 of legal costs. The financial cost to me was a £1,500 excess fee and an increase in my premiums, which no doubt will take some years to normalise. Legal complaints are a stressful time for all concerned and can last many months, if not years. During this time it is important to keep in close contact with your insurer, especially before communicating with your patient, to ensure that you do not

do anything to weaken your case or invalidate your cover. Solicitor letters are often worrying and use language that may overstate their position. Try not to take the process as a personal or professional attack – a successful claim from a patient is not always a sign that you have acted improperly in any way. Treat within your skill set, with care and diligence, and document every treatment as if a complication is expected. Even if you do this, you may well find yourself having to go through the claims process – but at least you will have protected yourself as best as you can. International trainer and UK medical consultant for Sculptra by Sinclair Pharma, Dr Askari Townshend qualified as a doctor in 2002 and was awarded MRCS in 2006. With extensive injectable experience, Dr Townshend opened his own clinic in 2008. In 2010, he sold the clinic to become director of medical services at sk:n until 2013. REFERENCES: 1. Hamilton Fraser Cosmetic Insurance, ‘Our top tips on how to avoid a potential claim’, Resources & Guides (2015) <http://cosmetic-insurance.com/wp-content/ uploads/2013/07/hfisc_3721-A52pp-TopTips-v1.pdf> Last accessed: 18 February 2015.

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Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015

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“It’s fascinating to see how our specialty and the industry is developing across the globe” Consultant nurse practitioner Constance Campion tells us about her varied career within aesthetics, and the values that come first Hailing from a family of medical professionals, becoming a nurse was a natural career path for Constance Campion. “The care of patients was something I was often exposed to as a young child,” she explains, “My grandmother and my aunt and uncle’s professional standing and benevolence was particularly noticeable and I wanted to emulate this.” In 1972, Campion began her nurse training at St. Vincent’s University Hospital in Dublin, after which she studied midwifery at The Rotunda Hospital. After an early nursing career, she worked in the private medical sector and was later headhunted into private equity. This led to a role as an analyst, where she became associated with the birth of the private medical sector in Denmark. Since 1989, Campion has been a partner at Plastic Surgery Associates – a plastic, reconstructive and aesthetic surgery practice based at Bupa Cromwell Hospital – and went on to expand this service by founding The London Wellness Age-Management Centre. In this time she also founded Medico Beauty Ltd. and The Medico Beauty Institute, an aesthetics distribution network and education company, established in 1998. Speaking to Campion, it is clear that she is fiercely passionate about the nursing profession. “Regretfully, there’s a great misunderstanding and lack of knowledge about the specialist nursing role which has to a great extent undermined the central role of nurses,” she says. “Nurses are the experts in patient care and that is not definable or negotiable in any setting where patients are placed. As competent nursing care underpins patient outcomes, it was regrettable that Keogh did not explore, let alone critically analyse, the elements of nursing care that should have been strengthened in the sector.” Voicing the sentiments and experiences of

aesthetic nurses, says Campion, is something that needs work. Whilst she is critical of the Keogh Review, she says the jury is out on the work of Health Education England (HEE). She does, however, fully support the work that is being done by nursing colleagues, who are representing and piloting the re-validation work being conducted by the Nursing Midwifery Council (NMC) and the British Association of Cosmetic Nurses (BACN). Campion has recently become the BACN’s London regional leader, having, alongside colleagues, first introduced and formally set out the aesthetic nursing specialism to The Royal College of Nursing in the early 90s; subsequently supporting the establishment of the BACN that followed. Education, specialist training and ethics are vital to improving the standing and branding of our mutual specialism and the aesthetics industry, argues Campion. “There is a clear demarcation and distinction between training and education,” she says. “There is still no core specialist education available and aesthetic practitioners have to rely on supply companies for professional development and information. There needs to be demarcation between what constitutes product-training and what’s generic specialist education.” Establishing competency standards in medical aesthetics has been pivotal to Campion’s work. She chaired the first steering committee at the Royal College of Nurses (RCN) and joined her nursing colleagues to help write registered competencies. Aesthetic practice is, “A lot tougher than people think”, she says. “You’re trying to enhance, rejuvenate, protect and heal – and this equates to a huge scope of responsibility to the patient and their family,” she explains. “You also carry the duty to hold yourself out as a reliable and competent professional as a nurse. You really do worry about patients, about the risks and possible complications, whilst having to balance this against the patient’s notion of expectation associated

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with their results – it’s always on your mind.” Reflecting on her career, Campion says, “Managing to have an entwined career, where I am an analyst, a businesswoman and a nurse, has been really rewarding and interesting. From the perspectives of the various threads I work in, it’s fascinating to see how our specialty and the industry is developing across the globe.” Whilst Campion acknowledges she is proud of her own success, she emphasises that her marriage and family hold more value than anything else. “My husband and my family have been pivotal in my make-up and shaped me as a person,” she says. “I am very grateful and I don’t deny that hard work and meaningful choices lead to achievements, but business and career success can never take away from the values I am rooted in – my family and care of my patients are what comes first.”

What treatment do you enjoy giving the most? Any treatment related to the skin. I enjoy facial augmenting and re-contouring. But I never cease to be amazed by what can be achieved in the skin. What technological tool best compliments your work? The skin is a very revealing organ and can be the most amazing tool if you understand how to assess it. You can harass its cellular biological regenerative processes to repair itself. You become far less reliant on magic wands and devices if you start first with educating and training in the cellular aspects of the skin. What’s the best piece of career advice you’ve been given? “When you’ve reached the end of your rope, tie a knot on it and hang on!” Do you have any industry ‘pet-hate’? I don’t like reliance on extrinsic rejuvenation alone, because it mimics and limits practitioners to the levels of a beauty menu. Almost every identifiable issue in aesthetics that we deal with is also linked to an intrinsic issue. What aspects of aesthetics do you enjoy the most? Comprehensive-integrated consultation and assessment, and skin analysis. That’s one of the busiest processes for us in our practice, because it sets out the specialist’s paradigm in patient consultation, which leads to appropriate treatment choices and patient care.

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015

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The Last Word Dr Steven Dayan argues for patient education in a world of distorted images “I’m not happy, look at my phone. My nose is too big.” Are these words familiar to you? When consulting with a patient, do we always know which version of the patient we are attempting to treat – what they see in a mirror, their appearance as we see it, or their appearance as they see it reflected in the screens of their phone? Over the last five years, the new craze for ‘selfies’ has exploded in popular culture, sometimes with no regard for boundaries or borders. It has without a doubt impacted our consultation process, and maybe even the way we practice cosmetic medicine. When the president of the US is caught taking a ‘selfie’ with the prime ministers of Britain and Denmark at a gathering of global leaders, there is no denying this craze is crosscultural, and adopted by people worldwide. Yet taking an effective photograph like this is no mean feat. A photo that is taken close to its object will often enlarge and distort the portion of the object that is closest to the lens, as demonstrated when taking a picture with a concave, or ‘fish eye’ lens. So when the lens of the phone camera is only a few centimeters away, or the distance of an arm, it makes whatever feature of the face that it is closest to look biggest. If the camera is straight on, then the nose looks largest; if from above then the eyes look greatest; if taken from below then the chin and the lower one third of the face predominates. Recent advances in product technology has allowed for the creation of a device known as a ‘selfie stick’ – a convenient portrait-pleasing device that is attached to a smart phone to allow users to take photographs from a distance of one metre. The end result is a more proportional and flattering facial image. For this same reason, professional photographs are taken from a distance, in such a way that all facial features are at a relatively similar distance from the lens. In our western society, the female face that is generally considered attractive is one with a large upper third, one highlighted by prominent infantile eyes and coupled with a small chin. Our culture also appreciates sumptuous lips. This is reflected in the myriad of ‘selfies’ we see, and that are brought to us, where the patient has taken the photograph from above and is consciously making the lips seem more prominent. In contrast, patients that

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take a selfie with the camera directly in front of their face notice a nose appearing bigger and inconsistent to what it is in real life; a discouraging reality to, say, the recent rhinoplasty patient, especially when they look in the mirror and are equally discontent but not sure why. A mirror is a reverse image of what is seen in a photograph. A bump on the left side of the nose now becomes a bump on the right side of the nose, and it can get confusing. Additionally, we tend to be most comfortable with our image in a mirror because this is the version of ourselves we see most frequently. But even the physics of a mirror misrepresents from what others see of us. In a mirror, our facial size is half of what it is in real life, regardless of the distance you stand from the mirror. Yet most people believe the dimension of their face is the same size in the mirror as it is in real life. So our brain compensates, overestimating facial features. So we have a mirror and a phone photo that are opposite images of each other, and both are varied images from what an outside observer perceives. Therefore when a patient is disappointed with how they look in a picture, when they tell us that they desire a smaller nose, which version of the patient are we attempting to improve? Without clear communication on the shifting parameters of image taking, this puts us, and the patient, in an Alice in Wonderland scenario of questioning what is real and who are we treating. I believe that the best way to address this is to first educate our patients, pulling out a mirror and a camera phone and demonstrating the image differences. It’s important to let them

We tend to be most comfortable with our image in a mirror because this is the version of ourselves we see most frequently know that while we want to improve their appearance and meet their expectations, we are also interested in maintaining a natural appearance, since if we treat only their ‘selfie’ image, we may inadvertently make their nose too small. We certainly are in a difficult position where we are tasked with making people look better naturally, yet also meeting their demands. In my opinion, part of being a practitioner is to be a teacher, and I think it is our responsibility to educate our patients, the media and a new generation of selfie takers about the physics of distorted imagery. In this evolving modern age, this kind of approach is integral to a successful consultation, and a successful aesthetic treatment. Dr Steven Dayan is a facial plastic surgeon who has had more than 90 articles published in medical journals and authored five books including Subliminally Exposed. His accolades include the AMA Foundation’s Leadership Award. He serves on the scientific and steering committees of multiple medical congresses, holding an elected position within his facial plastic surgery society.

REFERENCES 1. Lawson R, Bertamini M. ‘Errors in judging information about reflections in mirrors’, Perception 35(9) (2006) p 1265-88.

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015

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