Aesthetics April 2017

VOLUME 4/ISSUE 5 - APRIL 2017

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Managing Rosacea CPD Dr Priya Patel and Dr Sandeep Cliff examine treatment options and their efficacy

Special Feature: Dark Circles

Compensated Brow Ptosis

Practitioners discuss injectable techniques for rejuvenation of dark circles under the eye

Mr Marc Pacifico advises how to recognise the aesthetic concern

Using KPIs Reece Tomlinson details how to track and manage performance using key indicators

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Contents • April 2017 06 News The latest product and industry news 14 On the Scene

Out and about in the industry this month

16 News Special: HIS Registration Launch

A look at the private clinic registration introduced by Health Improvement Scotland and its potential impact on aesthetic practitioners

CLINICAL PRACTICE 21 Special Feature: Dark Circles

Special Feature Dark Circles Page 21

Practitioners discuss the causes of dark under-eye circles and how to correct the common concern with injectable treatments

26 CPD: Managing Rosacea

Dr Priya Patel and Dr Sandeep Cliff outline the efficacy of existing treatment options for the common facial redness concern

32 Recognising Compensated Brow Ptosis

Mr Marc Pacifico shares advice on how to recognise compensated brow ptosis and details the various treatments available

37 Case Study: Treating Severe Photoageing

Dr Harryono Judodihardjo presents a case study of treatment using a new thermo-mechanical fractional ablative skin resurfacing device

39 Advertorial: SkinCeuticals A look at the first SkinCeuticals Advanced Aesthetic Centre in the UK 41 Remodelling the Earlobe

Dr Salinda Johnson outlines non-surgical techniques for treating earlobes

47 Treating Cankles

Dr Sanjay Gheyi examines treatment options for lipodystrophy of the calf- ankle area and details the anatomical considerations to be aware of

52 Advertorial: Almirall

Introducing VANIQA, a non-hormonal topical treatment for female facial hirsutism

53 Abstracts

A round-up and summary of useful clinical papers

IN PRACTICE 55 Common SEO Faults and How to Avoid Them

In Practice Consulting Religious Patients Page 64

Clinical Contributors Dr Priya Patel is a core medical trainee at East Surrey Hospital. She is an aspiring dermatologist, currently working with Dr Sandeep Cliff, and takes an active interest in topics involving allergy and immunology.

Dr Sandeep Cliff is a consultant dermatologist and dermatological surgeon based in London and Surrey. He has lectured extensively both nationally and internationally on facial rejuvenation.

Mr Marc Pacifico is a consultant plastic surgeon based at Purity Bridge in Kent. He is on the Specialist Register for Plastic Surgery with the General Medical Council, sits on the BAAPS council and is a member of BAPRAS and ISAPS.

58 Performance Management Using KPIs

Dr Harryono Judodihardjo is the medical director of the Cellite Clinic Ltd in Cardiff. He obtained his Master’s degree and PhD in Dermatology from the University of Wales College of Medicine. Dr Judodihardjo specialises in aesthetic dermatology.

62 Advertorial: Viviscal Professional Learn about the Viviscal Professional Hair Growth Programme

Dr Salinda Johnson is an aesthetic practitioner who has completed a specialist fellowship programme in cosmetic dermatology. She has lectured and trained in the specialty for many years, incorporating up-todate procedures and best practice as they develop.

Marketing consultant Adam Hampson discusses how to effectively utilise search engine optimisation Global business executive Reece Tomlinson advises how to boost a clinic’s success using key performance indicators

64 Consulting Religious Patients

Dr Sabba Janjua outlines consultation considerations for Muslim patients

66 In Profile: The Ravichandrans

Dr Simon and Dr Emma Ravichandran detail their shared journey into medical aesthetics

68 The Last Word

Mr Ibby Younis discusses the importance of psychological education and training for professionals working in the aesthetics specialty

NEXT MONTH • IN FOCUS: Treating Lips • ACE 2017 in Review

Dr Sanjay Gheyi is the medical director and laser surgeon at the Coltishall Cosmetic Clinic in Norfolk. Dr Gheyi has triple board certifications in General Surgery, Family Medicine and Anti-ageing Medicine. Dr Gheyi offers surgical as well as non-surgical procedures.

Aesthetics Awards Entry Opens May 2!

www.aestheticsawards.com

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Editor’s letter Welcome to the April issue of the journal!

I hope that you are reading this on your break at ACE 2017; if all runs to plan it will be yet again the hottest weekend of the year so far, and you will be basking in the sun as it streams through Amanda Cameron that fabulous glass roof of the Business Design Editor Centre. If it’s raining – I am sorry! But even the weather cannot dampen the spirits of speakers and attendees as we have everything in place to make it the best conference yet!

If you could not make it to ACE (and I hope you have a good excuse not to be there!) we still have plenty of learning opportunities packed inside this issue. Dr Priya Patel and Dr Sandeep Cliff have written an extremely comprehensive review of rosacea as this month’s CPD article, one of the best I have read in fact. Make sure you turn to p.26 to learn more about this common aesthetic concern. While we focus primarily on the face in medical aesthetics, this month we look at other parts of the body, including rejuvenating earlobes by Dr Salinda Johnson on p.41 and treating ‘cankles’ by Dr Sanjay Gheyi on p.47 – an unsightly concern that is often talked about but rarely written about in aesthetics, making it an informative addition to the

journal. The Business Track is always popular at ACE and this year will be no exception, with a full agenda covering all your development requirements. But don’t forget, you can also read our In Practice section of the journal to increase your commercial acumen and consultation skills. This month, it features fantastic articles on consulting religious patients (p.63), search engine optimisation (p.55) and the second article in business executive Reece Tomlinson’s performance management series (p.58). Without efficient operation management systems and optimally performing staff we have no business, so Tomlinson lays out very easy-to-follow procedures to measure key areas of your business using KPIs – well worth implementing if you haven’t already done so!

I hope everyone has a wonderful time at ACE 2017, filled with learning and lively debate on the many topics presented. Look out for exclusive interviews and photos of the event’s highlights in next month’s issue!

Be sure to share your feedback and pictures with us by tagging: @aestheticsgroup - Twitter @theaestheticsjournal - Facebook @aestheticsjournalUK - Instagram Also, don’t forget to say hello to the team at ACE – we love to meet our readers to learn hear what you want to see more of in the journal!

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

Dr Raj Acquilla is a cosmetic dermatologist with more than 12

Sharon Bennett is chair of the British Association of

Dr Tapan Patel is the founder and medical director of VIVA

Dr Christopher Rowland Payne is a consultant

Mr Adrian Richards is a plastic and cosmetic surgeon with

Dr Sarah Tonks is a cosmetic doctor, holding dual

Dr Maria Gonzalez has worked in the field of dermatology

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.

Cosmetic Nurses (BACN) and the UK lead on the BSI committee for aesthetic non-surgical medical standards. Bennett has been developing her practice in aesthetics for 25 years and won The Institute Hyalual Award for Aesthetic Nurse Practitioner of the Year in 2015. 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. qualifications in medicine and dentistry. Based in Knightsbridge, London she practices a variety of aesthetic treatments.

Dr Tonks has appeared on several television programmes and regularly speaks at industry conferences on the subject of aesthetic medicine and skin health.

years’ experience in facial aesthetic medicine. In 2015 he won the Aesthetics Award for Aesthetic Medical Practitioner of the Year and in 2012 he was named Speaker of the Year. Dr Acquilla is a UK ambassador, global KOL and masterclass trainer in the cosmetic use of botulinum toxin and dermal fillers. and PHI Clinic. He has more than 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.

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

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Events diary

17th – 18th May 2017 BMLA Laser and Aesthetics Conference, Manchester www.bmlaconference.co.uk

18th May 2017 British Association of Sclerotherapists Annual Meeting, Windsor https://www.bassclerotherapy.com

15th – 17th June 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons Summer Scientific Meeting, Helsinki www.bapras.org.uk

4th – 6th July 2017 British Association of Dermatologists 97th Annual Meeting, Liverpool http://www.bad.org.uk

Allergan to spend €42 million in expansion Global pharmaceutical company Allergan has revealed plans to invest more than €42 million (approximately £36.7 million) into its Irish operations.

The plans were announced after Allergan celebrated 40 years of business in Ireland on March 1. According to the company, the money will be invested into the Westport facility, which produces Botox and eye care products, and in Clonshaugh, where its tablet-based medicines are manufactured.

Allergan chairman and chief executive Brent Saunders said, “We are excited to announce continued investment in our Ireland operations, which will help Allergan continue to provide patients in Ireland and around the world with our innovative medicines. As Allergan continues to grow its operations globally, Ireland continues to be a cornerstone of that growth. Our success has been built on strong teams globally, including our highly talented team we have here in Ireland, operating at state-of-the-art manufacturing facilities producing pharmaceutical products for the global market.”

With this announcement also came plans to implement a new annual €50,000 Innovation Award Programme, where Allergan will partner with six colleges around Ireland to recognise and support scholars who have excelled through innovative research in the field of Life Sciences.

Awards

2nd December The Aesthetics Awards 2017, London www.aestheticsawards.com Training

UK Aesthetic Academy launches A new training academy providing courses that teach techniques in non-surgical injectable treatments has launched. The UK Aesthetic Academy (UKAA) consists of clinical courses designed to provide delegates with knowledge of facial anatomy, develop practical skills for confident injections and learn about patient safety and skin health using the NeoStrata Skin Fitness regime.

The training will be provided by experienced registered nurses and UKAA founders, Yvette Newman and Gail Stewart. Dr Kuldeep Minocha, who trained with Newman prior to the launch of UKAA, said, “I owe a great debt of gratitude to Yvette for being an integral part of my learning and education during my formative years as an aesthetic practitioner. Her gentle manner, her experience and her expertise combine to make you very quickly feel comfortable and confident in your own ability.” Courses are currently available in London, East Midlands and Scotland and there are plans to launch in Manchester.

Aesthetics aestheticsjournal.com

Industry

6th – 8th April 2017 15th Aesthetic & Anti-aging Medicine World Congress, Monte Carlo v1.euromedicom.com/amwc-2017

Aesthetics Journal

Entry to the Aesthetics Awards 2017 opens in May

Practitioners, clinics, manufacturers and distributors in the aesthetics specialty will again have the opportunity to win a prestigious Aesthetics Award, with applications opening on May 2. The Aesthetics Awards is the premier Awards ceremony in the UK and brings together the best in medical aesthetics to celebrate the achievements of the past year. This year, there will be 26 categories for entrants to choose from, including Awards for clinics, individual practitioners and reception staff, as well as manufacturers, distributors, suppliers and products. Out of these categories, there are seven new categories that entrants can choose from: Wholesaler of the Year, Best Global Manufacturer/Supplier, Best Supplier Training Programme, Best Clinic Support Partner, Energy Treatment of the Year and Industry Initiative of the Year.

Aesthetics Awards organiser Amanda Cameron said, “I can’t believe it’s already time for aesthetic practitioners and companies to get their Awards entry prepared for May! As we are growing every year, we anticipate the standard will be higher than ever this year. There is so much competition so get ready to blow your own trumpet and accompany your claims with all the requested relevant supporting evidence. Good luck to all applicants!”

The Aesthetics Awards ceremony will take place at the Park Plaza Westminster Bridge Hotel on Saturday December 2. For more information and to enter on May 2, visit www.aestheticsawards.com

Reproduced from Aesthetics | Volume 4/Issue 5 - April 2017

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PRP

Biotherapy Services partners with Cosmedic Pharmacy Biotechnology research and development company Biotherapy Services has partnered with aesthetic supplier Cosmedic Pharmacy to supply the full range of systems and consumables for platelet rich plasma (PRP) on prescription.

Dr Janet Hadfield, director of Biotherapy Services, said, “We are delighted to have a UK pharmacy partner to help distribute the products we are seeing grow in the UK aesthetic market, our systems are extremely specialist and we are committed to build on supply with an emphasis on the safe efficacious use of PRP and excellent clinical support.”

Iain Ashby, superintendent pharmacist of Cosmedic Pharmacy, said, “We are looking forward to working with Biotherapy Services who have become one of the premium suppliers not only into the aesthetics market but in the wound healing sector. We are launching our new website soon to make ordering even quicker and more convenient for customers.”

Body contouring

Alliance is introduced to the UK A new body contouring device by aesthetic manufacturer LPG Endermologie is now available in the UK. Alliance is a mechanical massage system that aims to contour the body by eliminating localised fat deposits and firming the skin by stimulating it to naturally reactivate cell metabolism.

According to Technical Laser Care, the exclusive UK distributor of Alliance, the system has undergone three years of research and there are more than 145 clinical studies available.

Nigel Matthews, UK sales manager for Technical Laser Care, said, “We are very excited to be distributing the LPG range of technologies as the focus is on the ‘fight for natural beauty’, and the technology is non-aggressive and non-invasive. We understand that a lot of customers want to look great and feel great but still want the holistic approach and the new technology from LPG is the way forward.”

Matthews added, “From an aesthetic practitioner point of view, it’s all about results, treatment costs and turn-around times. With the new technology from LPG, it allows the original treatment time of 40 minutes to be cut in half to 20 minute sessions, this obviously would mean more customers over the working day and more ROI.”

Talk #Aesthetics Follow us on Twitter @aestheticsgroup #Anatomy Miss Sherina Balaratnam @MissBalaratnam Enjoying hosting a #Visionary training day for my colleagues in #Beaconsfield, training on facial fillers with the latest #MDCodes #IPL Dr Beatriz Molina @Medikas1 Getting fantastic results with our new IPL machine. Our patients love it! #BodyContouring Dr Galyna Selezneva @DrGalyna Delighted to be named in @TatlerUK Cosmetic Guide 2017 as a ‘flipping brilliant’ body expert! #Coolsculpting #bodycontouring #MaleAesthetics Dr Daniel Sister @DrDanielSister I enjoyed speaking to @CJAD800 today about the rising numbers of men seeking aesthetics treatment. #liveradio #maleaesthetics

#Launch Dr Jonquille Chantrey @misschantry A big stage for my big launch in Asia. The honour of teaching Asian beauty experts, strategies & techniques using Juvéderm & Botox #Melasma Dr Sam Bunting @drsambunting Really excited to be hearing about oral treatment options for #melasma #tranexamicacid #aad2017 #Teaching Dr Joney De Souza @DrJoneyDeSouza Teaching microsclerotherapy today at Wigmore Medical. @WigmoreMedical #microsclerotherapy #legthreadveins #aestheticdoctor

Reproduced from Aesthetics | Volume 4/Issue 5 - April 2017

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Hyaluronic acid

Allergan launches Juvéderm VOLITE

Pharmaceutical company Allergan has launched Juvéderm VOLITE to the UK, the company’s first injectable treatment specifically designed to improve skin quality.

The new hyaluronic acid (HA) injectable treatment aims to improve skin smoothness and increase hydration and elasticity with its VYCROSS technology, which is a combination of low and high molecular weight HA aimed to improve the cross-linking efficiency of HA chains. According to the company, Juvéderm VOLITE aims to deliver results that eliminates the need for multiple treatments and can be used to treat the face, neck, décolletage and hands, and contains lidocaine to increase patient comfort.

In a ten-month clinical trial of 131 patients by Allergan, results indicated improvement in skin quality and hydration; 96% of patients’ had

smoother cheeks one month after treatment and 91% reported they were more satisfied with their skin. Aesthetic surgeon Miss Jonquille Chantrey, who worked on the research trial, said, “Juvéderm VOLITE answers a real patient need for a treatment that delivers a healthylooking glow providing results from just one treatment. This product will be a game changer in my clinic. I believe that great skin can have a profound impact on patients’ everyday lives as smooth, radiant, hydrated skin from within hugely improves self-confidence. This is a genuinely innovative treatment option that I’m thrilled to be able to offer my patients.”

Senior vice president of international strategic marketing for medical aesthetics at Allergan, Caroline Van Hove, said, “The launch of Juvéderm VOLITE defines Allergan’s entrance into the skin quality category – an area that we know is set to experience huge growth over the next few years, and with a product designed to last up to nine months with just one treatment.”

Speaking about the new entry she added, “This demonstrates our ongoing commitment to delivering medical aesthetics treatment that physicians and their patients really want, that is convenient for patients and doctors, and of high quality in its results and safety.”

Nutraceutical

4T Medical to distribute new antiageing nutrient complex Aesthetic product supplier 4T Medical has become the UK distributor of a TimeBloc.

The new Swiss antiageing nutrient complex aims to support cell regeneration and protection, and slow down the biological ageing process in DNA. According to the company, the plantbased compounds in TimeBlock consist of antioxidants and polyphenols to reduce

inflammation and elongate telomeres, the caps found at the end of chromosomes that protect cells and genes.

TimeBlock is said to work by revitalising cells and boosting energy levels, which then supports the immune system and improves circulation, libido and optimises sleep patterns. Julien Tordjmann, managing director of 4T Medical, said, “We are

Distribution

really excited to be adding TimeBlock to our portfolio. The nuanced day and night capsules target the root causes of ageing which include DNA damage, inflammation and oxidative stress. The results can be seen in stages, with the first noticeable effects being higher energy levels, improved nail and hair growth, better sleep patterns and less joint pain.”

Sclerotherapy

Dalvi Humzah Training and MATA to provide Level 7 qualification The award-winning anatomy and complications courses by Dalvi Humzah Aesthetic Training are set to be offered as a Level 7 qualification. Working in collaboration with the Medical and Aesthetic Training Academy (MATA), Dalvi Humzah Aesthetic Training will offer Level 7 qualifications in both anatomy and complications. Mr Dalvi Humzah, consultant plastic surgeon and lead tutor, said, “We are delighted that these two courses will soon be awarded at Level 7 and become a qualification. I have had an amazing amount of support from assistant tutor Anna Baker, who has worked tirelessly with the development of these courses and this hard work and effort has now been completely justified.”

Delegates who have previously attended the courses will also have the opportunity to convert their previous training into a qualification.

BAS to hold sclerotherapy conference in May The British Association of Sclerotherapists (BAS) will hold its annual meeting on May 18 at the Dorney Lake Conference Centre in Windsor.

Delegates can expect to gain knowledge on the latest developments in foam sclerotherapy and microsclerotherapy, be able to network with peers and visit exhibitors at the conference. Speakers confirmed for the conference include Professor Jean-Francois, vice president of the French Society of Phlebology who will speak in a session on the 3D imaging of veins and compression treatments; consultant vascular surgeon, Mr Sudip Ray, who will lead a morning session on vein glue VenaSeal and will assess this technique in treating varicose veins; and Mr Philip Coleridge Smith, consultant vascular surgeon and president of BAS, who will discuss sclerotherapy for ankles, feet, hands, arms, chest and face. Delegates can also attend a business session covering marketing advice for clinics by Pam Underdown, CEO of Aesthetic Business Transformations.

Reproduced from Aesthetics | Volume 4/Issue 5 - April 2017

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Training

Dr Wolfgang Redka-Swoboda joins Dalvi Humzah Aesthetic Training International German educator and aesthetic surgeon Mr Wolfgang Redka-Swoboda will join consultant plastic, reconstructive and aesthetic surgeon and course founder Mr Dalvi Humzah to teach a session on ‘The Management of NonSurgical Complications Through Anatomy’ on May 18. Mr Redka-Swoboda received his board certification as a general surgeon in 1992 and has been running workshops for dermal fillers since 2002, with his main area of specialty being risk management and dealing with side effects after filler treatment. He is also the scientific director for all workshops and scientific meetings organised by Teoxane Germany. Mr Humzah said he is thrilled that Mr Redka-Swoboda will be providing his expertise to delegates. He said, “We are really excited to have Wolfgang on board – he is an established international educator both in anatomy and injectables so has great experience in both areas of knowledge.

Finding someone with strong knowledge in both these areas is difficult but more important than that, he is someone who makes learning fun.”

Mr Humzah added, “Wolfgang has a fantastic educating style that is enjoyable and memorable and with his experience he is a great addition to our complications and anatomy course that we run. We feel very honoured that he should come and join our faculty for this session.”

Aesthetics

Vital Statistics

In 2016, 66% of facial plastic surgeons in the US reported combined non-surgical procedures in the same patient as the top trend in their practice (AAFPRS, 2017)

Global mobile data usage grew by 63% in 2016

63%

(Cisco, 2017)

Normal hair loss is considered to be 100 hairs per day, based on the average scalp containing 100,000 hair follicles (belgraviacentre.com, 2017)

Body contouring

SmartMed to distribute LIPOcel Medical systems distributer, SmartMed, a subsidiary of Healthxchange Group, has become the exclusive UK and Ireland distributor of the LIPOcel, a body contouring system that provides treatment for fat reduction.

The non-invasive technology is designed to deliver high intensity focused ultrasound (HIFU) energy deep under the skin to destroy fat cells and is used to treat the flanks, stomach, underarms, knees and back of thighs.

According to the company, LIPOcel contains a cooling system that reduces the handpiece surface temperature. This lower temperature aims to minimise patient pain in epidermal and nerve areas, whilst providing high energy into the subcutaneous fat layer. SmartMed also claims the HIFU technology improves skin laxity and produces a smooth post-procedure result.

Karen Hill, operations and sales director at SmartMed, said, “SmartMed are delighted to announce the extension of our partnership with international medical device manufacturer Jeisys by launching LIPOcel in the UK and Ireland, which is a fantastic addition to our range of non-invasive aesthetic innovations including ULTRAcel and INTRAcel.” She added, “LIPOcel is a significant breakthrough in fat busting technology, delivering focused ultrasound through its patented contact cooling system, ensuring maximum heat energy transfer without causing pain or disruption to the skin’s surface.” The Dr Rita Rakus Clinic has added LIPOcel to its product portfolio and Dr Galyna Selezneva from the clinic said, “This is the newest addition to our range of body contouring treatments and we have been impressed with the results.”

There was a record 5.5 million private sector businesses at the start of 2016 (GOV.UK, 2016)

Acne is the most common skin condition in the US affecting up to 50 million people every year (American Academy of Dermatology, 2016)

36% of searches on Google are associated with location (Google, 2016)

In England, the prevalence of obesity among adults rose from 14.9% to 26.9% between 1993 and 2015 (Public Health England, 2017)

Reproduced from Aesthetics | Volume 4/Issue 5 - April 2017

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BACN UPDATES A roundup of the latest news and events from the British Association of Cosmetic Nurses

AUTUMN AESTHETIC CONFERENCE ‘Sharing our Vision, Shaping the Future’ Friday 15 & Saturday 16 September Birmingham International Convention Centre After an amazing event in 2016, the BACN has extended its Annual Conference to a two-day event. The Friday programme will include six workshop sessions and an exhibitors/delegates welcome get-together sponsored

by Wigmore Medical, while the Saturday programme will showcase the best speakers and developments in the industry. 2016 was a sell-out event with 300 delegates and 50 exhibitors, so we aim to improve on this even more for 2017! This event is primarily for BACN members but packages are available for non-members. Details regarding the programme and exhibitor packages will be available from April 1, so make sure you book soon. We have already received many repeat bookings from 2016!

Delegate Bookings: Please book through the BACN Conference Events Page.

Exhibitor Bookings: conference@bacn.org.uk

BACN MEMBERSHIP The BACN Membership year runs from April 1 2017 to March 31 2018. 2016-17 was a record year for the BACN, which is approaching 700 members and is growing at around 30 new members a month. With growth comes change and there are many new initiatives and services being launched in conjunction with our amazing strategic partners: Allergan, Galderma, Church Pharmacy, Hamilton Fraser Cosmetic Insurance, AlumierMD, AestheticSource, Cynosure UK, Teoxane, Sinclair Pharma, Merz Aesthetics and Healthxchange.

Look out for the new ‘BACN Mentoring Programme’, education/training events and our ‘Campaign’ themes for 2017, working with partners who share our vision.

BACN AND REGULATION The BACN members are passionate about regulation and patient safety. 2017 sees the launch of the new Joint Council for Cosmetic Practitioners (JCCP) which has generated much debate. The BACN is consulting its members on all aspects of the JCCP and will review the results of this survey in April.

MEET A MEMBER Jane Laferla is an independent nurse prescriber and BACN regional lead for Wales. Her nursing experience spans over 30 years, having worked in the aesthetic field since 2006. Laferla offers training, supervision and mentorship to newlyqualified aesthetic practitioners and is currently spearheading a BACN Mentoring programme due to be launched soon.

Come and see us on Stand 62 at ACE 2017!

This column is written and supported by the BACN

Aesthetics Journal

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Training

Acquisition Aesthetics announces new dates for injectables course Aesthetics training academy Acquisition Aesthetics has confirmed new training dates for the Combined Foundation Botulinum Toxin and Dermal Fillers course.

The course aims to train practitioners, dentists and nurses in the delivery of botulinum toxin and dermal filler treatments for wrinkle reduction, volume enhancement and lip augmentation. According to the training academy, the one-day training course covers the theoretical and practical elements of cosmetic injectables used for foundation level treatments. The topics covered within the programme include facial anatomy, skin histology, and background sciences of botulinum toxin and dermal fillers. The course is certified with six CPD points and the faculty consists of plastic and maxillofacial surgeons.

Lead trainer of the course and co-director of Acquisition Aesthetics, Dr Lara Watson, who is also a member of the Royal College of Surgeons, said, “We offer fully accredited foundation and advanced courses in botulinum toxin and dermal fillers, which provide delegates with in-depth and up-to-date theoretical teaching and hands-on training on live models.” The next upcoming training dates for the course, which will be held at the Royal College of General Practitioners in London, will be on March 25, April 29 and June 24 with an advanced course taking place on July 29.

LED

Cambridge Stratum to release DermaDeep IR Aesthetic equipment provider Cambridge Stratum has launched a new addition to the DermaDeep light therapy range. The DermaDeep IR uses LED light therapy and incorporates infrared (830 nm), which aims to treat injuries and encourage cell repair for improving indications such as acne, wrinkles and skin rejuvenation.

According to the company, the new DermaDeep IR includes MitoPulse technology, which provides a high-speed pulse that aims to enable faster absorption and deeper penetration of the wavelengths to the body tissue.

John Culbert, CEO of Cambridge Stratum, said, ”The DermaDeep range uses the latest LED cluster/light pipe technology to produce a higher output, in order to avoid over treating the epidermis, MitoPulse chops the output into 200 pulses a second. This enables us to increase the peak fluence by 100% without over treating the epidermis.”

Education

Esthetique Training Academy launches new programme Esthetique Training Academy has launched a new training programme designed to increase knowledge and experience for practitioners in the use of the First Lift LFL PDO Threads. According to the training academy, the new programme will consist of a series of hands-on courses with live demonstrations and one-to-one sessions. Aesthetic nurse prescriber Emeline Hartley, who will conduct most of the training, said, “Training and mentoring sessions are a wonderful and convenient option to advance your skills in the PDO threads application. The new offering at Esthetique Training Academy offers one-to-one mentoring sessions either in one of our training venues or within your own clinic.”

Reproduced from Aesthetics | Volume 4/Issue 5 - April 2017

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Martin Swann, divisional director at Enhance Insurance What makes Enhance Insurance unique? As an independent broker, not an insurance company, we work with the whole insurance market, ensuring we get the right insurer for each individual business we engage with. Enhance is part of Vantage Professional Risks, meaning we benefit from their expertise. Vantage specialise in a large range of industries, resulting in us understanding the types of businesses that aesthetic clinics work with and offering a better view of the best insurance options.

What changes should clinic owners and practitioners be aware of this year? A new legislation (General Data Protection Regulations) comes into force in 2018, relating to data privacies and breaches. It will become mandatory for business owners to notify ALL breaches or losses, even losing their phone or laptop (containing client data or contact details). The legislation also outlines mandatory remedies that all business owners must conform to, including costs of implementing provisions for monitoring, relating to financial data loss. Failure to adhere could result in the business incurring costs of investigations and fines of between 2-5% of global revenues. Clinic owners and practitioners will have a duty to protect patients’ data, maintain confidentiality and protect civil liabilities.

How can Enhance Insurance help? An area we’re particularly experienced in is data privacy and cyber exposure. Working with aesthetic clinics and medical professionals, we identify and advise on more than just treatment risks or malpractice exposures.

We consider obligations for data privacy, and exposures to areas like third party products, cybercrime, data storage and backups and the risks and costs of an interruption. We undertake the due diligence needed to understand risks and exposures, offering advice on how to reduce them, giving medical professionals the complete solution to their insurance business needs.

What’s your main message to the aesthetics specialty? Enhance help professionals understand obligations owed to clients/patients, ensuring they understand and manage compliance and regulatory risks surrounding data protection. With Enhance, aesthetic practitioners and clinic owners are assured they have protection to meet the business’s needs.

This column is written and supported by

Aesthetics Journal

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Dermal filler

New HA filler launches UK distributor Dermal Revolution has launched the Dermal Revolution (DEEP) hyaluronic acid gel. Dermal Revolution DEEP is a filler that according to the company, is best used to augment the zygomatic arch and improve deep nasolabial lines and marionette folds. The product is a 20mg/ml sodium hyaluronate filler that does not contain lidocaine. According to the company, the filler is CE marked and manufactured under the International Organization for Standardization’s standards, a standard-setting body composed of representatives from various national standards organisations that develops and publishes international standards.

Dr Michael Aicken, managing director of Visage Aesthetics UK, which owns Dermal Revolution, said, “Using Dermal Revolution, practitioners can increase their profit per treatment. Our product is fully CE marked, created using standard manufacturing processes (Good Manufacturing Practice) and ISO standards and it is recognised by the major aesthetic insurance companies such as Hamilton Fraser, Lonsdale and Cosmetic Insure.”

Although the product has only recently officially launched, some practitioners have been using it for the past year. Aesthetic nurse Deborah Davy said, “I have been using Dermal Revolution DEEP since my training at Visage Academy and won’t use anything else now as Dermal Revolution is pretty much your one size fits all of fillers, being suitable for cheek augmentation, nasolabial folds and marionette lines, as well as lip volume and definition, I’ve used Dermal Revolution for all the dermal filler procedures I do.”

Hair growth

Healthxchange extends supply of RevitaLash and RevitaBrow Pharmaceutical supplier Healthxchange extends offering with RevitaLash Advanced Eyelash Conditioner and the RevitaBrow Eyebrow Conditioner.

RevitaLash aims to strengthen and encourage the growth of eyelashes, whilst RevitaBrow aims to enhance brows that may appear damaged and improve their appearance. The products, which are manufactured by US-based company Athena Cosmetics, contain natural botanicals that protect against breakage and brittleness, as well as aiming to improve the flexibility and moisture to eyelashes and brows.

Karen Hill, managing director at Heathxchange, said, “RevitaLash is a well recognised brand in the aesthetics industry and is known for delivering results, something we insist on for all our products here at the Healthxchange.”

Skinbrands is the distributor of RevitaLash and RevitaBrow in the UK. Industry

New association established A new association aimed at promoting patient safety in facial aesthetics for dental professionals has launched. The British Association of Cosmetic Dental Professionals (BACDP) represents dentists, dental hygienists and therapists who carry out non-surgical aesthetic treatments. The association will provide training, mentoring, business and insurance support to members. Jane Reynolds, president of the BACDP, said, “We hope to achieve unity and clarity for those dental professionals choosing to work in the field of non-surgical facial aesthetics, an area which can often see you working alone without support. We would like to see recognition from suppliers and training providers for dental professionals delivering these treatments.”

She continued, “The BACDP believes that thorough training and understanding is at the heart of providing non-surgical facial aesthetics safely and competently.”

Reproduced from Aesthetics | Volume 4/Issue 5 - April 2017

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News in Brief Mr Dalvi Humzah becomes president of F.A.C.E 2 f@ce Congress 2017 Consultant plastic, reconstructive and aesthetic surgeon Mr Dalvi Humzah has become the president of the seventh F.A.C.E 2 f@ce Congress, an international aesthetic congress that will take place in Cannes, France on September 15 and 16.

Mr Humzah said he is delighted with this new role, “It is a great honour to be asked to be president of the F.A.C.E 2 f@ce Congress in Cannes. I have had the pleasure of attending this congress for many years as a delegate, presenter and faculty member and have seen it flourish over the last few years.”

Naturastudios appoints new KOL Aesthetic equipment supplier Naturastudios has appointed aesthetic nurse prescriber Natali Kelly as its new key opinion leader.

Simon Ringer, national sales manager at Naturastudios, said, “Natali’s fresh approach to facial aesthetics and deep understanding of the Dermapen made her a natural choice as the latest KOL for Naturastudios and ambassador for the Dermapen.” Kelly added, “I am excited to be part of a supportive and innovative company and I look forward to helping develop new protocols, training and education.”

OMG Software launches new system to assist practitioners Technology company OMG Software has launched Visage, a system aimed to support aesthetic practitioners in managing their clinics. According to the company, the system stores patient information and appointments, and uses electronic signatures for medical questionnaires and consent.

Vida Aesthetics to distribute TOSKANI Cosmetics in the UK Aesthetic distributor Vida Aesthetics has begun distributing Spanish cosmeceutical skincare brand TOSKANI Cosmetics in the UK. The range includes skincare products, antiageing cocktails and skin peels to aid skin rejuvenation. Eddy Emilio, director of Vida Aesthetics said, “Vida Aesthetics is delighted to be offering this fantastic range of skincare to our customers. TOSKANI Cosmetics are backed by science, making them a proud addition to our portfolio.”

Aesthetics Journal

Aesthetics aestheticsjournal.com

On the Scene

River Aesthetics Canford Cliffs Launch, Dorset Guests were invited to celebrate the official opening of the new River Aesthetics Canford Cliffs clinic in Dorset on the evening of March 2.

Approximately 90 guests enjoyed live music, gourmet canapés and a cocktail bar, while a magician provided entertainment for the night.

The main reception took place at HNB Salon & Spa and live demonstrations were showcased in the River Aesthetics treatment rooms upstairs.

Clinic owners Dr Charlotte Woodward and Dr Victoria Manning welcomed guests, thanking them for their support, while River Aesthetics ambassador and celebrity Meg Matthews cut the ribbon.

“It was a wonderful evening, both in introducing River Aesthetics and our story and ethos of ‘look well, not done’,” said Dr Manning. She continued, “We were able to showcase our stunning treatment rooms with demonstrations and a glowing reference from guest speaker and VIP, Meg Matthews. We met so many wonderful people, we’re thrilled to have been warmly welcomed into the Canford Cliffs community and look forward to helping our new clients look 10 years younger and feel more confident naturally.”

On the Scene

IAAGSW’s first Middle East Training in Aesthetic Gynaecology, Cairo Practitioners came together to attend the The International Association of Aesthetic Gynaecology and Sexual Wellbeing’s (IAAGSW) first Middle East Training in Aesthetic Gynaecology at the Fairmont Heliopolis, Cairo on March 10.

Course director and IAAGSW president Dr Sherif Wakil, who is also a cosmetic aesthetic and sexual doctor, opened the congress, and discussed the rise in aesthetic gynaecology popularity and how new technology has allowed for more treatment options for patients.

The morning focused on theoretical aesthetic gynaecology including non-surgical procedures, such as regenerative medicine in vaginal rejuvenation, dermal fillers, lasers in genital rejuvenation, botulinum toxin in vaginismus, chemical bleaching for intimate areas and the role of threads in vaginal rejuvenation. Surgical procedures were also discussed, including reversal of female genital mutilation and new techniques for labiaplasty. Delegates had the opportunity to see a variety of live demonstrations on the above topics in the afternoon. Joining Dr Wakil in the training and presentations was Polish gynaecologist Dr Dawid Serafin, who demonstrated dermal fillers, Spanish gynaecologist Dr Fernando Miguel Aznar, who discussed botulinum toxin in the area and presented surgical videos and techniques, and consultant gynaecologist from Egypt, Dr Amr Seifeldin, who discussed reversal of FGM techniques.

“The event was incredible, we are having a lot of positive feedback,” Dr Wakil said, adding, “I wanted to raise awareness about this speciality to practitioners in Egypt and for them to be able to offer it their patients, who do not know much about the possibilities of treatments available, and for them to be well informed and to realise that there is actually something that they can offer. There were a lot of prominent and eminent consultants attending the event who were keen to understand the speciality.”

Reproduced from Aesthetics | Volume 4/Issue 5 - April 2017

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On the Scene

Aesthetics On the Scene

Regenyal Launch, London Aesthetic practitioners were invited to The Lansdowne Club in Mayfair for the launch of the Regenyal injectable range on the evening of March 1. Guests enjoyed drinks and a welcome from Ben Sharples, managing director of UK distributor Belle, and Roberto Speroni, international sales and business development consultant who consults for many aesthetic companies. Aesthetic practitioner Dr Rikin Parekh discussed the science behind the Regenyal range, which includes Regenyal Biorivolumetria dermal fillers and Regenyal Bioregen injectable hyaluronic acid gel. Dr Parekh said, “The Regenyal Biorivolumetria products go through a very unique manufacturing process and there is a very different crosslinking process, which results in a very homogeneous product that can naturally spread really nicely and evenly within the tissues creating a really soft result.” Dr Parekh concluded the evening with a question and answer session and a live demonstration. Sharples said of the evening, “The event was fantastic; it was great to have a mix of plastic and oculoplastic surgeons, aesthetic nurses, cosmetic doctors and dentists. It was gratifying that our guests embraced the efforts we have made to produce the safest possible product; with 30% less BDDE and the lowest levels of endotoxins and free BDDE on the market. They also saw the benefits of the extremely small particles in Regenyal products with the very natural results achieved on our model.”

RSM annual meeting Delegates representing all fields of aesthetics attended the Royal Society of Medicine Aesthetics 9, the 9th international multidisciplinary annual meeting at the RSM on Wimpole Street in London on February 24. Associate dean at the RSM, Miss Kaji Sritharan, made the welcome address, followed by a day of aesthetic-focused scientific sessions. “The RSM Aesthetics meeting was another huge success; as usual, information was shared in a convivial, humorous yet challenging and thought-provoking manner,” said consultant plastic and cosmetic surgeon, Mr Paul Banwell.

He added, “I was particularly lucky to chair an excellent session discussing unusual roles for botulinum toxin, which stimulated some interesting questions on its role in rosacea. We also had another talk from Dr Raj Acquilla on treating the ‘sad face’.”

Among the other sessions were; body dysmorphic disorder by Dr Anthony Bewley, a sponsored Cynosure workshop on body contouring with Dr Joney De Souza and blepharoplasty using the Plexr device by Mrs Sabrina Shah-Desai. Mr Banwell said, “The meeting is becoming an ever-important forum for discussion, free of industry involvement and the delegates certainly welcomed this approach. We must thank the incredible Dr Christopher RowlandPayne for all his hard work as outgoing president and welcome the equally dynamic and enthusiastic consultant plastic surgeon Mr Jonathan Britto as the incoming president.”

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Reproduced from Aesthetics | Volume 4/Issue 5 - April 2017

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HIS Registration Launch Aesthetics looks at the Healthcare Improvement Scotland registration that has come into effect for medical aesthetic clinics in the country Regulation in the medical aesthetic specialty throughout the UK, or lack thereof, causes huge discussion and debate.

In April 2016, it was announced that private clinics that are independent of NHS Scotland that have practising doctors, nurses and/or dentists must be registered with Healthcare Improvement Scotland (HIS) or risk violating the law.1,2 Clinics were given one year to pay the £1,990 fee to apply to have their clinics assessed and approved by the healthcare improvement organisation and become registered.

As of April 1 2017, it became an offence to operate an unregistered independent clinic in Scotland; meaning those clinics that are not registered are breaking the law.2 Kevin Freeman-Ferguson, senior inspector at HIS, explains that clinics that are not already registered must pay an increased registration fee, or alternatively, will be subject to a £5,000 fine and/or up to three months’ imprisonment for continuing their practice.3,4 To many practitioners, regulation of any kind is welcome, but some are skeptical as to what this registration will achieve.

How are private clinics in Scotland now regulated?

Due to concerns about patient safety following the Poly Implant Prostheses (PIP) breast implants recall and the Keogh Review,5 the Scottish Government requested an expert group be set up to make recommendations on the regulation and provision of cosmetic procedures.6 The Scottish Cosmetic Interventions Expert Group (SCIEG) was established by Scottish ministers in 2014 to determine how the industry could be regulated. Recommendations in their 2015 report suggested that healthcare improvement and quality organisation HIS, should regulate all independent clinics.6,7 Under the regulations, doctors, nurses and dentists cannot practise unless they are working for a clinic that is registered with HIS and clinics are not allowed to run without registering.2

Aesthetics Journal

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Freeman-Ferguson says, “The new registration system for independent clinics creates a system of quality assurance, which is extremely important. Once registered, clinics will be subject to regular inspections. A report of each inspection will be published so the public can see how a clinic is performing. The service will be graded on the quality of care, environment, staffing, management and information.”

According to HIS, inspections will be carried out every 12 or 24 months, depending on the performance of the clinic, and the majority of inspections will be unannounced.7 Grading of different quality areas will be published in a report online eight weeks after the inspection so the public can determine how it is performing.8 HIS also has the ability to receive and investigate complaints from patients.2 Freeman-Ferguson says, “We can take enforcement action if services do not comply with the requirements of the law.

This action includes imposing conditions on a service’s registration, serving a notice on a service, which requires them to improve and, ultimately, if a service continues to ignore our requests to comply with the law we can cancel their registration.”

According to Freeman-Ferguson, in mid-March around 200 clinics were still yet to register. He says that there will be consequences if they continue to practise after April 1 and do not submit their registration, noting, “We will report providers who are willfully evading registration to the Procurator Fiscal Service (prosecution service in Scotland) for prosecution.”

What are the benefits of regulating clinics?

Independent nurse prescriber and clinic owner Frances Turner Traill, who practises in Glasgow and Inverness, believes that this regulation framework encourages patients’ confidence in clinics. She says, “It gives the public a form of redress for when a patient has had an issue or a bad experience. I think these regulations bring the benefit of being able to demonstrate to the public that medical cosmetic clinics operate to the highest professional standards.”

Dr Nestor Demosthenous, who owns a clinic in Edinburgh and is on the HIS board, says that an additional benefit is that patients treated by anyone not registered by HIS can also complain to the body.

Although he notes that, at present, HIS will have limited authority for action. He says, “Hopefully this will help build some sort of database of those who have performed treatments that have led to complications because at the moment, the complaint from many

“I think these regulations bring the benefit of being able to demonstrate to the public that medical cosmetic clinics operate to the highest professional standards” Frances Turner Traill

Reproduced from Aesthetics | Volume 4/Issue 5 - April 2017

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Government institutions is that, overall, we don’t have any evidence that it is dangerous for beauty therapists to inject because there has never been anywhere for patients to voice their complaints.” He hopes this will eventually provide evidence of the dangers of nonmedically trained practitioners performing non-surgical treatments.

Glasgow-based clinic co-owner and Association of Scottish Aesthetic Practitioners founder Dr Simon Ravichandran believes the HIS regulation is a step in the right direction, “It’s going to mean that every medical practitioner in Scotland practising aesthetic medicine has to practise within a regulated clinic. I think there are other aspects of aesthetic medicine that we could be regulating, but there’s no doubt that we have to start somewhere and clinics are a good place to start,” he says.

What concerns surround the new regulation?

Like many new developments, there is going to be some criticism, says Dr Ravichandran, “The main criticism is that we are regulating a group of people who are already regulated – and that’s true. The currently regulatory provision has no space for non-medical people, which means it doesn’t even apply to podiatrists, pharmacists or beauty therapists.”

Turner Traill agrees, saying, “Someone’s got to be regulated first but the wider issues do need to be tackled. To me, that is those who are not already registered with a regulatory body.”

However, the concerns surrounding the regulation of non-medical professionals has been recognised by HIS. Freeman-Ferguson says, “There are plans to address this and the Scottish Government

Aesthetics

is currently working on this issue. The SCIEG recommended a second phase of change, which will bring aesthetic treatments provided by other professionals into an appropriate regulatory framework.5 Further information will be available in due course from the Scottish Government.”

Turner Traill believes that although some Scottish practitioners may be apprehensive about the HIS regulation, she says, “I think we need to look at the bigger picture and look at what the landscape is going to look like in 10 years’ time. Hopefully it will be better for patients’ safety – if you are inviting inspectors into your clinic it shows your transparency – and this can only be a good thing.”

REFERENCES 1. Aesthetics, ‘Clinic regulation comes into effect in Scotland’, Aesthetics journal, (2016) <https://aestheticsjournal.com/news/clinic-regulation-comes-into-effect-in-scotland?authed> 2. HIS, ‘Regulation of independent clinics: Frequently Asked Questions’, Healthcare Improvement Scotland, (2017) <http://www.healthcareimprovementscotland.org/our_work/inspecting_and_regulating_care/independent_healthcare/regulation_of_clinics/regulation_of_clinics_faqs.aspx> 3. Evening Times, ‘Hundreds of private clinics still to register ahead of first steps in crackdown on Scotland’s cosmetic industry’, (2016) <http://www.eveningtimes.co.uk/news/15118467.Hundreds_of_ private_clinics_still_to_register_ahead_of_first_steps_in_crackdown_on_Scotland_s_cosmetic_industry/> 4. Kevin Freeman-Ferguson, data on file, 2017.

5. Sir Bruce Keogh, ‘Review into the quality of care and treatment provided by 14 hospital trusts in England: overview report’, (2013), <http://www.nhs.uk/NHSEngland/bruce-keogh-review/Documents/ outcomes/keogh-review-final-report.pdf> 6. S Vittal Katikireddi, A Malyon, Scottish Cosmetic Interventions Expert Group (July 2015), <http:// www.gov.scot/Resource/0048/00481503.pdf> 7. HIS, The regulation of independent healthcare in Scotland, Healthcare Improvement Scotland, (2017) <http://www.healthcareimprovementscotland.org/our_work/inspecting_and_regulating_ care/independent_healthcare.aspx> 8. HIS, ‘Independent healthcare regulation: How our inspection process works’, Healthcare Improvement Scotland, (2017), < http://www.healthcareimprovementscotland.org/our_work/inspecting_and_regulating_care/independent_healthcare/our_inspection_process.aspx>

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Reproduced from Aesthetics | Volume 4/Issue 5 - April 2017

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Aesthetics

Anatomy and general ageing In youth, the intersection between the lower eyelid and the check junction blends , and the area is naturally convex. But as we start to age, soft tissue breaks down, showing more of the underlying bone.2 Consultant aesthetic oculoplastic surgeon Mrs Sabrina Shah-Desai explains how changes in the anatomy can create the appearance of dark circles. “By the time patients are in their 30s, they will start to see the appearance of mild under-eye dark circles due to the loss of the subcutaneous fat in the eyelid tissue, thinning skin and hyperpigmentation.”

She continues, “By the mid 30s and early 40s, bony changes commence; the eye sockets will start expanding, and the midface will start collapsing. The maxillary bone, which is responsible for projection of the anterior cheek, starts collapsing. Due to soft tissue and bony loss, the appearance of a dark circle worsens due to volume loss under the eye. These anatomical changes also contribute to the appearance of an ‘eye bag’, the fat bulge casts a shadow on the hollow lid cheek junction, creating an illusion of a worsening dark circle.”2

Periorbital Dark Circles Aesthetics speaks to practitioners about their approach to treating dark under-eye circles As every aesthetic practitioner knows, the skin around the eye is the most delicate on the body; in fact, it is said to be up to 10 times thinner compared to the skin on the rest of the face.1 Yet, treatments in the periorbita are popular requests from aesthetic patients, as the appearance of the eye area can be one of the least forgiving when it comes to ageing. One common periorbital concern, with patients complaining of looking run-down, tired and older than their years, is dark under-eye circles.

Dark circles, according to practitioners interviewed for this feature, are notoriously hard to treat, with a very small margin for error. They therefore all assert that periorbital treatments should only be carried out by advanced practitioners with a thorough understanding of the anatomy of the area. There is an assortment of treatments available for the periorbital area, and in this article, practitioners focus on the use of injectable treatments – explaining their best treatment methods for rejuvenation and how to manage any complications.

What causes dark circles?

There are many reasons why patients might appear to have dark circles under their eyes. However, consultant ENT and facial plastic surgeon Mr Kambiz Golchin believes there are two main reasons. “The number one reason is hyperpigmentation of the skin and the second reason is to do with the anatomy of the area. As the skin is very thin, you don’t have a huge amount of subcutaneous or fatty tissue to ‘bulk it out’, therefore you are just looking at skin and blood vessels, which gives that dark appearance.” Aside from these reasons, the practitioners will also discuss how lifestyle can have an impact.

Hyperpigmentation When it comes to hyperpigmentation around the eye, a huge contributing factor is ethnicity, with patients of darker skin types being genetically more prone to developing periorbital hyperpigmentation.3 Aesthetic nurse prescriber Natali Kelly explains, “In my clinic, I see a lot of Asian and darker Fitzpatrick skin type patients as they are more genetically inclined to develop hyperpigmentation.3 It is harder to treat and it takes longer to see the results. And you’re rarely just treating the dark circles, they usually have other concerns with general skintone; sun exposure has played a big role.”

Hyperpigmentation occurs when the cells that contain melanin are damaged or over-stimulated. This, in turn, can lead the affected cells to begin to produce too much melanin. Therefore, practitioners advise that those of darker skin types need to be extra careful with the amount of sun exposure they have.4 Dermatologist Dr Jane Ranneva, who practises in Spain, says, “In my clinic, most of the patients who suffer from periorbital hyperpigmentation have a skin type of 4 or more. Their skin reacts more easily to any irritation, which can lead to hyperpigmentation.”5 Kelly explains that patients suffering from hyperpigmentation in the periorbita are likely to need a combination of treatments over a long period of time, as there is not one ‘perfect’ treatment. “It would need to be a long-term programme of treatments,” she emphasises.

Lifestyle Lifestyle is another important factor to consider, as a dark under-eye can be a reflection of the patient’s general health. “If a patient is in their 20s and has dark circles, it may be due to poor diet, anaemia, eye rubbing and late nights,” says Mrs Shah-Desai. “Often the patient needs to address their lifestyle. Although Indian-Asian and Hispanic ethnicities can have dark circles in their 20s, it is not common in Caucasians.”

Dr Ranneva adds, “There are so many reasons why patients develop dark under-eye circles. Commonly, it is due to a circulation problem, or a genetic disorder. But much can come down to lifestyle factors, whether the patient suffers with chronic fatigue, has a poor diet and is constantly dehydrated. So this is something I discuss with patients.”6

Reproduced from Aesthetics | Volume 4/Issue 5 - April 2017

NEW

A DERMAL FILLER TO CONTOUR1 & DEFINE1

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M-RAD-UKI-0030 Date of Preparation September 2016

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2015

NEW

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Ready-to-use, premixed with 0.3% lidocaine2

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Favourable rheological properties to create contours, shape & definition1

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Enhanced patient comfort when compared with Radiesse® non-lidocaine3

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New 27G Terumo needle S TAND 28 31 ST MAR - 1 ST AP R 20 17, LO ND O N A E ST H E T I C SCO N F EREN C E.CO M

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

1. Sundaram H, et al. Comparison of the Rheological Properties of Viscosity and Elasticity in Two Categories of Soft Tissue Fillers: Calcium Hydroxylapatite and Hyaluronic Acid, Derm Surg 2010;1076-0512 2. Instructions for Use (IFU) Radiesse® 3. Schachter D, et al. Calcium Hydroxylapatite With Integral Lidocaine Provides Improved Pain Control for the Correction of Nasolabial Folds. Journal of Drugs in Dermatology. August 2016; Volume 15. Issue 8. 1005-1011 4. http://www.fda.gov/medicaldevices/productsandmedicalprocedures/ deviceapprovalsandclearances/pmaapprovals/ucm439066.htm

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CONTOUR & DEFINE

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Consultation is key Mr Golchin explains that the only way to see beneficial results is to ensure you have as much patient history as possible in order to make the correct diagnosis. He says, “The key to treating the periorbital area is assessment; assessment is probably the most important step because it is crucial to figure out what is actually causing the majority of that darkness.”

He continues, “For example, if it is more of a pigmentation problem, then you can treat the pigmentation either using peels, creams or lasers. If it is to do more with the appearance of the blood vessels, and they don’t have pigmentation, but they have got very thin skin, then you can treat this differently with the likes of injectables.”

Mrs Shah-Desai agrees, “You have to take a detailed history; find out if they have allergies, or if they have recurrent colds or sinus disease – if they rub their eyes a lot temporary dark circles could become permanent dark circles, as they will constantly have engorged veins.”

Treatment options Hyaluronic acid (HA) The elimination of dark circles can be effectively achieved by volume augmentation of the tear trough, and this seems to be the most common treatment choice amongst practitioners.7 Using a non-crosslinked HA in this area is what Dr Ranneva refers to as a ‘camouflage treatment’. “If patients have hyperpigmentation we can create a camouflage treatment, where we use volumising product to reflect the light from the face, so you don’t see that shadow.” Dr Ranneva uses RRS HA Eyes, that also aims to stimulate lymphatic drainage as well as volumise. “I inject deep and superficial and inject 0.65ml around each eye,” she says.

Kelly also uses HA filler in her practise, “Most of the time in my clinic, we are replacing the volume with a light-reflecting HA dermal filler, which can build support and soften the dark circles. I would use a small amount, I would never inject more than half a syringe in each side. In most cases I will usually provide some structure and support in the cheek; usually the tear trough is quite sunken because the cheek Before

Before

After

After

Figure 1: Before and after treatment with HA filler in the tear trough. Images courtesy of Natali Kelly.

has lost volume, especially in patients that are very slim and don’t have as much body fat on the face.” Kelly continues, “If you provide support around the cheekbone and the eye, it pulls the skin tighter to support it, and means you might only need a small amount in the actual tear trough. If you imagine, under the eye, the cheek should be like a lovely ski slope, whereas if someone is really hollow under the eyes, and in the cheeks, and someone just treats the eyes, you will find that they end up looking puffy.”

Mrs Shah-Desai uses her own trademarked technique when using

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HA in the tear trough, the ‘Eye Boost’. “I use a very light filler and I give very tiny injections. I find that if you put a heavy filler on the bone medially it will become a ‘speed bump’, but if you use a very soft hydrating product it just hydrates the skin and it won’t become a visible bump,” she explains. “I inject deep and superficial, most patients need this ‘sandwich’ technique in order to get a natural result. Between the medial canthus and the medial limbus, dictated by the anatomy of the tear trough ligament, I place superficial injections of a hydrating filler, in a very small quantity. In the central and lateral parts of the trough, I use a cohesive filler, placed preperiosteally below the orbicularis retaining ligament. As the unique tear trough anatomy is respected, I don’t see the ‘speed bumps’ associated with placing a bolus of filler in the tear trough.”

It is important to remember that even in the most qualified and experienced hands, complications can occur and every practitioner should be prepared. “The anatomy is complicated, so you do see complications even from the most astute practitioners,” says Mr Golchin. “Any complications in this area can be quite upsetting, which at the one end includes bruising, swelling, the Tyndall effect, puffiness and lumpiness, and at the other end, albeit much more rare, skin necrosis and blindness – thankfully, for most people, we can do something about the majority of these side effects.”8 He explains that the HA needs to be dissolved, “We use an injection of an enzyme to dissolve the filler. It starts working instantly and takes two to three days to complete and see full resolution.”

Before

After

Figure 2: Before and after treatment with the ‘Eye Boost’ treatment (HA filler) in the tear trough. Images courtesy of Mrs Sabrina Shah-Desai.

PRP Another treatment option for this area is to use stem cells to regenerate the skin in the form of platelet rich plasma (PRP). This is becoming a more popular addition to the aesthetic practitioner’s repertoire – enquiries from patients regarding PRP rose 67% last year according to WhatClinic.com.9 Kelly uses PRP in conjunction with microneedling and says she has seen good results from this combination. “The plasma is your own body’s growth factors, so when you use this under the eyes – and I like to treat the full face at the same time – you can actually see improvement in the texture of the under-eye skin, you can provide some hydration and some stimulation; you will never get lifting or volume replacement like you would from dermal fillers, but it does work nicely on the dark circles to provide skin rejuvenation.” Kelly applies the PRP around the eyes by gently dropping the plasma

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SHOW HIGHLIGHTS FRIDAY

Business Track with Dr. Simon Zokaie

SATURDAY

Masterclass with Dr Dev Patel & Victoria Hiscock

Succesful Results with AlumierMD Combining Peels and Homecare Condition: Fine Lines & Texture

*Improvements in texture are shown using the Visia Digital Mask, illustrated by less blue and yellow areas.

Condition: Hyperpigmentation (Melasma)

Treatment: Two AlumierMD Glow Peels combined with Hydraboost, EvenTone, Retinol Resurfacing 0.5%, HydraDew, Sheer Hydration Broad Spectrum SPF40.

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“Smoking is toxic to the blood so there is absolutely no point doing a PRP treatment for smokers as we are depending on the blood to have growth factors to stimulate” Natali Kelly, aesthetic nurse prescriber

from a syringe on to the skin and then using her hand to cover the treatment area. Using roughly 1ml of PRP for the eyes, or up to 5ml for the full face, Kelly then moderately runs the microneedling device over it. “The microneedling pen causes micro-trauma, it stimulates collagen and tightens the skin; it’s fractional, so it pushes all of the tiny micro droplets of the PRP deeper into the skin. Usually 0.5mm would be the maximum needle size I would use around the eyes.” She adds, “In my experience, it usually gives less bruising, swelling and downtime than filler treatment and you get more stimulation than if you just applied the PRP with a syringe.” Kelly says she would generally offer a course of three treatments about four to six weeks apart for best results.

PRP is a common treatment in Mr Golchin’s clinic for tear trough concerns, “I use a very super-concentrated PRP and I inject with a cannula technique at two different levels – one injection just beneath the skin and one deeper. By doing this we are trying to improve the vasculature and the area around the blood vessels, to improve collagen.10 It takes about three to six months to see the best results; it is not a treatment that works instantly but it works beautifully, it just takes time. Generally, I do two treatments; I do one and then another three months later.”

When using PRP, it is even more important to check the health of the patient first, in order to ensure the treatment will provide positive results. “As long as the patient has a healthy diet and they don’t drink too much and they don’t smoke, then they are suitable for treatment,” says Kelly. “Smoking is toxic to the blood so there is absolutely no point doing a PRP treatment for smokers as we are depending on the blood to have growth factors to stimulate. In this case, I would possibly use a mesotherapy product instead.” Mr Golchin adds that in his experience, the only complication with PRP is bruising, “The only way of avoiding that is technique and careful, precise injection.”

Fat transfer Using fat is another way of using stem cells in the tear trough, although this would require a surgical procedure. “The nice thing with fat is that it is what you would have had there in the first place, so you are replacing like with like,” says Mr Golchin. “Because fat

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is full of stem cells, it can regenerate the skin to help with the dark circles and quality of skin in the long term. That’s the advantage.”11 Another advantage, according to Mr Golchin, is that one treatment produces benefits in two areas, as they will also have fat taken from an area of concern, such as the abdomen or hips. “You don’t need much for the eye area, a tiny amount, but most people have a little bit they would like to get rid of from the abdomen.” Practitioners must also ensure they use a sufficient technique because, according to Mr Golchin, “If too much is done, and the surgeon is too aggressive, or if the fat is not processed properly, it can be left a little bit lumpy. It is a very technical procedure to do, but if done properly, the results can be stunning.”

Conclusion In conclusion, there are many different and successful treatment options at the practitioner’s disposal for the treatment of this common eye-concern. In order to achieve the best results, however, practitioners must provide a detailed assessment of the patient to discover the reasons behind their dark under-eye circles.

Otherwise, the wrong treatment method may be selected, leading to patient dissatisfaction.

This risk of complication in the delicate eye area also shouldn’t be underestimated, and even those practitioners who practise at an advanced level should ensure they are prepared for any adverse events. “I speak candidly with my patients about the risk of complications, and ensure they have made more than enough time for downtime, just in case something was to occur,” says Dr Ranneva, adding, “And I only go ahead with treatment if they fully understand these risks.”

Mrs Shah-Desai adds, “To avoid unsuccessful outcomes, tear trough treatments should ideally be undertaken by advanced practitioners who understand why the periorbital area ages the way it does, have a good knowledge of the anatomy and be able to customise treatment, as this area can age differently based on ethnicity, systemic conditions and environmental factors.”

Regular training in both the periorbital area and handling complications can help to ensure best practice and minimise trauma for the patient. Mr Golchin concludes, “The periorbita is not an area your ‘average injector’ could or should inject. It is definitely a more advanced area and needs to be treated with more respect.”

REFERENCES 1. Mediniche, Caring for the skin around the eye, (2017) <http://www.mediniche.com/ocularskincare. html> 2. Cláudio Cardoso de Castro and Kristin A. Boehm, Midface Surgery, Saunders Elsevier; China (2009) P.94 3. Sami Rahman, How to tackle dark under eye circles in ethnic skin, (2014) <http://www.netdoctor. co.uk/beauty/a8995/how-to-tackle-dark-under-eye-circles-in-ethnic-skin/> 4. Susan Taylor, Brown skin, (2017) <http://www.brownskin.net/hyperpigmentation.html> 5. Skin Renewal, Post Inflammatory Hyperpigmentation - Dark Skin, (2017) <http://www.skinrenewal. co.za/post-inflammatory-hyperpigmentation-in-dark-skin-types> 6. Dr Mounir Bashour, Dark Circles Under The Eyes — What You Can Do, (2017) <http://www. eyehealthweb.com/dark-circles-under-eyes/> 7. Cláudio Cardoso de Castro and Kristin A. Boehm, Midface Surgery, Saunders Elsevier; China (2009) p37. P.94 8. David Funt and Tatjana Pavicic, Dermal fillers in aesthetics: an overview of adverse events and treatment approaches, (2013), Clin Cosmet Investig Dermato <https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC3865975/> 9. Enquiries made to 4,528 UK medical aesthetic clinics listed on WhatClinic.com in the period 01.122015 – 01.12-2016, compared to 01.12.2014 – 01.12.2015.

10. Andriani Daskalaki, Medical Advancements in Aging and Regenerative Technologies: Clinical Tools and Applications (Advances in Medical Technologies and Clinical Practice), IGI Global; US (2013) 11. Chang Yung Chia and Diego Antonio Rovaris, Autologous periorbital fat grafting in facial rejuvenation: a retrospective analysis of efficacy and safety in 31 cases, Revista Brasileira de Cirurgia Plástica, (2012) <http://www.scielo.br/scielo.php?pid=S198351752012000300013&script=sci_arttext&tlng=en>

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Managing Rosacea Dr Priya Patel and Dr Sandeep Cliff review current treatments available for rosacea and examine their efficacy Rosacea is a chronic inflammatory dermatosis, which globally affects 1 to 22% of the world’s population, with higher percentages seen in western countries.1-4 There are four internationally recognised subtypes: erythematotelangiectatic (ETR), phymatous (PR), papulopustular (PPR) and ocular (OR).5 Patients do not clinically progress through subtypes, but may have symptoms that fit into multiple subtypes. Some of the signs and symptoms can include: papules, pustules, erythema, flushing, telangiectasia, oedema, plaque formation, rhinophyma or ocular involvement, or a combination of the above.1,6,7 These symptoms can be transient or persistent and can progress in severity. Although rosacea is a benign condition, it can cause significant psychosocial distress, leading to a decreased quality of life (QoL) and mental health conditions. For instance, a study surveying more than 400 patients indicated that 75% had low self-esteem9,10 and an American survey conducted between 1995-2002, with 13.9 million rosacea patients, suggested 65% had symptoms of depression.8,9 Fortunately, these improve once treated.1,9 This effect was seen in 11 studies each assessing QoL for various treatments ranging from topical, systemic and cosmetic.11 In this article some of the current available management options for rosacea will be discussed.

Background Rosacea predominantly affects western populations and those aged between 30-50 years.3,12 Patients often experience flares then quiescent periods.3,12,13 Interestingly, some studies indicate no gender difference, while others illustrate women are predominately affected, with men presenting more with PR or PPR subtypes and increased severity of disease.12,14,15 Given the Northern European predilection, a genetic element has been suggested. However, no gene has yet been found. Some studies suggest human leukocyte antigens (HLA) could be implicated (HLA-DRB1, HLA-DQB1 and HLADQAI).16-18 Several hypotheses exist for rosacea, including dysregulation of the innate and adaptive immunity and the neurovascular system. These involve increased concentrations of Cathelicidin (IL-37) and Interleukin-8 (IL8), which stimulate inflammatory pathways.1,19-22 Additionally, certain bacteria or mites are found in higher concentrations in rosacea patients, for instance: Demodex folliculorum, Staphylococcus epidermidis, Bacillus oleronius, Helicobacter pylori and Chlamydophila pneumoniae; although the exact pathophysiology of these agents in rosacea is unclear.1,2,5 Environmental factors potentially causing and/or exacerbating rosacea include: a high amine diet e.g. alcohol and cheese, spicy food, hot beverages, exercise or changes in temperature (including menopausal symptoms), ultraviolet (UV) light or emotional distress.17,23 Lastly, exogenous stimuli such as, but not limited to, micro-trauma, chemical peels or topical products containing irritants can trigger symptoms.4,7,24 Rosacea commonly affects the central face, although extra-facial manifestations can occur. The four main subtypes are explained;.3,4,14

1) ETR: characterised by persistent flushing, telangiectatic vessels and periocular sparing

2) PPR: includes ongoing erythema with papules and pustules of varying severity

3) PR: has characteristic facies with nasal skin hypertrophy and has four histological subtypes: glandular, fibrous, fibroangiomatous and actinic16 4) OR: involves dry eyes, burning, oedema, blepharitis, conjunctivitis, multiple styes and potential corneal damage resulting in sight loss Several treatment options are available with varying degrees of evidence and efficacy. Treatments are largely based on the subtype and symptom severity, but management remains problematic given the unclear pathophysiology.1,5 The current options available are discussed below.

Lifestyle modifications Patient education is critical to explain the condition and trigger avoidance.24 Good hygiene can improve the skin and ocular symptoms for example eye-bathing, lubricating eye-drops and total make-up/fragrance avoidance.7 Good skincare via moisturisers and sunscreens prevents the trans-epidermal water loss seen in rosacea.4 Sunscreens also protect against UV, which reduces the number of reactive oxygen species (ROS) and IL37 produced, both of which generate oxidants that damage the skin. IL37 additionally activates growth factors resulting in angiogenesis. Additionally, short wave ultraviolet B, can stimulate keratinocytic receptors, resulting in pain and inflammation.17 Sunscreen must be at least factor 30 and gels or fluids are generally better tolerated.24 No specific sunscreen or moisturiser is superior, although products containing titanium dioxide, zinc oxide, non-alkaline and lipid-free materials result in less irritation.7-8 Lastly, ascertaining accurate drug histories can ensure withdrawal of exacerbating medications like topical steroids or niacin.5,24

Topical treatments Sodium sulfacetamide Sodium sulfacetamide contains an antibiotic combined with sulphur providing keratolytic, antidemodetic and antifungal properties.17,25 This can be administered via creams, lotions or cleansers.4,24 It is particularly efficacious for PPR or concomitant seborrheic dermatitis.4,24 Multiple reviews indicate improvement in inflammation and erythema, with one noting 65% reduction in inflammation and 66% reduction in facial erythema.26 Sulfacetamide can be combined with other topicals like metronidazole.4 Its mechanism of action is unclear; but it has suggested to have anti-inflammatory properties in clinical studies.17,27-29 The main disadvantages of sodium sulfacetamide include: a sulphurous odour, dry skin, erythema and localised irritation; although, the frequency of these side effects decreases over time, and newer ‘wash-on-wash-off’ formulations have a transient odour.13

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Metronidazole Another established therapy is topical metronidazole. The exact mechanism is also unknown, but it appears to reduce ROS, opposes existing oxidants and has anti-inflammatory properties.7,24 Multiple trials have demonstrated its efficacy, at either 0.75% or 1%.30-34 Pooled data of 195 patients, with severe PPR, from three moderate-quality studies

by Bjerke (1989), Breneman (1998) and Nielsen (1983) suggested 94 patients had reduced papules, pustules and erythema compared to placebo.3 Furthermore, reoccurrence of symptoms appears to be uncommon. One study indicated 23% relapse-rate compared to 42% on tetracyclines after six months discontinuation.35 It is generally safe and well-tolerated, with side effects including irritation and dermatitis.4,7 Azelaic acid Azelaic acid (AA) is a natural saturated dicarboxylic acid, with antioxidant, antimicrobial and anti-inflammatory properties.24 One study suggests it also reduces Kallikrein-5 (KLK5) and cathelicidin expression.36 A Cochrane review, a resource for systematic reviews in health care, of six pooled studies indicated that 70-80% of patients underwent complete remission or significant improvement in their symptoms compared to placebo.30 Further studies have also suggested some superiority to metronidazole gel, but other studies have indicated no statistical difference.17,19 Additionally, it has been shown to have equal efficacy to tetracyclines.4,7 This is a well-tolerated once daily topical treatment of either: 15% gel (with the gel having increased bioavailability), 20% cream or a newer 15% foam formulation.1,17,24 It is safe in pregnancy and side effects include: irritation, dryness and transient stinging/burning.7 Brimonidine tartrate Brimonidine tartrate is an alpha-2-adrenergic receptor agonist (AARA).

It reduces facial erythema by vasoconstriction of dermal blood vessels.24 However, telangiectasia remains as AARAs are not antiinflammatories and the telangiectatic vessels lack vasomotor tone.24 Brimonidine gel is applied once daily, at either a 0.5% or 0.33% dose, resulting in erythema improving between 30 minutes-12 hours before the effects diminish.7 One study of 296 patients showed statistical significance in 30.2% of patients with two grades of improvement in patient satisfaction and baseline erythema scores, compared to vehicle after four weeks of treatment.37 A Cochrane review indicated two grades of improvement in facial erythema (scaled from 0-4).3,5,24 Overall, brimonidine tartrate is well-tolerated and safe; however, there have been reports of rebound erythema, flushing and pruritus; therefore, patient education on the side effect profile and dose titration are recommended, starting with the lowest dose and working upwards as tolerated.

Another AARA, clonidine, taken orally at low doses (0.05mg BD), has suggested a reduction in facial erythema and flushing.4 This dose did not significantly decrease systemic blood pressure, but this is a risk with any AARA. Additionally, some patients respond to treatment and others do not, but the reason for this is unclear.

Therefore this should be given on an individual basis with monitoring for response.4 There are additional topical AARA i.e. selective alpha1-agonists: oxymetazoline and xylometazoline, which have provided improvements in erythema but are not routinely available yet.1,19,24 Ivermectin Ivermectin is a broad-spectrum anti-parasitic agent, which is used orally as an anti-inflammatory agent and for its ability to decrease Demodex (mites).24,38 Topical ivermectin has recently been approved

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for moderate-severe PPR.2 Two large scale North-American studies performed on 683 and 688 patients indicated ivermectin 1% cream was statistically superior to placebo after 12 weeks, with the majority of rosacea patients reporting complete or almost complete resolution.1,2,39 Furthermore, another study indicated topical ivermectin improved symptoms by 86% compared to 75% with topical metronidazole.14 Additionally, there were improvements in wellbeing, QoL and better tolerability when compared with azelaic acid (i.e. less skin dryness, burning and pruritus).19 Additionally, no significant adverse events were reported during 52 week follow-up and longer relapse times were demonstrated.5,7,19 Permethrin is another topical agent with antiparasitic effect; suggesting similar efficacy to metronidazole gel in a double blind RCT in reducing erythema and papules.4,7,24 However, it was ineffective for other subtypes.24 Other topical therapies Lastly, smaller case series have suggested the following topical therapies may benefit some patients.

• Benzyl benzoate can abolish Demodex mites, and although in one study it reduced the number of lesions in rosacea,3 it was only efficacious at 5% concentrations versus placebo.40 From the same study 1% concentration reduced more lesions compared to placebo but further studies are needed.5,40 • Retinoids stimulate connective tissue remodelling, thus repairing and reversing UV damage. Furthermore, they have antiinflammatory and anti-keratolytic properties.7,24 Some retinoids have indicated in-vitro down-regulation of toll-like receptor 2 (TLR2).24 Studies have indicated a clinical reduction in erythema, telangiectasia, papules and pustules as a monotherapy or in combination with other topicals.41,42 However, clinical benefit can take months and more data is required.

• Calcineurin inhibitors inhibit T-cells, thus decreasing inflammatory cytokines and erythema.24 Some promising results have been seen for PPR and ETR in open-labelled studies.43,44 However, two randomised control trials noted no significant difference when compared to placebo.45,46 Controversially, pimecrolimus ointment, usually given for atopic dermatitis, has reportedly induced erythematous eruptions.7 Therefore, further studies are needed and these agents should only be considered in refractory cases.

• For OR, ciclosporin ophthalmic emulsion suggested statistically significant improvements in symptoms and QoL compared to oral doxycycline.1,3,4,7 However, this was only in one small study of 37 patients assessing QoL and Schirmer’s score (a test that determines whether the eye produces enough tears to keep it moist).3 A separate study comparing ciclosporin to artificial tears, indicated ciclosporin to be effective in treating the corneal changes of OR, with only transient and mild side effects.13 Topical azithromycin helps meibomian gland dysfunction seen in OR and oral doxycycline has shown success at low doses.7 However, this subtype remains refractory to many treatments.

• Of note, some cosmetics have been used in studies with minimal benefit.7,47,48 These studies suggested skincare products with Ambophenol, Neurosensine, and La Roche-Posay thermal spring water as a monotherapy or in combination with metronidazole could reduce symptoms of rosacea.48

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â&#x20AC;˘ Conversely, many cosmetics can irritate the skin.7 Patients may find green or yellow-tinted makeup effective for camouflage.

Additionally, mineral makeup containing silica or talc is generally well-tolerated.8,16,19

Systemic therapies Current therapies include antibiotics, beta-blockers and isotretinoin.24 Tetracyclines are antibiotics utilised in rosacea for more than 50 years.

Their efficacy has been demonstrated by several clinical studies, especially for PPR.24,49-51 They are generally perceived to be safe, but have many side effects such as gastrointestinal distress, vulvovaginal candida, teratogenicity and photosensitivity.3,52 Doxycycline, when used at an anti-inflammatory dose i.e. â&#x2030;¤50mg, is effective for treating rosacea, avoids development of antibiotic resistance and has less severe side effects.12,17,53 It works by decreasing expression of matrix metalloproteinases (MMPs) that activate KLK5.24 Additionally, it lowers the pro-inflammatory cytokines, ROS and nitric oxide levels.54 Overall, this decreases neutrophil migration, tissue damage and vasodilation. Multiple studies demonstrate the efficacy and safety profile of doxycycline. For example, two studies suggested two grades of improvement in erythema compared to placebo.3-4,53 It is effective in OR, by decreasing bacterial lipases in the meibomian glands and reduces both inflammation and risk of corneal perforation.4 Minocycline has indicated potential benefit in PPR but the evidence is scanty.7 Erythromycin has shown to be effective for PPR, but has significant gastrointestinal side effects.4 However, at 250mg per day; it can be used as an alternative to Doxycycline, where allergies or intolerances to Tetracyclines exist. Other studies suggest clindamycin and azithromycin reduce facial erythema and papules but as there is limited data these should only be used in refractory cases.2,5 Furthermore, metronidazole at 200mg BD is helpful in PPR but limited by its potential side effects of neuropathy and seizures, although these are rare.55 Lastly, all the antibiotics have gastrointestinal effects, but to varying degrees, therefore, patients should be appropriately counselled. Beta-blockers work by vasoconstricting the dermal blood vessels, and thus reducing erythema and flushing. A case series from 2005 indicated that eight out of nine patients had decreased severity of flushing with fewer episodes when using propranolol.24 Further studies also noted a drop in facial temperature by 2.2°C.53 Carvedilol, is normally used for heart failure and hypertension, but has shown anti-inflammatory and anti-oxidant properties.24, 56,57 Beta-blockers are generally well tolerated, however, bradycardia and hypotension can occur and therefore, vital signs need assessing prior to use.

Isotretinoin, in several studies, suggests efficacy, especially for severe refractory PPR and early PR.4,17,19,24 Doses utilised vary from 0.5-1mg/kg, but doses as low as 10mg per day have been used effectively and have a reduced side-effect profile. However, all women of childbearing age need counselling, as it is teratogenic.17 Isotretinoin was shown to be superior to doxycycline and placebo after 12 weeks.3,7 Its mechanism of action involves reduction of TLR2 expression. Additionally, in vitro it decreased levels of KLK5 and KLK7.24 However, recurrence has been seen on discontinuation and therefore low, life-long maintenance doses may be required.

Procedural therapies Different forms of lasers have been utilised in rosacea, especially for telangiectasia, as medical therapy has limited effects.4,19 Previously, flashlamp-pumped long-pulse dye and potassium-titanyl-phosphate lasers were used. Nowadays, high energy lasers such as 595 nm long-pulse duration pulsed-dye lasers (PDL) are often well tolerated.4

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Another effective laser is the long-pulsed neodymium-doped yttrium aluminium garnet (Nd:YAG) laser, which is safe and affects deeper vessels.19, 58 Nd:YAG has shown to be effective in reducing facial erythema, however, after four treatments PDL was more effective, but considerably more painful.19 Intense pulsed light (540950 nm) uses visible light to improve vascular lesions in rosacea.

It targets, heats and destroys the red pigment in blood without impacting on surrounding structures.59 Other available options include: photodynamic therapy, CO2 lasers and erbium-doped YAG (Er:YAG).19 Both PDL and intense-pulsed-light therapy suggest equal efficacy for erythema and telangiectasia.3 Additionally, PDLs have been suggested to have greater efficacy for reducing symptoms compared with Nd:YAG, but this was only in one study with few participants.59 Side effects of light or laser therapies can include purpura, stinging and hyper/hypopigmentation but more trials are needed for all modalities.17 Botulinum toxin is a neuromodulator and disrupts neuromuscular signalling, which reduces facial erythema and flushing.4 It is generally perceived to be safe but associated headaches have been reported.

Therefore, it is used for the treatment of refractory erythema and larger studies are needed as only case studies currently exist.60 PR may require surgical therapy, which is beyond the scope of this article, but some procedures involve: lasers, electrocautery, cryotherapy, radiotherapy, dermabrasion, excisions or reconstruction with flaps or grafts.59 These are operator dependant and have associated surgical risks including; bleeding, scarring and pigmentary changes. However, further evidence is needed for the procedural management of rosacea.

Novel modalities New therapies in the literature include: topical serine protease inhibitors (SPI) and topical mast cell stabilisers (MCS) e.g. cromolyn sodium.24 SPIs reduce KLK5, cathelicidin and IL-37.24 One study investigating epsilon-aminocaproic acid, a topical SPI, indicated statistically significant reduction in erythema after 12 weeks compared to controls.61 MCS also reduce cathelicidin release, IL-37, MMP and proinflammatory cytokines. An eight-week trial of 10 patients using topical cromolyn sodium or vehicle applied twice daily, suggested reduced facial erythema with cromolyn sodium, but larger trials are required to confirm the data.62

Conclusion Currently no single modality exists to cure rosacea. Therefore treatment must be tailored according to symptoms, the severity/ grading of rosacea and the subtype. ETR is the most challenging to treat but topical preparations of metronidazole, AA or combinations with laser/light therapies have been most effective. For PPR, similarly, either topical or systemic antibiotics, topical AA, Ivermectin or Brimonidine seem to be most effective. PR usually requires dermatological procedures and OR is best treated via topical or systemic antibiotics.

Overall, a combination of patient education regarding their condition, the importance of sunscreens, good skincare and hygiene is paramount. Furthermore, support via camouflage services or the National Rosacea Society could be beneficial. Secondly, utilisation of available therapies as mono or poly-therapy and knowledge of novel pathways for refractory cases is important for effective management.

However, further research is needed to better understand the pathophysiology of rosacea and thus target treatment to provide individualised care.

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Dr Priya Patel is a core medical trainee at East Surrey Hospital. She is an aspiring dermatologist, currently working with Dr Cliff, and takes an active interest in topics involving allergy and immunology.

Dr Sandeep Cliff is a consultant dermatologist and dermatological surgeon based in London and Surrey. He has lectured extensively both nationally and internationally on facial rejuvenation.

REFERENCES 1. Gold LM & Draelos ZD, ‘New and Emerging Treatments for Rosacea’, American Journal of Clinical Dermatology, 2015, 16, pp. 457-461. <https://www.ncbi.nlm.nih.gov/pubmed/26396117> 2. Weinkle AP & Doktor V, et al., ‘Update on the management of Rosacea’, Clinical, Cosmetic and Investigational Dermatology, 2015, 8, pp.159-177. <https://www.ncbi.nlm.nih.gov/pubmed/25897253> 3. Van Zuuren EJ & Fedorowicz Z, ‘Interventions for Rosacea’, Journal of American Medical Association: Clinical Evidence Symposium, 2015, 314, pp. 2403-2407. <https://www.ncbi.nlm.nih.gov/ pubmed/21412882> 4. Abokwidir M & Feldman SR ‘Rosacea Management’, Skin Appendage Disorders. 2016. 2:26-34. <https://www.karger.com/Article/FullText/446215> 5. Two AM, Wu W, Gallo RL, Hata TR. Rosacea: Part I. Introduction, Categorization, Histology, Pathogenesis, and Risk Factors. Journal of American Academy of Dermatology.2015. 72(5):749-60. <https://www.ncbi.nlm.nih.gov/pubmed/25890455> 6. Schaller M, Schöfer H, Homey B, Hofmann M, Gieler U, Lehmann P, Luger TA, Ruzicka T, Steinhoff M. Rosacea Management: Update on general measures and topical treatment options. Journal of the German Society of Dermatology.2016. 6:17–27. <https://www.ncbi.nlm.nih.gov/pubmed/27869379> 7. Van Zuuren EJ and Fedorowicz Z. Interventions for Rosacea: abridged update Cochrane systematic review including GRADE assessments. British Journal of Dermatology, 2015, 173:651-662. <https:// www.ncbi.nlm.nih.gov/pubmed/26099423> 8. Oge LK, Muncie HL and Phillips-Savoy AR. Rosacea: Diagnosis and Treatment. American Academy of Family Physicians.2015. 92(3):187-196. <https://www.ncbi.nlm.nih.gov/pubmed/26280139> 9. Gupta MA, Gupta AK, Chen SJ, Johnston AM. Comorbidity of Rosacea and Depression: an analysis of the national ambulatory care survey: outpatient Department data collected by the U.S. National Center for Health Statistics from 1995 to 2002. British journal of dermatology.2005. 153(6):1176-1181. <https://www.ncbi.nlm.nih.gov/pubmed/16307654> 10. Barrington IL. Coping with Rosacea: Tips on Lifestyle Management for Rosacea Sufferers. National Rosacea Society. 1996.

11. Moustafa F, Lewallen RS, Feldman SR. The psychological impact of rosacea and the influence of current management options. Journal of the American Academy of Dermatology. 2014. 71(5):973–80.

12. Korting HC and Schöllmann C. Current topical and systemic approaches to treatment of rosacea.

Journal of the European Academy of Dermatology and Veneriology.2009. 23:876–882. <https:// www.ncbi.nlm.nih.gov/pubmed/19508315> 13. Jonette K. What’s new in acne and rosacea? Seminar in Cutaneous Medicine and Surgery.2016:35:103-106. <https://www.ncbi.nlm.nih.gov/pubmed/27416316> 14. Fortuna MC & Garelli V et al., ‘A case of Scalp Rosacea treated with low dose doxycycline and probiotic therapy and literature review on therapeutic options’, Dermatologic Therapy, 2016, 29, pp.249–251. <https://www.ncbi.nlm.nih.gov/pubmed/27087407> 15. Steinhoff M & Schmelz M et al., ‘Facial Erythema of Rosacea – Aetiology, Different Pathophysiologies and Treatment Options’, Advances in Dermatology and Venereology. 2016. 96:579–586. <https:// www.ncbi.nlm.nih.gov/pubmed/26714888> 16. Mikkelsen CS & Holmgren HR et al., ‘Rosacea: a clinical review’, Dermatology Reports. 2016. 6387:1-5. <https://www.ncbi.nlm.nih.gov/pubmed/27942368> 17. Elsaie ML & Choudhary S, ‘Updates in the pathophysiology and management of acne rosacea’, Postgraduate medicine, (2009) 5:1-9, <https://www.ncbi.nlm.nih.gov/pubmed/19820288> 18. Asai Y & Tan J et al., ‘Canadian Clinical Practice Guidelines for Rosacea’, Journal of Cutaneous Medicine and Surgery. 2016. 20: 432-445. <https://www.ncbi.nlm.nih.gov/pubmed/27207355> 19. Lanoue J & Goldenberg G, ‘Therapies to Improve the Cosmetic symptoms of Rosacea’. Cutis. 2015.

96: 19-26. <https://www.ncbi.nlm.nih.gov/pubmed/26244351> 20. Del Rosso JQ & Gallo RL et al., ‘An evaluation of potential correlations between pathophysiologic mechanisms, clinical manifestations and management of rosacea’. Cutis. 2013. 91:1-8. <https://www. ncbi.nlm.nih.gov/pubmed/23833998> 21. Del Rosso JQ & Gallo RL et al., ‘Why is rosacea considered to be an inflammatory disorder? The primary role, clinical relevance, and therapeutic correlations of abnormal innate immune response in rosacea-prone skin’ Journal of drugs in dermatology. 2012. 11: 694-700. <http://jddonline.com/articles/ dermatology/S1545961612P0694X/1> 22. Steinhoff M & Buddenkotte J et al. ‘Clinical, cellular, and molecular aspects in the pathophysiology of rosacea’, Journal of Investigative Dermatology Symposium Proceedings. 2011.15: 2-11. <https://www. ncbi.nlm.nih.gov/pubmed/22076321> 23. Crawford GH & Pelle MT et al., ‘Rosacea: I Etiology, pathogenesis, and subtype classification’, Journal of American Academy of Dermatology. 2004. 51: 327-341. <https://www.ncbi.nlm.nih.gov/ pubmed/15337973> 24. Two A M & Wu W et al., ‘Rosacea: Part II. Topical and systemic therapies in the treatment of rosacea’, Journal of American Academy of Dermatology. 2015. 72: 761-770. <https://www.ncbi.nlm.nih.gov/ pubmed/25890456> 25. Wolf K and Silapunt S. The Use of Sodium Sulfacetamide in Dermatology. Cutis. 2015. 96(2):128-130 26. Del Rosso JQ. Evaluating the role of topical therapies in the management of rosacea: focus on combination sodium sulfacetamide and sulfur formulations. Cutis. 2004.73:29-33.

27. Sauder DN, Miller R, Gratton D, et al. The treatment of rosacea: the safety and efficacy of sodium sulfacetamide 10% and sulfur 5% lotion (Novacet) is demonstrated in a double-blind study. Journal of Dermatology Treatments.1997. 8(2):79–85.

28. Lebwohl M, Medansky RS, Russo CL, et al. The comparative efficacy of sodium sulfacetamide 10%/ sulfur 5% (Sulfacet-R®) lotion and metronidazole 0.75% (Metrogel®) in the treatment of rosacea.

Journal of Geriatric Dermatology. 1995.3(5):183–185.

29. Trumbore MW, Goldstein JA, Gurge RM. Treatment of papulopustular rosacea with sodium sulfacetamide 10%/sulfur 5% emollient foam. Journal of Drugs in Dermatology. 2009.8(3):299–304.

Aesthetics 30. Van Zuuren EJ, Kramer SF, Carter BR, Graber MA, Fedorowicz Z, ‘Effective and evidence-based management strategies for rosacea: summary of a Cochrane systematic review’, British Journal of Dermatology, 2011.165:760-781.

31. Nielsen PG, Treatment of rosacea with 1% metronidazole cream, ‘A double-blind study’, British Journal of Dermatology, 1983.108:327-332.

32. Bleicher PA, Charles JH, Sober AJ, ‘Topical metronidazole therapy for rosacea’, Archives of Dermatology, 1987.123:609-614.

33. Breneman DL, Stewart D, Hevia O, Hino PD, Drake LA, ‘A double-blind, multicenter clinical trial comparing efficacy of once-daily metronidazole 1 percent cream to vehicle in patients with rosacea’, Cutis, 1998. 61:44-47.

34. Lowe NJ, Henderson T, Millikan LE, Smith S, Turk K, Parker F. Topical metronidazole for severe and recalcitrant Rosacea: a prospective open trial’, Cutis, 1989. 43:283-286.

35. Dahl MV, Katz HI, Krueger GG, et al. ‘Topical metronidazole maintains remissions of rosacea’, Archives of Dermatology, 1998.134:679-683.

36. Coda AB, Hata T, Miller J, et al, ‘Cathelicidin, kallikrein 5, and serine protease activity is inhibited during treatment of rosacea with azelaic acid 15% gel’, Journal of American Academy of Dermatology, 2013.69:570-577.

37. Fowler J, Jarratt M, Moore A, et al. Once-daily topical brimonidine tartrate gel 0.5% is a novel treatment for moderate to severe facial erythema of rosacea: results of two multicentre, randomized and vehicle-controlled studies’, British Journal of Dermatology, 2012, pp.166:633-641 38. Forstinger C, Kittler H, Binder M, ‘Treatment of rosacea-like demodicidosis with oral ivermectin and topical permethrin cream’, Journal of American Academy of Dermatology, 1999. 41:775-777.

39. Stein L, Kircik L, Fowler J, et al, ‘Efficacy and safety of ivermectin 1% cream in treatment of papulopustular rosacea: results of two randomized, double-blind, vehicle-controlled pivotal studies’, Journal of Drugs in Dermatology, 2014.13(3):316–323.

40. Leyden JJ, ‘Randomized, phase 2, dose-ranging study in the treatment of rosacea with encapsulated benzoyl peroxide gel’, Journal of Drugs in Dermatology, 2014, 13:685–8.

41. Ertl GA, Levine N, Kligman AM, ‘A comparison of the efficacy of topical tretinoin and low-dose oral isotretinoin in rosacea’, Archives of Dermatology, 1994.130:319-324.

42. Freeman SA, Moon SD, Spencer JM, ‘Clindamycin phosphate 1.2% and tretinoin 0.025% gel for rosacea: summary of a placebo-controlled, double-blind trial, Journal of Drugs in Dermatology, 2012.11:1410-1414.

43. Kim MB, Kim GW, Park HJ, et al, ‘Pimecrolimus 1% cream for the treatment of rosacea’, Journal of Dermatology, 2011.38:1135-1139.

44. Bamford JT, Elliott BA, Haller IV, ‘Tacrolimus effect on rosacea’, Journal of American Academy of Dermatology, 2004.50:107-108.

45. Weissenbacher S, Merkl J, Hildebrandt B, et al, ‘Pimecrolimus cream 1% for papulopustular rosacea: a randomized vehicle-controlled double-blind trial’, British Journal of Dermatology, 2007.156:728-732.

46. Karabulut AA, Izol Serel B, Eksioglu HM, ‘A randomized, single-blind, placebo-controlled, split-face study with pimecrolimus cream 1% for papulopustular rosacea’, Journal of European Academy of Dermatology and Venereology, 2008.22:729-734.

47. Leyden JJ, ‘Efficacy of a novel rosacea treatment system: an investigator-blind, randomized, parallelgroup study’, Journal of Drugs in Dermatology, 2011. 10:1179–1185.

48. Seit_e S, Benech F, Berdah S et al, ‘Management of rosacea-prone skin: evaluation of a skincare product containing Ambophenol, Neurosensine and La Roche-Posay thermal spring water as monotherapy or adjunctive therapy, ‘Journal of Drugs in Dermatology’, 2013. 12:920–4.

49. Del Rosso JQ, Preston NJ, Caveney SW, Gottschalk RW, ‘Effectiveness and safety of modified-release doxycycline capsules once daily for papulopustular rosacea monotherapy results from a large community-based trial in subgroups based on gender’, Journal of Drugs in Dermatology, 2012.11:703707.

50. Alexis AF, Webster G, Preston NJ, Caveney SW, Gottschalk RW, ‘Effectiveness and safety of oncedaily doxycycline capsules as monotherapy in patients with rosacea: an analysis by Fitzpatrick skin type’, Journal of Drugs in Dermatology, 2012.11:1219-1222.

51. McKeage K, Deeks ED, ‘Doxycycline 40 mg capsules (30 mg immediate-release/10 mg delayedrelease beads):anti-inflammatory dose in rosacea, ‘Journal of American Academy of Dermatology, 2010.11:217-222.

52. Schaller M & Schöfer H et al., ‘State of the art: Systemic rosacea management’, Journal of the German Society of Dermatology. 2016. 6:29-37. <https://www.ncbi.nlm.nih.gov/pubmed/27869374> 53. Layton A & Thiboutot D, ‘Emerging therapies in rosacea’, Journal of American Academy of Dermatology. 2013. 69:57-65. <https://www.ncbi.nlm.nih.gov/pubmed/24229638> 54. Wise RD, ‘Submicrobial doxycycline and rosacea’, Comprehensive Therapy, 2007.33:78-81.

55. Pye RJ, Burton JL, ‘Treatment of rosacea by metronidazole, Lancet, 1976. 1(7971):1211–1212.

56. Hsu CC, Lee JY, ‘Carvedilol for the treatment of refractory facial flushing and persistent erythema of rosacea’, Archives of Dermatology, 2011. 147:1258-1260.

57. Hsu CC, Lee JY, ‘Pronounced facial flushing and persistent erythema of rosacea effectively treated by carvedilol, a nonselective beta-adrenergic blocker’, Journal of American Academy of Dermatology, 2012. 67:491-493.

58. Tanghetti E, Del Rosso JQ, Thiboutot D, et al, ‘Consensus recommendations from the American Acne & Rosacea Society on the management of rosacea, part 4: a status report on physical modalities and devices, Cutis. 2014. 93:71-76.

59. Hofmann MA & Lehmann P, ‘Physical modalities for the treatment of rosacea’, Journal of the German Society of Dermatology. 2016. 14(6):38–43. <https://www.ncbi.nlm.nih.gov/pubmed/27869377> 60. Park KY, Hyun MY, Jeong SY, Kim BJ, Kim MN, Hong CK, ‘Botulinum toxin for the treatment of refractory erythema and flushing of rosacea’, Dermatology, 2015. 230: 299–301.

61. Two AM, Hata TR, Nakatsuji T, et al, ‘Reduction in serine protease activity correlates with improved rosacea severity in a small, randomized pilot study of a topical serine protease inhibitor’, Journal of Investigative Dermatology, 2014. 134:1143-1145.

62. Muto Y, Wang Z, Vandenberghe M, Two A, Gallo RL, Di Nardo A, ‘Mast cells are key mediators of cathelicidin initiated skin inflammation in rosacea’, Journal of Investigative Dermatology, 2014. 134: 2728-2736.

Reproduced from Aesthetics | Volume 4/Issue 5 - April 2017

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UPPER FACIAL LINES Now Available in 100u Vial

Botulinum toxin type A free from complexing proteins Bocouture® (Botulinum toxin type A (150 kD), free from complexing proteins) 50/100 unit vials. Prescribing information: M-BOC-UK-0046.

Please refer to the Summary of Product Characteristics (SmPC) before prescribing. Presentation: 50/100 units of Clostridium Botulinum Neurotoxin type A, free from complexing proteins as a powder for solution for injection. Indications: Temporary improvement in the appearance of moderate to severe upper facial lines (glabellar frown lines, crow’s feet lines, horizontal forehead lines) in adults ≥18 and <65 years when the severity of these lines has an important psychological impact for the patient. Dosage and administration: For intramuscular use only. Unit doses recommended for Bocouture are not interchangeable with those for other preparations of Botulinum toxin. Bocouture may only be used by physicians with suitable qualifications and proven experience in the application of Botulinum toxin. The intervals between treatments should not be shorter than 3 months. Reconstitute with 0.9% sodium chloride.

Horizontal Forehead Lines: The recommended total dose range is 10 to 20 units; a total injection volume of 0.25 ml (10 units) to 0.5 ml (20 units) is injected into the frontalis muscle in five horizontally aligned injection sites at least 2 cm above the orbital rim. An injection volume of 0.05 ml (2 units), 0.075 ml (3 units) or 0.1 ml (4 units) is applied per injection point, respectively. Glabellar Frown Lines: Total recommended standard dose is 20 units. 0.1ml (4 units) into 5 injection sites (2 injections in each corrugator muscle and 1 injection in the 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: Total recommended 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. Contraindications: Hypersensitivity to the active substance or to any of the excipients.

Generalised disorders of muscle activity (e.g. myasthenia gravis, Lambert-Eaton syndrome). Infection or inflammation at the proposed injection site. Special warnings and precautions: It should be taken into consideration that horizontal forehead lines may not only be dynamic, but may also result from the loss of dermal elasticity (e.g. associated with ageing or photodamage). In this case, patients may

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not respond to Botulinum toxin products. Should not be injected into a blood vessel. Not recommended for patients with a history of dysphagia and aspiration. Caution in patients with amyotrophic lateral sclerosis, peripheral neuromuscular dysfunction, or in targeted muscles displaying pronounced weakness or atrophy. Bocouture should be used with caution in patients receiving therapy that could have an anticoagulant effect, or if bleeding disorders of any type occur. 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, undesirable effects are observed within the first week after treatment and are temporary in nature. Undesirable effects independent of indication include; application related undesirable effects (localised pain, inflammation, swelling), class related undesirable effects (localised muscle weakness, blepharoptosis), and toxin spread (very rare exaggerated muscle weakness, dysphagia, aspiration pneumonia).

Hypersensitivity reactions have been reported with Botulinum neurotoxin products. Upper Facial Lines: very common: Headache.

Common: Hypoaesthesia, injection site haematoma, application site pain, eyelid ptosis, dry eye, facial asymmetry, sensation of heaviness, nausea. Glabellar Frown Lines: Common: Headache, Muscle disorders (elevation of eyebrow). Crow’s Feet Lines: Common: Eyelid oedema, dry eye, injection site haematoma. For a full list of adverse reactions, please consult the SmPC. Overdose: May result in pronounced neuromuscular paralysis distant from the injection site. Symptoms are not immediately apparent postinjection. Legal Category: POM. List Price: 50 U/vial £72.00, 50 U twin pack £144.00, 100 U/vial £229.90. Product Licence Number: PL 29978/0002, PL 29978/0005 Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer Landstraße 100,60318 Frankfurt/Main, Germany. Date of Preparation: December 2016.

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 UKdrugsafety@merz.com or on +44 (0) 333 200 4143.

1. Bocouture® 50 units Summary of Product Characteristics (SmPC).

March 2016. Available from: https://www.medicines.org.uk/emc/ medicine/23251.

2. Bocouture® 100 units Summary of Product Characteristics (SmPC). September 2016. Available from: https://www.medicines. org.uk/emc/medicine/32426.

3. Kerscher M, et al. Efficacy and Safety of IncobotulinumtoxinA in the Treatment of Upper Facial Lines: Results From a Randomised, Double-Blind, Placebo-Controlled, Phase III study. Dermatol Surg 2015;41:1149-1157.

Bocouture® is a registered trademark of Merz Pharma GmbH & Co, KGaA. M-BOC-UK-0040 Date of Preparation November 2016

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Botulinum toxin type A free from complexing proteins

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Recognising Compensated Brow Ptosis Mr Marc Pacifico discusses how to successfully recognise and treat compensated brow ptosis Do you understand compensated brow ptosis? Do you examine for it routinely prior to considering rejuvenation of the upper face? Do you have a plan if you recognise it?

We are all likely to see patients with compensated brow ptosis as part of our upper facial rejuvenation practice. Recognising it is key, as failure to do so can result in poor planning and treatment decisionmaking, even if the execution of the chosen procedure goes well.

Compensated brow ptosis is usually a feature that the patient will be unaware of and they are more likely to notice wrinkles on their forehead, excess upper eyelid skin or occasionally, but not often, they may notice that their brow is low. Rarer still are those who realise they are raising their eyebrows to compensate for this. However, if it is present, educating patients on its occurrence is vital to successfully managing their expectations and ensuring that they understand the recommended treatment options.

This article addresses the sometimes complex issues surrounding compensated brow ptosis and how to manage patients in whom it presents, as well as the pitfalls and problems that can be encountered if it is not recognised.

What is compensated brow ptosis?

Compensated brow ptosis is brow ptosis (droop) that is corrected subconsiously by the patient, through contraction of the frontalis muscle in the forehead to raise the brow to a more desirable or functional position. Instead of doing it for a short time such as when showing expressions, it happens continuously.1-4 Two factors principally contribute to compensated brow ptosis. The first is the brow ptosis itself, where, with age, the brow gradually descends to a more low lying position. This is most apparent at the lateral (outer) brow, while the mid-brow can often be associated too.

Interestingly, the medial brow usually maintains a reasonably good position, despite descent of the other parts of the brow. The second contributory factor can occur because of the weight of excess upper eyelid skin (dermatochalasis).1-4 Both a low-lying brow and heaviness of the upper eyelid skin will be recognised by the patient subconsciously and will therefore stimulate contraction of the frontalis, to raise the brow to a better, more functional position. This alleviates the heaviness of the brow, but also helps to take the weight off the upper lids in those with excess upper lid skin.

Recognising compensated brow ptosis Patients with compensated brow ptosis typically present for treatment of forehead rhytids, or alternatively present with upper eyelid skin excess. Understandably, I have found that they rarely appreciate the significance of their brow, its position or the

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contraction of their frontalis.

The way I find most useful to assess a patient for compensated brow ptosis is to ask the patient to close their eyes and relax. As they do this, I look for a descent of the brow, and improvement in their transverse forehead rhytids. I then ask them to open their eyes and look at me, and inevitably see their brows elevate and the restoration of the forehead lines.

From my experience, another good tip is to look for lateral eyelid hooding. If there is hooding that extends laterally beyond the lateral canthus, it is inevitably the result of lateral brow descent that may not be fully compensated for.

I would also always encourage patients to bring photographs of themselves when they were in their 20s, prior to age-related brow changes, to the consultation. This will enable a comparison of the brow position (on eye closure and opening) as well as the appearance of their forehead, eye shape, and relationship of brow to upper lids.

Why recognition is important The brow and upper lids are intimately linked, and whether patients are presenting for treatment of their forehead lines or are presenting with complaints of excess upper eyelid skin, if compensated brow ptosis is not recognised and discussed, it can often lead to problems.

For example, if the forehead is treated with botulinum toxin injections to improve the transverse rhytids, the brow will subsequently descend.

Whilst the rhytids will improve (which the patient is likely to be happy with) it will often be at the expense of the brow descending to an unaesthetic position. The patient may then complain of a heaviness to their brow, and often dislike the ‘natural’ position to which the brow has dropped, as they will not be used to seeing their brow in this position. Furthermore, the descent of the brow will have a knock-on effect on the upper lid skin, which will, in effect, be squashed down, giving the impression of the patient requiring an upper blepharoplasty, when in fact the primary problem is the brow.

On the other hand, a patient may present for an upper blepharoplasty, which may be entirely reasonable; however, if the brow is not addressed simultaneously, the outcome will be disappointing.

Removal of the ‘heavy’ upper lid skin will often provoke a subconscious relaxation of the brow, as it no longer has to contribute to alleviating the weight on the upper lids. Again, this will result in descent of the brow and give the impression that the upper blepharoplasty was under-treated.1-4

Consulting patients As ever, managing patient expectations is key. If you discuss potential issues before you treat the patient, it comes across as an explanation, but if you try to explain it after a procedure, it sounds more like an excuse. It is much harder to regain your patient’s confidence and trust again after this.

In an upper blepharoplasty consultation, I have found that a discussion about a patient’s brow often comes as a surprise to the patient as they would never know that their frontalis is the underlining issue. However, if a full and clear explanation is given, along with a demonstration (I find taking a photograph of the patient with their eyes closed and then eyes open immediately afterwards is very helpful), most patients understand what you are talking about.

Similarly, when patients come in for botulinum toxin injections, it is important to explain to them that using toxin to carefully balance the alleviation of forehead rhytids, with simultaneous relaxation of brow depressors to minimise brow descent, can be challenging.

This challenge can be seen in the occasional ‘Mephisto brows’

Reproduced from Aesthetics | Volume 4/Issue 5 - April 2017

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Compensated brow ptosis summary1-4 What it is: subconscious elevation of the brow to compensate for age-related brow descent and/or excess upper eyelid skin How to quickly recognise it: ask the patient to relax and close their eyes and watch for brow descent Why it is important: lack of recognition may lead to poor treatment planning, undesired outcomes and unhappy patients How to manage it: non-surgical and surgical approaches may be used, but in my experience, surgical brow re-positioning is the most reliable

when attempting to elevate the brow using toxin injections just under the lateral brow. This refers to an unnatural appearance of raised lateral brows, with increased lines only on the edges of the forehead, much like the appearance of Mephistopheles, the demon from folklore. Again, this comes back to managing patients’ expectations, and clearly explaining what effect they are likely to experience if the impact of any compensated brow ptosis is not taken into account.

Non-surgical procedures As discussed, a patient with compensated brow ptosis will present with forehead rhytids. Therefore, using botulinum toxin alone is challenging. A combination of low dose toxin to ‘soften’ the forehead rhytids, whilst also injecting doses just inferior to the tail of the brow, and superficially into the corrugators may help to achieve a degree of brow elevation. It is important to ensure that there is a dose given to the lateral forehead just medial to the temporal crest to avoid a ‘Mephisto brow’ being created. Hyaluronic acid (or other) filler can be used to subtly re-volumise and build the bony orbit, which, in some circumstances, can help to support the brow to compensate for the use of toxins. However, it is not fundamentally a bony support issue, so trying to solve the problem by building up the hard tissues will have limited effectiveness. Therefore, in my opinion, it may be best to get a plastic surgeon’s opinion in cases when botulinum toxin Before

After

Figure 1: Patient A showing subtle demonstration of compensated brow ptosis – note forehead rhytids. After upper blepharoplasty, there is a lowering of the brow, resulting in appearance of undercorrected upper lids, as well as some smoothing of forehead rhytids.

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has not worked, rather than use hyaluronic acid fillers, which may raise the patient’s expectations without being able to reliably deliver the results hoped for. Skin resurfacing to tighten the forehead will help with the rhytids and may also achieve a degree of skin contraction that will help to elevate the brow. Deeper resurfacing, such as CO2 laser or chemical peels would usually be required to achieve a meaningful result.

Surgical procedures

There are a number of surgical procedures to elevate the brow. If the brow is satisfactorily elevated, the frontalis will no longer need to contract and the rhytids will usually improve. If they do not improve, then there is more leeway in using toxins, as the brow is now supported and should not descend.

Indeed, I would recommend treatment of the forehead with toxin prior to a brow-lifting procedure to minimise tension from the muscles in the early post-operative period.

Local anaesthetic procedures Under local anaesthetic, a direct brow lift, leaving a relatively inconspicuous scar just above the lateral half of the brow can achieve excellent results. This involves a carefully planned skin excision in the appropriate part of the upper border of the brow, with or without fixation of the dermis to the underlying periosteum.

Alternatively, a brow lift can be achieved via an upper blepharoplasty incision in some cases.

General anaesthetic procedures The endoscopic (key hole) brow lift remains the gold standard procedure for the brow. Recognition that the medial brow rarely descends has shifted emphasis towards the central and lateral brow elevation, with toxin treatment for the glabella. Previously, the glabella musculature was addressed by surgical excision from the deep surface as part of the brow lift, however this gave rise to an undesired elevation of the medial brow (producing a surprised appearance) as well as limited effectiveness, on occasion, due to a lack of spacer being inserted (such as fat graft) to prevent the muscle and scar going on to re-produce movement in this area.1-4 In cases of pure lateral elevation of the brow, an endoscopicallyassisted lateral temporal brow lift is an excellent procedure. This is a relatively quick and straightforward day case operation to perform, but requires a general anaesthetic due to the deep planes in which the surgery is performed, between the superficial and deep temporal fascia.

Evaluation of treatment outcomes Patient A, shown in Figure 1, requested a 4-lid blepharoplasty (a combined upper and lower blepharoplasty). His compensated brow ptosis was pointed out and a brow lift was recommended as the severity of his symptoms meant no non-surgical methods would be effective for this patient and he declined the brow procedure. He did this as he was losing his hair so he wanted to see what result he got without any further risk of scarring.

Note the evidence of forehead rhytids, as well as his upper lid skin excess. Post-operatively, a good result can be seen on his lower lids; however, his upper lids look under-done because his brow lowered after surgery as the brow elevation no longer happened.

Note the lowering of his eyebrows compared with the pre-operative

Reproduced from Aesthetics | Volume 4/Issue 5 - April 2017

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Before

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In addition, the forehead rhytids have improved due to the lack of contraction of the frontalis.

Conclusion More people have a degree of compensated brow ptosis than many may think. Although I cannot find any official statistics, in my experience, at least 50% of upper blepharoplasty consultations involve a discussion about the brow that the patient was not expecting. Whilst occasionally a degree of brow descent can be desirable if the brow is over-elevated, in my experience brow descent is usually unwanted.

Recognising compensated brow ptosis and educating patients on its occurrence is key to helping manage their expectations and allowing them to understand why you may be recommending additional procedures or referring them for surgical intervention.

After

Figure 2: Patient B demonstrating compensated brow ptosis. After image shows lowering of brow following upper blepharoplasty.

photograph. This is actually a phenomenon of brow descent due to the relaxation of the frontalis, after the upper lid skin has been removed. The brow descent has effectively squashed down the upper lid skin. The correct further treatment is a surgical brow lift. Patient B (Figure 2) presented with over-compensated brow ptosis, because of the weight of the upper eyelid skin and the unaesthetic cranial position of her brows. Following a local anaesthetic upper blepharoplasty, the brow has subconsciously descended to a more desirable position.

Mr Marc Pacifico is a consultant plastic surgeon at Purity Bridge in Kent. He is a fully accredited specialist in plastic surgery, and is on the Specialist Register in Plastic Surgery with the General Medical Council, sits on the BAAPS council and is a member of BAPRAS and ISAPS. REFERENCES More information, the referenced sections can be found within the below texts, however, they are suggested for further reading only and do not necessarily have the original descriptions of the aforementioned text.

1. Foad Nahai, ‘The Art of Aesthetic Surgery: Principles and Techniques’, Three Volume Set, 2nd Edition, CRC Press 2, (2010).

2. Nerad, JA, ‘Techniques in Ophthalmic Plastic Surgery’, 2nd Edition, (2009) pp. 140-150, 177-187.

3. Robert S. Flowers & Eugene M. Smith Jr., ‘Blepharoplasty’, Plastic Surgery Secrets Plus, 2nd Edition, (2010), pp.487–497.

4. Codner MA, Kikkawa DO, Korn BS, Pacella SJ, ‘Blepharoplasty and brow lift’, Plast Reconstr Surg, 126(1) (2010).

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Reproduced from Aesthetics | Volume 4/Issue 5 - April 2017

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Before

Adverse events should be reported. Reporting forms and information for United Kingdom can be found at www.mhra.gov.uk/yellowcard.

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After 180 days

STAND 28 31 S T MAR - 1 S T APR 2017, LONDON AESTHETICSCONFERENCE.COM

References: 1. http://www.accessdata.fda.gov/cdrh_docs/pdf13/k134032.pdf Accessed April 2016 2. Sasaki GH & Tevez A. JCDSA. 2012; 2: 108-116 3. Ulthera System Instructions for Use, 1001393IFU Rev H 4. Lee HS, et al. Dermatol Surg. 2011;1-8 5. Data on File: ULT-DOF-008 – Ultherapy Mechanism of Action White Paper 6. Brobst RW, et al. Facial Plast Surg Clin N Am. 2014;22:191-202 7. ULT-DOF-003 Ultherapy Treatment Duration. Merz - July 2015 8. Alam M, et al. J Am Acad Dermatol. 2010;62:262-269 *stimulates new collagen and elastin which can reverse the signs of ageing

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Case Study: Treating Severe Photoageing Dr Harryono Judodihardjo shares a case study of treatment using a new thermo-mechanical fractional ablative skin resurfacing device for severe photoageing The structure of the skin degrades with time and this degradation is accelerated by factors such as ultraviolet exposure, smoking, stress, poor diet and genetics. While neurotoxins and dermal fillers can restore the appearance of the skin to a certain extent, to regain a patient’s youthful appearance, the structure of the skin needs to be corrected so that the integrity of the dermis and epidermis is restored.

The treatments for improving the skin’s surface and thickness are a group of procedures known as ‘skin resurfacing’. This can traditionally be done by three well-known treatment modalities: deep chemical peels, dermabrasion and ablative lasers.1 While these treatments can deliver very good results, some patients are not keen to have them because they all are associated with the following issues:2,3,4 • Unwanted side effects such as permanent scarring and skin depigmentation or hyperpigmentation.

• Pain that needs topical anaesthesia, nerve block and sometimes even general anaesthesia.

• Long recovery time for the skin to heal and then a long period of facial erythema before the skin colour returns to normality.

• High cost to the patients because of the complexity of the procedures.

Recently, a new fractional ablative treatment modality using thermo-mechanical action (TMA) became available. The machine is a small device weighing about five kilograms that can be placed on a table top or transported in an airline hand carry-on bag. It is not a laser; hence, registration with the Care Quality Commission and annual maintenance contracts are not required. In this article, I shall detail the use of this device in a patient with severe photoageing and the results that were obtained.

Figure 1: Tixel treatment tip with titanium arrays of pyramids to create the fractional treatment.

Figure 2: Illustration of the Tixel treatment tip creating craters in fractional pattern on skin.

What is TMA? TMA is a hot metal plate that is pushed momentarily, using a sophisticated and precise mechanical action, to heat the skin surface. The fractional effect of the treatment is achieved by small pyramidal shapes on the surface of the metal plate (Figure 1). During the treatment, only the tips of the pyramids touch the skin surface (Figure 2). It is designed to treat the skin fractionally with about 10% density. I believe the idea for inventing TMA came after Choi et al in 1999 published a study that suggested that when a CO2 laser hits the skin surface, it will heat the skin to around 400°C.5 Thus, in theory, if another treatment modality can heat the skin to a similar temperature, it could deliver the same results as the ablative CO2 laser. In 2012, Slatkine et al published an article on a device they invented that

used small metal rods that were heated to 400°C to create a microthermal zones (MTZ), that histologically was like those made by a fractional CO2 laser.6 This device, which was the precursor to the Tixel, then went through an extensive redesign to make it safer and more efficient.

The first clinical paper that uses Tixel fractional treatment was published by Elman et al in 2016.7 In this study, 33 females within the age range 42 to 75 years were recruited, and 26 subjects completed the study. Seven subjects did not complete the study, all were for non-clinical reasons. All subjects had three treatments spaced one to two months apart, without any anaesthesia, and all agreed that no anaesthesia was needed for the treatments. The average pain score recorded (Pain scale: 1 = minimum; 10 = maximum) was 3.1. All subjects noted improvement in skin complexion or reduction in signs of photodamage. Wrinkle reduction was noted in 75% of the subjects. One subject developed herpes labialis but other than this, no other complications were recorded. The downtime of the treatment included oedema and crusting, due to MTZ, (which cannot be covered up with makeup for 24 to 48 hours for most people), and was recorded as zero to three days.

The Elman paper also looked at the histological effect of the TMA treatment with different treatment parameters. The researchers suggested that by varying the dwell time, depth of penetration and number of pulse stacking, the TMA device can deliver both ablative or non-ablative treatments.

When set at the lowest setting, Tixel has also been shown to be able to increase drug permeability to the skin.8 Case Study: Severe photodamaged skin A 59-year-old patient had her first consultation with me in 2001 when she was 43 years old. She was a ‘sun worshipper’ and even at the age of 43 she already had advanced photodamage with static lines (Glogau9 stage 3) that is normally seen in patients 50 years of age and above (Figure 3). She was a single mother with two children and could not take time off work. Therefore, at that time, all the patient wanted was to correct her deep nasolabial folds (Figure 4) and have neurotoxin injections to her upper facial muscles. The treatments went well and since then she kept coming to see me regularly for similar treatments. I wanted to reduce the patient’s photodamaged skin condition further and encouraged her several times to have fractional CO2 laser treatments,

Reproduced from Aesthetics | Volume 4/Issue 5 - April 2017

@aestheticsgroup Before

Aesthetics Journal

After

Figure 3: Photograph of the patient in 2001 before any treatment. Note the deep nasolabial lines and other signs of severe photodamaged skin.

Figure 4: Photograph of the patient in 2001 immediately after the injection of hyaluronic acid dermal fillers into the nasolabial folds.

but she was afraid of the treatment and could not afford the long downtime period that was needed. I lost contact with the patient in 2009 for a few years when she had to move to southern Spain due to her work.

We reconnected again in August 2016 when she moved back to South Wales and was planning for her wedding. However, the patient’s health had changed as she was diagnosed with rheumatoid arthritis and was receiving regular methotrexate injections and occasional oral corticosteroids. Her skin had deteriorated further due to both age and more sun exposure in Spain. I graded her skin then as severely photodamaged (Glogau stage 4) (Figure 5).

The patient’s treatment plan now had to consider the limitations set by the immunosuppressive treatment she was under

and her severe photodamaged skin. I started treating her cautiously with neurotoxins to the glabellar and crow’s feet areas only, but not her frontalis muscles, as this might cause drooping to her brows. This went well, so I then started the patient on a course of laser peels to regularly and gently remove her upper epidermis. She had only one treatment and then decided that she needed something that could work quicker.

The patient came back again in October 2016 and we discussed the new Tixel treatment as an option for her. She liked this suggestion and decided to go ahead with the treatment.

Before

The treatment The treatment process is simple; after cleaning and sterilising the face, the treatment can start right away as no anaesthesia is needed. The treatment head is placed gently on the skin surface and when the trigger is squeezed the treatment head is gently pushed by the machine’s mechanism to touch the skin for the predetermined exposure time and depth. The exposure time is faster than the time needed for the patient to feel the heat and this is what makes the treatment tolerable.

Figure 5: Photograph of the patient in August 2016, before any treatment. Note the signs of advanced photodamaged such as wrinkles all over, dull and loose skin.

After

Figure 6: Photograph of the patient in February 2017, two months after two Tixel treatments and hyaluronic acid injections into her lips. Note the improvement to her skin texture and firmness.

The patient had her first treatment on 9 November 2016 and the entire treatment only took 20 minutes to complete and the patient was very pleased when she saw the results a few weeks later.

She told me that the downtime was short as she could put on makeup and go back to work after only two days. The patient described the treatment as ‘very bearable’. She was not afraid and without hesitation had her second treatment on 7 December 2016.

The treatment parameters for both of the procedures was 14

Aesthetics aestheticsjournal.com

milliseconds dwell time, 700 micrometres protrusion and a single shot. I reviewed her on 1 February 2017 and she was extremely pleased with the outcome of the treatment.

The patient had no complications despite her immunosuppressive treatments.

On examination, her skin had obvious improvement in texture, volume and wrinkle reduction. She still had static lines that can be corrected by dermal fillers, but overall, in my opinion, her skin health appearance had gone back to what she used to look like when I first met her 16 years ago (Figure 6). The only aftercare advice needed is to avoid sunlight and apply moisturiser for seven days.

Conclusion Neurotoxins and dermal fillers are the foundations of all aesthetic medical practice.

However, to be able to truly reverse the effect of photodamage and skin ageing, skin resurfacing treatment is often needed. Tixel is a new skin resurfacing device that has largely taken over from deep chemical peels and fractional CO2 laser in my practice. So far, I have been very impressed with the device; the results are pleasing to the patients and the side effects appear to be minimal.

Disclosure: Dr Harryono Judodihardjo is currently working with AZTEC Services Ltd to distribute Tixel in the UK and Ireland.

Dr Harryono Judodihardjo is the director of Cellite Clinic Limited in Cardiff, winner of the Aesthetics Award 2016 for Best Clinic Wales. He is also a partner of Belgravia Dermatology Ltd in London and the President Elect Designate for the Royal Society of Medicine Professional Aesthetic group.

REFERENCES: 1. Matarasso SL, Hanke CW and Alster TS, ‘Cutaneous resurfacing’. Dermatol Clin, (1997) Oct;15(4):569-82.

2. Metelitsa AI and Alster TS, Fractionated laser skin resurfacing treatment complications: a review. Dermatol Surg, (2010) Mar;36(3):299-306.

3. Matarasso SL and Glogau RG. ‘Chemical face peels’. Dermatol Clin. (1991) Jan;9(1):131-50.

4. Kim EK, Hovsepian RV, Mathew P and Paul MD, ‘Dermabrasion’. Clin Plast Surg. (2011) Jul;38(3):391-5, v-vi.

5. Choi B, Chan EK, Barton JK, Thomsen SL and Welch AJ, ‘Thermographic and Histological Evaluation of Laser Skin Resurfacing Scans’. IEEE Journal of selected topics in Quantum Electronics, VOL. 5, NO. 4, (1999) 6. Lask G, Elman M, Fournier N and Slatkine M, ‘Fractional vaporization of tissue with an oscillatory array of high temperature rods – Part I: Ex vivo study’. Journal of Cosmetic and Laser Therapy, (2012); 14: 218–223 7. Elman M, Fournier N, Barnéon G, Bernstein EF and Lask G, ‘Fractional treatment of aging skin with Tixel, a clinical and histological evaluation’. J Cosmet Laser Ther. (2016);18(1):31-7.

8. Sintov AC and Hofmann MA, ‘A novel thermo-mechanical system enhanced transdermal delivery of hydrophilic active agents by fractional ablation’. Int J Pharm. (2016) Sep 25;511(2):821-30.

9. Glogau RG, ‘Aesthetic and anatomic analysis of the aging skin’. Semin Cutan Med Surg. (1996) Sep;15(3):134-8.

Reproduced from Aesthetics | Volume 4/Issue 5 - April 2017

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Advertorial SkinCeuticals

Launch of the UK’s First SkinCeuticals Advanced Aesthetic Centre with Sarah White Laser & Aesthetics

Your clinic has just been made the UK’s First SkinCeuticals Advanced Aesthetic Centre – what does this mean and how has it impacted your business?

Our long-standing relationship and passion for SkinCeuticals, combined with our unique clinical setup, made us an obvious choice when SkinCeuticals were looking to establish a UK Centre of Excellence. Moreover, we believe that quality education in cosmeceutical skincare is vital for success and our convenient location gives us the chance to act as a SkinCeuticals Training Academy for the North of England. Our centre is undergoing a two-stage refurbishment process, with a revamped reception area featuring a SkinCeuticals retail wall (see image). We also plan to rebrand the treatment rooms, which will each be equipped with a dedicated skin analysis station. These rooms will be used for professional SkinCeuticals treatments, as well as practitioner training sessions.

Tell us about your background in aesthetics and your partnership with SkinCeuticals?

I worked in the NHS for over 20 years and have always been passionate about skin health. Since leaving the NHS nearly ten years ago I have specialised in aesthetics and built a thriving practice based around core principles of good skin health.

I noticed that many patients pay a great deal of money for injectable treatments such as botulinum toxin and fillers whilst neglecting the most critical factor – healthy skin. I therefore began looking for a science-based ‘cosmeceutical’ skincare range and quickly discovered that SkinCeuticals products truly deliver and produce tangible results for my patients. Since then, cosmeceutical skincare has become a key component of my business and I strongly advocate my peers to include skincare in their business model, not just from a profitability standpoint, but because it is what patients need, desire and expect as part of their aesthetic treatment journey.

How has your status as a SkinCeuticals Advanced Aesthetic Centre supported your existing ethos and positioning?

My passion is an integrated holistic skincare approach – combining injectables, laser, cosmeceuticals and peels. We know that a quality cosmeceutical skincare regime is in our patient’s best interests as it can enhance areas not addressed, for example, by injections. A dedicated commitment to skincare is essential to achieving a global improvement in appearance, particularly in areas of skin tone, texture, and pigmentation. Of course, it is also a vital component of our business: last year, our skincare business alone grew by +86% versus the previous year.

Our strategy is to dedicate part of the patients’ initial consultation time to discussing their skin health, to help them understand that this is the foundation of all aesthetic enhancements. We find that talking through SkinCeuticals’ fundamental principles of preventing future damage, correcting visible signs of previous skin damage and protecting healthy skin very powerful. If a patient isn’t already following a basic evidenced-based skincare regime, we provide samples of a SkinCeuticals antioxidant serum and an SPF as a bare minimum.

We also encourage injectable patients to book a skin analysis and SkinCeuticals facial at the same time as their follow-up appointment.

The cost of this is then redeemable against SkinCeuticals retail products. Customising a skincare regime for our patients allows us to further personalise the service we provide and differentiates us from other clinics that currently focus exclusively on in-clinic treatments.

Ultimately, when patients experience the amazing results of our approach, they remain loyal and also act as our advocates. All of this helps build and maintain our business!

Interestingly, your clinic is based in a private hospital setting – how has this model worked for your business and patients?

In 2015 I was offered the opportunity to relocate my clinic into the Aesthetic Suite at the Spire Murrayfield Hospital in the Wirral.

We are one of the first clinics in the UK to use this more holistic approach and it has taken our business to another level. With the increased space, we introduced three experienced Level 4 aestheticians who deliver the cosmeceutical skincare and laser services, which has led to a significant increase in sales and business growth. We can offer a truly integrated skincare approach from cosmeceuticals, all the way up to referring patients to specialist dermatology or surgery consultants, depending on their needs.

Aesthetics | April 2017

Sarah White is an advanced medical aesthetic nurse practitioner, independent prescriber and trainer with over 25 years’ medical experience. www.sarahwhiteaesthetics.com 0151 929 5223 / 07764 615934

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Aesthetics

Remodelling the Earlobe Dr Salinda Johnson outlines non-surgical techniques to treat common patient concerns surrounding the earlobes Earlobes form an integral part of facial aesthetics and are considered an important part of the facial appearance. They offer significant characteristic features that could cause concern if they are asymmetrical or too large. In this article, I will discuss the relevant anatomy that must be considered and will examine common conditions that can affect the earlobe.

Anatomy Understanding external ear anatomy is vital in treating the earlobe (Figure 1).2 The external ear comprises the auricle, or pinna, and the ear canal. The auricle (visible part of ear) is composed mainly of cartilage covered by skin and consists of the helix, antihelix, lobule, tragus, and concha. The human earlobe (lobulus auriculae) is composed of tough areolar and adipose connective tissues, lacking the firmness and elasticity of the rest of the auricle. There are mainly two types of earlobes; one where the lower lobe is connected to the side of cheek and another where the lower lobe is free from the side of cheek. The earlobe has a large blood supply to help with warming the ear and maintaining balance.2 The blood vessels and nervous systems must be considered while treating a patient and good anatomical knowledge of this area is critical.

Blood supply to the ear The external carotid artery consists of three branches that supply blood to the ear. These are the occipital artery, posterior auricular artery and the anterior auricular branch of superficial temporal artery.2 The veins run together with each artery, as illustrated in Figure 2. Having knowledge of the blood supply helps the practitioner to ensure that the flap will continue to have blood supply when cutting the earlobe.

Sensory innervation of the external ear Knowledge of the nerve anatomy is integral in understanding anaesthesia of the ear.3 There are four sensory nerves supplying the ear (Figure 3); the great auricular nerve (1), which supplies the lower two Triangular Fossa Helix Scapha Anti Helix Concha Cymba Anti Tragus

Superior Crus Inferior Crus Helicis Crus Tragus

thirds of the anterior and posterior external ear (earlobe); the auriculotemporal nerve (4), which supplies the anterior superior one third of the ear (tragus, crus, helix and superior helix); the lesser occipital nerve (2), which supplies the posterior surface of the superior one third of the external ear; and the auricular branch of vagus nerve (3), which supplies the external auditory canal floor and concha.2

Earlobe concerns Ear piercings and wearing earrings are known to cause trauma to the ear, some of which include split earlobe, an enlarged ear piercing hole and keloid scarring.

Split earlobe Split earlobe, commonly caused by wearing large and heavy earrings that are suspended from a fine ring, will gradually cut through the earlobe. Going to bed without removing heavy earrings can also cause split earlobe, as the earring puts weight on the earlobe through minor pulling on the earrings that occurs as the head rubs and moves on the pillow. Catching earrings whilst combing hair can also cause trauma. The traumatic split earlobe can be divided into two categories: complete and incomplete, where the hole from which the piercing has been made is either slightly torn or completely torn.

Enlarged ear-piercing hole The number of young patients wearing enlarged plugs in their earlobes has been gradually increasing over the years. According to Victoria Pitts, assistant professor of sociology at Queenâ&#x20AC;&#x2122;s College, City University of New York, ear stretching was popularised in the 1980s with the rise of the body art movement.4 It has continued to be fashionable for teenagers to enlarge the ear piercing hole with a method called â&#x20AC;&#x2DC;gaugingâ&#x20AC;&#x2122;. Gauging involves gradually placing gauge earrings that expand in size to enable the hole to continually stretch and enlarge. The gauge size could increase from 1mm up to more than 2cm by using a tapering tool. When one wants to reduce the hole, reversing the size of earrings gradually is recommended, however this does not completely reduce an overly stretched hole.9

Treatments When it comes to choosing the right technique, rather than taking a one-size-fits-all approach, each case should be evaluated on an

Anterior Auricular Artery & Vein

4

Superficial Temporal Vein

2

Posterior Auricular Artery

3

Concha Cavum 1

Intertragic Notch Lobule

Occipital Artery

Superficial Temporal Artery

External Carotid Artery Figure 1: Earlobe anatomy

Figure 2: Blood supply to the ear

Figure 3: Sensory nerves of the external ear

Reproduced from Aesthetics | Volume 4/Issue 5 - April 2017

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individual basis to decide which technique is likely to offer the best result in a given case. The following are my preferred treatment techniques: Split earlobe repair A variety of techniques to repair split earlobes can be applied with or without reconstructing the piercing’s hole.5,6 I prefer to repair without reconstructing the hole and advise patients to wait to re-pierce the ear six months later, at either about 2mm medial or lateral to the scar to prevent the risk of the recurrent of the split.

In general the technique of split earlobe repair falls into two categories, a straight line or a broken line of repair. The straight line repair is simple but, aesthetically, the final result might be unacceptable as the scar contracts and a notch at the free border will appear. The straight line can be avoided either by using a broken line of repair technique such as a Z-plasty7 (also known as the lab-joint technique6 or by L-plasty,8,9 which is my preferred technique). Z-plasty is a technique that leaves the wound in a Z-shape to prevent the risk of the scar shrinking and causing a notch effect on the free border of the treated earlobe.

Incomplete split earlobe repair For incomplete split earlobe repair, the L-plasty is recommended, rather than cutting skin around the edge of the split and stitching. Doing so may cause elongation of the earlobe, which is an unacceptable shape for some patients.

Aesthetics

white marker, as per the left image. Draw the line from the tragus to the white mark level (as shown in the middle image) and the second line on the earlobe from the tragus to the lateral end of the white mark. Measure the length of both lines, create a triangle and draw on the second line as illustrated, whilst making sure the size of the triangle base is the same as the length of the first and second line, as this triangle cut will help reduce the length of the second line to the same as the first line. Excise the earlobe as marked, then stitch the triangle in first to shorten the second line, before joining the first and second line with deep dermal and vertical mattress stitches.

Enlarged ear-piercing hole repair My preferred treatment is the Y-plasty10 for a very large ear piercing hole, L-plasty for a large piercing hole, depending on the amount of earlobe tissue available, and elliptical excision for very small ear piercing holes.

Procedure approach A earlobe repair procedure is carried out under local anaesthesia in an out-patient theatre. I have detailed the procedure approach below:

Earlobe reduction I have developed a method to remove earlobe tissue without leaving a notch or scar on the free border by excising the earlobe, as depicted in Figure 6. Firstly, the practitioner should discuss with the patient how big of an earlobe they prefer and draw it with the

1. For L-plasty, it’s essential that the lines of excision are drawn on the highest point of either side of the cleft before the edges start curving in gently, as failure to do so will invariably lead to leaving a groove along the repair line giving the impression of split earlobe with a notched border.

2. Inject local anaesthetic (2% xylocaine with epinephrine or 2% lidocaine) at the junction of the earlobe and cheek superficially at the sub-dermal layer (to prevent the risk of facial nerve injury) at the front and back of the junction, from the lowest end of the

Figure 4: Before and after incomplete split repair with L-plasty technique

Figure 5: L-plasty technique for incomplete split earlobe repair

Figure 6: Before and after earlobe reduction using my own technique

Figure 7: My earlobe reduction technique

Figure 8: Before and after enlarged earlobe repair of 1.5cm diameter gauge with the Y-plasty technique

Figure 9: Y-plasty technique for enlarged earlobe repair

Reproduced from Aesthetics | Volume 4/Issue 5 - April 2017

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Advise patients prior to the procedure that there is a chance that the earlobes may not look exactly the same, dependent on the tissue available junction up to the intertragic notch, about 2ml. Alternatively, infiltrate the earlobe with the anaesthetic solution (without epinephrine) until it becomes firm and pale; this will make the excision using a scalpel easier but it might be difficult if using Iris scissors.

3. For the L-plasty and Y-plasty techniques, the areas are excised as per the desired marking, starting from the free border to the apex of the cleft of the earlobe, using an Iris scissor or scalpel.

It’s important to check that the back side of the earlobe has been cut to the same shape as the front. The flap is then inserted accurately, starting from the anterior aspect, and any discrepancy that may arise is transferred to the posterior aspect, making sure that there is no irregularity in the free border of the earlobe.

4. Non-absorbable sutures are used to stitch to the desired shape using a vertical mattress technique to the front and back of the earlobe. It’s important to stitch earlobes with a vertical mattress technique to prevent the scar heal rolling inward, which will make the scar more visible.11

Precautions to take When choosing the right method for repair of the earlobe, assess the tissue available in each individual case and discuss options and the patient’s preference prior to choosing the treatment technique.

Taking added precaution during the procedure will assist in avoiding further complications. Some of the measures to take include: 1. When cutting the earlobe, ensure that the earlobe is cut through properly in the desired shape by checking the back side of the earlobe before you start stitching the wound.

2. Ensure all stitches are tightened properly, otherwise the patient may experience bleeding post procedure and/or the wound may not close properly.

3. Stitches can loosen from stress or pressure applied on the area.

Advise the patient to avoid any stress on the area by sleeping on their back and avoiding contact sports or any activity that may cause pulling of the ear.

4. Ensure the shape of the earlobes are similar both sides by measuring the marking on both earlobes and establishing that they have the same angle and length, by sitting the patient up to check. Advise patients prior to the procedure that there is a chance that the earlobes may not look exactly the same, dependent on the tissue available. In case of earlobe reduction, measurement of the marking on the earlobe must be done to ensure similar results for both earlobes.

5. Bleeding, bruising and haematoma may occur, ensure all stitches are tightened properly. Advise patients to avoid taking bloodthinning substances such as alcohol, aspirin, ibuprofen and vitamin C and E prior the procedures.

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6. Triamcinolone (TCN) could cause an anaphylactic reaction, which is a type 1 anaphylactic reaction, mainly caused by Immunoglobulin E (IgE) antibodies. The allergens in TCN can not only be steroid itself, but can also be carboxymethyl cellulose (CMC)14 and succinate in liquid used in the solution.16 Ensure a medical history of the patient’s allergic reaction occurrence is taken, particularly their history of allergic reaction to steroids.

7. Scarring can occur in skin types V-VI patients. Any patients who have a history of keloid or hypertrophic scars should be advised that the risk of keloid scarring could occur.

8. If an infection occurs, advise patients to avoid touching and contacting the affected area with water for at least the first two to three days after the infection presents. Patients should wash their hair in the morning of surgery and avoid washing their hair for two to three days after.

Conclusion There is a variety of earlobe repair treatments and many factors involved in choosing the right technique for each individual case. Split earlobe repair with the L-plasty technique, and earlobe reduction and large piercing hole repair with the Y-plasty technique, can provide excellent results with minimal risk of complications.

Dr Salinda Johnson is a medical director at The London Cosmetic Clinic in Knightsbridge. Dr Johnson began her career in the aesthetics specialty having completed a specialist fellowship programme in cosmetic dermatology in 2000. She has been a lecturer and trainer in aesthetic medicine for many years and regularly trains doctors, nurses and other medical practitioners on a range of medical aesthetic procedures.

REFERENCES 1. Urioste SS & Arndt KA et al., ‘Keloid scars and hypertrophic scars: review and treatment strategies’, Seminars in Cutaneous Medicine Surgery, 1999, pp. 159-71. <https://www.ncbi.nlm. nih.gov/pubmed/10385284> 2. Reena A Bhatt, ‘Eat anatomy’, Medscape, 2016. <http://emedicine.medscape.com/ article/1948907-overview#a2> 3. Daniel J Hutchens, ‘Ear aneasthesia’, Medscape, 2016. <http://emedicine.medscape.com/ article/82698-overview#a1> 4. Pitts V, ‘In the Flesh: The Cultural Politics of Body Modification’, 2003 5. Boo-Chai K, The cleft ear lobe’, Plastic and Reconstructive Surgery, 1961, 31, pp. 337-338. <https://www.ncbi.nlm.nih.gov/pubmed/?term=The+cleft+earlobe+Boo-chai> 6. Argamaso RV, ‘The Lap-joint principle in the repair of the cleft earlobe’, British Journal of Plastic Surgery, 1978, 31, pp. 337-8. <https://www.ncbi.nlm.nih.gov/ pubmed/?term=The+Lapjoint+principle+in+the+repair+of+the+cleft+earlobe> 7. Hamilton R & Larossa D., ‘Method for repair of cleft earlobes’, Plastic Reconstructive Surgery, 1975, 55, pp. 99-101. <https://www.ncbi.nlm.nih.gov/ pubmed/?term=Hamilton+and+Larossa%2C+1975> 8. Fatah MF, ‘L-plastic technique n the repair of split earlobe’, British journal of Plastic Surgery, 1985, 38, pp. 410-414. <https://www.ncbi.nlm.nih.gov/pubmed/4016430> 9. Chiummariello, S, Iera M et al., ‘L-Specular plasty versus Double round plasty: Two new techniques for earlobe repair’, Aesthetic Plastic Surgery, 2011, 35, pp. 398-401 <https://www. ncbi.nlm.nih.gov/pubmed/?term=L-specula+plasty> 10. Yabe T & Muraok M, ‘Double opposing V-Y hinge flap’, Annals of Plastic Surgery, 2003, 51, pp.

641-2. <https://www.ncbi.nlm.nih.gov/pubmed/14646668> 11. Silvia Mandello Carvalhaes & Andy Petroianu et al., ‘Assesment of the treatment of earlobe keloids with triamcinolone injections, surgical resection, and local pressure’, Revista do Colegio Brasileiro de Cirurgioes, 2015, 42, <http://www.scielo.br/scielo.php?script=sci_ arttext&pid=S0100-69912015000200009&lng=en&nrm=iso&tlng=en> 12. Julian Mackay-Wiggan, ‘Suturing techniques technique’, Medscape article, 2016. <http:// emedicine.medscape.com/article/1824895-technique#c3> 13. Griffith BH & Monroe CW et al., ‘A follow-up study on the treatment of keloids with triamcinolone acetonide’ Plastic Reconstructive Surgery, 1970, 46, pp. 145-50. <https://www. ncbi.nlm.nih.gov/pubmed/?term=A+follow-up+study+on+the+treatment+of+keloids+with+triamci nolone+acetonide.+Griffith+bh> 14. Linares HA & Larson DL et al., ‘Historical notes on the use of pressure in the treatment of hypertrophic scars or keloids’, Burns, 1993, 19, pp. 17-21. <https://www.ncbi.nlm.nih.gov/ pubmed/8435111> 15. Sasidharan A & David A et al., ‘Simple device to determine the pressure applied by pressure clips for the treatment of earlobe keloids’, Indian Journal of Plastic Surgery, 2015,48,pp.293296. <https://www.ncbi.nlm.nih.gov/pubmed/?term=Simple+device+to+determine+the+pressure+applied+by+pressure+clips+for+the+treatment+of+earlobe+keloids> 16. Patterson DL & Yunginger JW et al., ‘Anaphylaxis induced by carboxymethylcellulose component of injectable triamcinolone’, Annals of Allergy Asthma & Immunology, 1995, 74, pp. 163-6. <https://www.ncbi.nlm.nih.gov/pubmed/?term=Anaphylaxis+induced+by+carboxymethylcellulose+component+of+injectable+triamcinolone>

Reproduced from Aesthetics | Volume 4/Issue 5 - April 2017

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Treating Cankles Laser surgeon Dr Sanjay Gheyi examines the treatments available for lipodystrophy of the calfankle area A ‘cankle’ is defined as an obese or otherwise swollen ankle that blends into the calf without clear demarcation.1 Lipodystrophy, or abnormal fat distribution, can mean that there is little definition between the calf and ankle, which can be a frustrating aesthetic concern for some patients.

The appearance of cankles is not necessarily dependent on body weight and can be exacerbated by genetic conditioning and special resistance to diet.2 Calf and ankle lipodystrophy is usually present from early adolescence3 and the most common cause of cankles in patients seen in an aesthetic clinic is excess of fatty tissue without a systemic condition.

Clinical assessment Most of us see medically fit and well patients for body contouring. However we must still take a thorough medical history and perform a clinical examination to make the correct diagnosis and eliminate conditions that our treatments can’t address or may

make worse. It is imperative to rule out other causes of lower extremity swelling,8 which includes: • Lymphoedema – a chronic condition that causes swelling in the body’s tissues – it can affect any part of the body9 • Venous disease – a chronic venous insufficiency, deep vein thrombosis • Systemic disease – congestive heart failure, renal disease, hypoalbuminemia • Cellulitis • Cyclical and idiopathic oedema • Myxoedema Clinical history should include onset and duration of symptoms, symptom progression, symptom exacerbation, and any prior attempts at treatment. Practitioners should consider if there is any prior history of lymph node biopsy, lymph node surgery or radiation as this may point towards lymphoedema. A history of previous varicose veins, venous surgery, fractures, soft tissue injuries or deep vein thrombosis (DVT) may indicate a vascular etiology.8 In these cases a practitioner should refer a patient to a GP or an appropriate specialist.

Cardiovascular and renal history may indicate that fluid is a cause of ankle swelling.8

Figure 1: Ankle fat pad located at the lateral aspect of the ankle.

Recognising lipoedema It is also important to distinguish and to rule out lipoedema during a physical examination, which is a rare and long-term chronic condition that typically involves the abnormal build-up of fat cells in the

legs, thighs and buttocks, where legs usually become enlarged from the ankles up to the hips.7 Increased awareness of lipoedema and its presentation may enable practitioners to diagnose and treat patients more efficiently.8 Diagnosis and treatment should be made as early as possible to prevent complications associated with increased functional and cosmetic morbidity.8 Lipoedema is a condition that can be treated through the use of surgical options such as liposuction and/or excisional lipectomy in patients who are resistant to non-surgical treatment such as exercise, compression therapy and massage. Liposuction appears to be one of the most effective and longlasting treatments to date, although many patients often require ongoing non-surgical treatment postoperatively to maintain results.8 The fatty hypertrophy seen in patients typically starts at the hips and extends throughout the legs, one of the major distinguishing features of lipoedema is the sparing of the feet, which can create a distinct ‘step-off’ at the ankle.11,12 A helpful diagnostic tool during a physical examination to distinguish lipoedema from lymphoedema is to pinch the skin over the dorsum of the base of the second toe. If the skin appears thickened and is difficult to lift off of the underlying tissue, then this could be an indication of Stemmer’s sign, which is considered a diagnostic tool for lymphoedema.13 To avoid patients raising complaints that treatment has caused neurovascular conditions, I would advise performing a neurovascular evaluation prior to treatment. Review of family history may also be useful as patients with lipoedema often have other female family members with similar symptoms.10

Physical examination A typical patient presenting for treatment will have subcutaneous fat around the ankle region. Typically, fat distribution, in my experience, is anterolateral and posteromedial in mild cases, while circumferential in patients with a larger amount of fat. It may be the only area of concern or may be associated with excess fat around the knee, medial and lateral thighs or involve the whole lower extremities. The pinch test will reveal areas amenable to treatment.

Anatomy For practical purposes it is important to note that the two danger areas are the popliteal

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Before

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After

© Dr Sanjay Gheyi Figure 2: Patient A has excess fat distribution along calves, ankles, knees, inner and outer thighs. Topographic markings for areas to be suctioned.

Before

© Dr Sanjay Gheyi Figure 3: Patient A 12 weeks after the liposuction procedure. (Photos taken without flash to highlight contour abnormalities).

fossa (the shallow depression located at the back of the knee joint)4 and the area around the malleoli (the bony projection on either side of the ankles)5 as important nerves and vessels reside in this area superficially. In the superior aspect we have skin, superficial fascia and subcutaneous fat, followed by a deep fascia envelope around the anterior, posterior and lateral muscular compartments.5 The posterior compartment has three layers of calf muscles, mainly gastrocnemius soleus and tibialis posterior. The anterior compartment has the tibialis anterior and extensor muscles and the lateral compartment has the peroneal muscles. Tendons of these muscles are located in the lower part, along with nerves and blood vessels, which are located superficially in this area. It is of course important to take note of the nerves and blood vessels as any oedema here can cause compartment syndrome, which is a painful condition that occurs when pressure within the fascial envelope builds. Compartment syndrome is likely to cause neurovascular complications if it is not recognised and treated effectively.5 A fat pad called the lateral inframalleolar fat pad (LIMFP), located at the lateral aspect of the ankle, has been described in a clinical article by D. Brémond-Gignac and H. Copin et al; they claim it is not often referred to in anatomical texts so it is imperative to be aware of.6 They outline how the LIMFP is oval and made up of an unilocular fatty tissue that is distinct from the subcutaneous plane. The sural nerve is a sensory nerve in the calf region that runs over the surface

After

© Dr Sanjay Gheyi Figure 4: Pre-op image in a slender patient with small amount of localised cankle fat highlighting area of maximum fat.

of the fat pad and supplies cutaneous sensation to part of the fifth toe. This is accompanied by the short saphenous vein, which gives off a medial perforator that traverses the LIMFP. It is necessary to recognise the location of this fat pad before any procedure on the lower limbs, in order to prevent over correction or under corrections during treatment.6

Treatments Liposuction Liposuction is one of the most evidencebased and preferred ways to remove fat.14 The two key principals for successful liposuction procedures are good patient selection and realistic expectations. Many liposuction procedures can be performed under local anesthesia in an office surgical suite. A conservative approach is always appropriate as overcorrection can be difficult to treat.14 Current technology for liposuction includes suction-assisted, ultrasoundassisted, power-assisted, laser-assisted, and radiofrequency-assisted liposuction.

The choice of technology and technique often depends on patient characteristics and surgeon preference.15 My preferred approach is laser lipolysis2 and microcannula liposuction, administered under local anaesthesia.16 Sometimes a circumferential liposuction of knees, calves, and ankles is the best option to create more slender looking legs.17 This procedure can also be combined with

© Dr Sanjay Gheyi Figure 5: Post-op image, a small area of hyperpigmentation from cannula entry point is noticeable, treatment of laser liposuction.

fat injections into the calf area to achieve further reshaping and contrast between the calves and ankles. Other procedures to augment calves include silicone calf implants.15 Calf contouring with endoscopic fascial release, calf implant, and structural fat grafting have also been described.18 In patients with minimal fat many practitioners opt not to aspirate, further limiting direct tissue trauma.19 As a result, patients can quickly return to daily activities within three to five days.19 A variety of laser wavelengths have been used to try and correct excess fat. My preferred approach is laser lipolysis2 and micro-cannula liposuction under pure local anaesthesia20 due to the following advantages; fast patient recovery, diminished post-operative pain, ecchymosis and oedema.21,19 The coagulation of blood vessels may explain these advantages.9 I use tumescent anaesthesia followed by a 1470 nm diode laser lipolysis. The laser energy is delivered by a 600 micron laser fibre. Following this I use a 14G micro-cannula to suction the liquefied fat. I then provide patients with a compression bandage that is changed to Class 2 compression stockings at the postop check up. Compression stockings are used day and night for at least one week. I encourage patients to use these during the daytime for as long as possible.

Complications As with any aesthetic treatment, complications can occur. Patient selection and a thorough pre-procedure discussion are necessary to minimise any difference

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An alternative approach: botulinum toxin Although not directly related to the appearance of cankles, enlarged medial gastrocnemius muscles in the calves can also cause psychological distress in some women.22 In 2004, Lee et al described the use of botulinum toxin injections for the reduction of calf muscle size.22 Botulinum toxin A injections of 32, 48 or 72 units were injected into each medial head of the gastrocnemius muscle in six women.

In all of the participants there was a reduction in the medial gastrocnemius muscle after the injection. According to the study authors, the reduction in the medial calf was noticed even after one week and the effect was well maintained for six months.

Leg contouring was obtained by the botulinum toxin treatment. The middle leg circumference indicated a slight decrease in five subjects. No functional disabilities were observed.23

Patient selection and a thorough pre-procedure discussion are necessary to minimise any difference between the patients’ expectations and treatment results

between the patients’ expectations and treatment results. It is critical to avoid aggressive superficial liposuction, which could cause lipotrops and liponots. These indicate uneven areas where either too much or not enough fat has been removed, respectively. I advise that practitioners administering this procedure remain above the deep fascia and wait 30 minutes after the injection of tumescent fluid to allow for detumescence to be able to grasp the fat, before cannula introduction. Liposuction complications can include injury to adjacent structures, transient numbness, and temporary hyperpigmentation at cannula entry sites, but specific to this area is prolonged oedema.24 Due to their dependent position, legs and ankles are prone to oedema, which can last between six and 12 months. For this reason, I encourage the use of a small cannula of 14G or smaller, gentle technique and compression stockings.

Conclusion Laser-assisted liposuction in the remodeling of the calf and ankle area is a safe and reproducible technique that is particularly appreciated by the patient. The procedure allows for homogeneous reduction of fatty tissue together with skin tightening.2 Dr Sanjay Gheyi is the medical director and laser surgeon at the Coltishall Cosmetic Clinic in Norfolk. Dr Gheyi has triple board certifications in General Surgery, Family Medicine and Anti-ageing Medicine. He offers full range of laser, skin and vein care services including surgical treatments to his patients.

REFERENCES 1. English Oxford Dictionary, ‘Cankle definition’, 2017. <https:// en.oxforddictionaries.com/definition/cankle> 2. Leclère FM & Moreno-Moraga J et al., ‘Laser-assisted lipolysis for cankle remodeling: a prospective study in 30 patients’, Laser in Medical Science, 2014, 1, pp.131-6. <https://www.ncbi.nlm.nih.gov/ pubmed/23471498> 3. Patrick J. Lillis, ‘Liposuction of the knees, calves and ankles’ Dermatologic Clinics, 1999, 4, pp.865-879. <http://www.derm. theclinics.com/article/S0733-8635(05)70134-0/abstract> 4. Dagur G & Gandhi J, ‘Anatomical Approach to Clinical Problems of Popliteal Fossa’, Current Rheumatology Reviews, (2017). <https://www.ncbi.nlm.nih.gov/pubmed/27894238> 5. Susan Stranding, ‘Gray’s Anatomy: The Anatomical Basis of Clinical Practice, Expert Consult’, 2008.

6. Brémond-Gignac D & Copin H et al., ‘The lateral inframalleolar fat pad: a poorly recognized anatomical structure’ Surgical and Radiological Anatomy, 2001, 5, pp.325-9. <https:// www.researchgate.net/publication/11536366_The_lateral_ inframalleolar_fat_pad_Apoorly_recognized_anatomical_ structure> 7. NHS, ‘Lipoedema definition’ 2014. <http://www.nhs.uk/conditions/ lipoedema/Pages/Introduction.aspx> 8. Warren Peled A & Kappos EA et al., ‘Lipedema: diagnostic and management challenges’ International Journal of Women’s Health, 2016, 8, pp.389-95. <https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC4986968/> 9. NHS, ‘Lymphoedema definition’ 2014. <http://www.nhs.uk/ conditions/lipoedema/Pages/Introduction.aspx> 10. Wold LE & Hines EA et al., ‘Lipedema of the legs; a syndrome characterized by fat legs and edema’ Annals of Internal Medicine, 1951, 34:5, pp.1243-50. <https://www.ncbi.nlm.nih.gov/ pubmed/14830102> 11. C.A Harwood & R.H. Bull et al., ‘Lymphatic and venous function in lipoedema’ British Journal of Dermatology, 1996, 134:1 pp.1-6. <https://www.ncbi.nlm.nih.gov/pubmed/8745878> 12. BeninsonJ & Edelglass JW, ‘Lipedema–the non-lymphatic masquerader’ Angiology, 1984, 35:8, pp.506-510. <https://www. ncbi.nlm.nih.gov/pubmed/6476475> 13. Stemmer R, ‘A clinical symptom for the early and differential diagnosis of lymphedema’ Vasa, 1976, 5:3, pp.261-262. <https:// www.ncbi.nlm.nih.gov/pubmed/969857> 14. Arthur J. Sumrall, ‘A review of Liposuction as a Cosmetic Surgical Procedure’ Journal of the National Medical Association, 1987, 79:12, pp.1275-1279. <https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC2625655/> 15. Shridharani SM & Broyles JM, ‘Liposuction devices: technology update’ Medical Devices: Evidence and Research, 2014, 21:7, pp.241-51.<https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC4114741/> 16. Jeffrey A. Klein, ‘Tumescent Technique: Tumescent Anaesthesia and Microcannular Liposuction’, Ophthalmic Plastic and Reconstructive Surgery, 2000. <http://journals.lww.com/oprs/ Citation/2001/11000/Tumescent_Technique__Tumescent_ Anesthesia_and.20.aspx> 17. Ersek RA & Salisbury AV, ‘Circumferential liposuction of knees, calves, and ankles’, Plastic and Reconstructive Surgery, 1996, 98, pp.880-883. <http://journals.lww.com/plasreconsurg/ Citation/1996/10000/Circumferential_Liposuction_of_Knees,_ Calves,_and.24.aspx> 18. Karacaiglu E & Zienowicz RJ, ‘Calf contouring with endoscopic fascial release, calf implant and structural fat grafting’, Plastic and Reconstructive Surgery, 2013, 1:5, pp.35. <https://www.ncbi.nlm. nih.gov/pmc/articles/PMC4174200/> 19. Goldman A & Gotkin RH, ‘Laser-assisted liposuction’, Clinics in Plastic Surgery, 2009, 36:2, pp.241-53. <http://www. plasticsurgery.theclinics.com/article/S0094-1298(08)00136-3/ abstract> 20. Jeffrey A. Klein, ‘Tumescent Technique: Tumescent Anaesthesia and Microcannular Liposuction’, Ophthalmic Plastic and Reconstructive Surgery, 2000. <http://journals.lww.com/oprs/ Citation/2001/11000/Tumescent_Technique__Tumescent_ Anesthesia_and.20.aspx> 21. Palm MD & Goldman MP, ‘Laser lipolysis: current practices’, Seminars in Cutaneous Medicine and Surgery, 2009, 28:4, pp.212-9. <https://www.ncbi.nlm.nih.gov/pubmed/20123419> 22. Han KH & Joo YH et al., ‘Botulinum toxin A treatment for contouring of the lower leg’, Journal of Dermatological Treatment, 2006, 17:4, pp.250-4. <https://www.ncbi.nlm.nih.gov/ pubmed/16971324> 23. Lee H J & Lee D W et al., ‘ Botulinum toxin a for aesthetics contouring of enlarged medial gastrocnemius muscle’, Dermatologic Surgery, 2004,6, pp.967-71. https://www.ncbi.nlm. nih.gov/pubmed/15171764 24. Varun V. Dixit & Milind S. Wagh, ‘ Unfavourable outcomes of liposuction and their management’, Indian Journal of Plastic Surgery, 2013, 46, pp. 377-392. <https://www.ncbi.nlm.nih.gov/ pmc/articles/PMC3901919/>

Reproduced from Aesthetics | Volume 4/Issue 5 - April 2017

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Introducing VANIQA® (eflornithine 11.5% cream) An Expert Q&A with Dr Firas Al-Niami Dr Firas Al-Niami is an internationally-known consultant dermatologist, Mohs and laser surgeon and is the medical director of sk:n clinics. Here, Dr AlNiami gives his insights into VANIQA® – the only nonhormonal topical treatment option for female facial hirsutism.

1. How big a problem is female facial hirsutism (FFH) in aesthetic clinical practice?

Female facial hirsutism is considered relatively uncommon but in reality, it is thought that approximately 40% of women have some degree of unwanted facial hair.1 Hirsutism itself (where terminal and coarse hair is present in a male-like pattern) affects 5-15% of all women, so there’s a good chance that a significant proportion of all female patients we see in our clinics are affected by some degree of dissatisfaction or clinical problems with unwanted facial hair.2 Aside from physical symptoms, FFH can represent a significant psychological burden, causing a detrimental effect on patients’ confidence and quality of life, and even becoming associated with high levels of anxiety and depression.3

2. What are the current treatment options and challenges for women facing recurrent unwanted facial hair?

Laser hair removal (LHR) is one of the most common aesthetic treatment options for dealing with unwanted facial hair. Whilst this can be very effective for certain skin types and offer long-lasting hair reduction, it requires multiple treatments and can cause pain, unwanted side-effects and be costly. In addition, removal of white or light-coloured hair can be difficult due to the lack of melanin. Thus, most women need to use a combination of hair removal methods, each with advantages and disadvantages. The majority report also using waxing or plucking, which are cost-effective but often painful and still result in regrowth. Electrolysis or drug therapies are the next most common methods which may give long-lasting removal, but again are less than ideal from a pain, cost and potential side-effect perspective.

3. What is VANIQA® (eflornithine 11.5% cream) and how does this work differently to other topical treatments?

VANIQA® is the only topical non-hormonal prescription treatment for facial hirsutism in women, proven to slow the growth of facial hair.4,5 This FDA-approved therapy is suitable for all skin and hair types and works by inhibiting ornithine decarboxylase – an enzyme that prevents polyamine synthesis which is essential for hair growth. This method of action means that VANIQA® can be used alone or in combination with 52

other hair removal methods and aesthetic treatments. Studies have shown VANIQA® is a highly effective monotherapy: in just eight weeks, twice-daily VANIQA® treatment delivered positive results, with up to 70% of patients reporting positive symptom improvement at 24 weeks.6

4. What are the clinical results for a combination approach using VANIQA® and LHR? What’s exciting for me is that VANIQA® has been proven to enhance the results of LHR, making for an effective and synergistic treatment combination. Because it doesn’t affect hair diameter, VANIQA® can fit in seamlessly with a simultaneous or subsequent LHR series. When used twice daily between and after laser treatments, VANIQA® provides significantly faster, more complete results than LHR alone. A randomised, double-blind, placebo-controlled, right-left comparison study showed that complete or almost complete hair removal was achieved in 94% of laser plus VANIQA® treated sites, compared to 68% of laser plus VANIQA® treated sites.4 In addition, VANIQA® is effective across all skin types and is suitable for long-term use, with open-label studies showing good tolerability for up to 12 months.7

5. How do you think VANIQA® can support practitioners dealing with FFH? I think that VANIQA® represents an exciting, effective partner treatment option which could help practitioners to improve women’s results and satisfaction with LHR for unwanted facial hair. FFH is a common problem in aesthetic clinical practice, which is not sufficiently addressed by current treatment methods alone, therefore I welcome the opportunity to provide a clinically effective and well-tolerated home maintenance approach for patients which can help deliver better results in a shortened timeframe.

Dr Firas Al-Niaimi is a consultant dermatologist, Mohs and laser surgeon and is the medical director of sk;n clinics. He completed his full specialist training in dermatology in Manchester, one of the largest dermatology centres in Europe where he worked alongside nationally-renowned dermatologists.

REFERENCES 1. Blume-Peytavi U, et al. Dermatology 2007; 215: 139-46.

2. Azziz R. Obstet Gynaecol 2003; 101: 995-1007.

3. Lipton MG, Sherr L, Elford J, et al. J Psychosom Res (2006) 61:161-168.

4. Hamzavi I, Tan E, Shapiro J, Lui H. J Am Acad Dermatol 2007; 57(1): 54-59.

5. VANIQA®. Summary of Product Characteristics.

6. Schrode K, Huber F, Staszak J, et al. Poster 291 presented at 58th Annual Meeting of the Academy of Dermatology 2000, 10-15 March, San Francisco; USA. 7. Schrode K, Huber F, Staszak J, et al. Poster 294 presented at 58th Annual Meeting of the Academy of Dermatology 2000, 10-15 March, San Francisco; USA.

Aesthetics | April 2017

Job code UKEFL3691 - Date of preparation: March 2017

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A summary of the latest clinical studies Title: A Prospective, Open-Label, Observational, Postmarket Study Evaluating VYC-17.5L for the Correction of Moderate to Severe Nasolabial Folds Over 12 Months Authors: Sattler G, Philipp-Dormston WG, Van Den Elzen H, Van Der Walt C et al.

Published: Dermatologic Surgery, February 2017 Keywords: Nasolabial folds, dermal filler, skin depression, hyaluronic acid Abstract: To evaluate 12-month effectiveness and safety of VYC17.5L (17.5 mg/mL hyaluronic acid, 0.3% lidocaine) a dermal filler, for the treatment of moderate/severe nasolabial folds (NLFs). Subjects ≥18 years old with moderate/severe NLFs were recruited (N = 70).

Injected volume was aimed at achieving optimum correction; top-up treatment was given at 2 weeks if needed. The primary endpoint was investigator-assessed change in NLF severity over 12 months using the validated photonumeric NLF Severity Scale. Secondary endpoints included investigator- and subject-assessed satisfaction and safety. Adverse events judged to be more severe or prolonged than routinely observed were recorded. Sixty-five subjects completed study requirements. Mean volume injected was 3.0 ± 1.0 mL for both NLFs combined. Significant improvement was maintained in investigatorassessed NLF severity at 12 months. VYC-17.5L is effective and well tolerated for the treatment of moderate to severe NLFs for 1 year.

Title: Differential Morphological and Functional Features of Fibroblasts Explanted From Solar Lentigo Authors: Goorochum R, Viennet C, Tissot M, Locatelli F et al.

Published: British Journal of Dermatology, February 2017 Keywords: Ultraviolet radiations, hyper pigmentation lesions, Solar Lentigo Abstracts: Upon ageing, chronic exposure to ultraviolet radiations and pollution induces benign hyper-pigmented lesions, such as Solar Lentigo maculae (SL).1 Well-defined histologically, SL is distinguishable from other hyper-pigmented diseases and can be classified relative to its evolution.2-4 Differential gene-profiling analyses comparing SL and normal skin biopsies revealed that SL tissues are mainly composed of epidermal activated melanocytes as well as hypo-

Vaniqa 11.5% Cream eflornithine Prescribing Information. (Please consult the Summary of Product Characteristics (SmPC) before prescribing).

Active Ingredient: eflornithine 11.5% (as hydrochloride monohydrate). Indication: Treatment of facial hirsutism in women. Dosage and Administration: Should be applied to the affected area twice daily, at least eight hours apart. Application should be limited to the face and under the chin. Maximal applied doses used safely in clinical trials were up to 30 grams per month. Improvement in the condition may be noticed within eight weeks and continued treatment may result in further improvement and is necessary to maintain beneficial effects. Discontinue if no beneficial effects are noticed within four months of commencing therapy. Patients may need to continue to use hair removal methods (e.g. shaving or plucking) in conjunction with Vaniqa. Application of Vaniqa should be no sooner than 5 minutes after use of other hair removal method, as increased stinging or burning may occur. A thin layer of the cream should be applied to clean and dry affected areas. The cream should be rubbed in thoroughly. The medicinal product should be applied such that no visual residual product remains on the treated areas after rub-in. Hands should be washed after applying this medicinal product. For maximal efficacy, the treated area should not be cleansed within four hours of application.

Cosmetics (including sunscreens) can be applied over the treated areas, but no sooner than five minutes after application. The condition should improve within eight weeks of starting treatment. Paediatric populations: The safety and efficacy of Vaniqa in children 0-18 years has not been established. Hepatic/renal impairment: caution should be used when prescribing Vaniqa. Consult SmPC for further information. Contraindications, Warnings, etc: Contraindications: Hypersensitivity to eflornithine or to any of the excipients.

Warnings & Precautions: Excessive hair growth can result from serious underlying disorders (e.g. polycystic ovary syndrome, androgen secreting neoplasm) or certain active substances (e.g. cyclosporin, glucocorticoids, minoxidil, phenobarbitone, phenytoin, combined oestrogen-androgen hormone replacement therapy). These factors should be considered in the overall medical treatment of patients who might be prescribed Vaniqa. For cutaneous use only.

proliferating and hypo-differentiated keratinocytes with a background of chronic inflammation. In absence of fibroblast markers, immunostaining analyses for several growth factors and secreted proteins in the upper dermis of SL biopsies strongly suggest that dermal fibroblasts contribute functionally to dysregulation of epidermal cells.5 These observations are strengthened by recent studies using a pigmented reconstructed skin model that demonstrates the influence of dermal fibroblasts on skin pigmentation.6 However, data on the morphological and functional features of the SL primary fibroblasts that could explain their role in SL disease are not available.

Title: Intense Pulsed Light Alone and in Combination with Erbium Yttrium-Aluminum-Garnet Laser on Small-to-Medium Sized Congenital Melanocytic Nevi: Single Center Experience Based on Retrospective Chart Review Authors: Lee MS, Jun HJ, Cho SH, Lee JD et al.

Published: Annals of Dermatology, February 2017 Keywords: Intense pulsed light therapy, pigmentation, skin Abstract: Treatment of congenital melanocytic nevi (CMN) with intense pulsed light (IPL) has recently produced promising results. To evaluate the clinical and histological outcomes of small-to-medium sized CMN treated with IPL alone and in combination with erbium: yttrium-aluminum-garnet (Er: YAG) laser. We performed a retrospective chart review of 26 small-tomedium sized CMN treated as described above. The reduction in visible pigmentation, signs of recurrence and any adverse skin changes were evaluated by two independent clinicians. Seventeen patients completed treatment and were followed-up. Nine were not able to complete treatment due to work, change in residence, and treatment related stress. Ten patients received IPL alone (mean: 10.5 sessions) and 7 underwent treatment with IPL (mean: 7.7 sessions) and Er:YAG/IPL combination therapy (mean: 4.7 sessions).

The initial treatment outcome was cleared in 5 patients and excellent in 12. Fourteen patients (82.4%) showed CMN recurrence one year after treatment completion. The histological results from a patient with an excellent clinical outcome showed remnant nevus cells nests in the deep dermis.

Contact with eyes or mucous membranes (e.g. nose or mouth) should be avoided. Transient stinging may occur if applied to abraded or broken skin. If skin irritation or intolerance develops, the frequency of application should be reduced temporarily to once a day. If irritation continues, treatment should be discontinued and the physician consulted. Contains cetostearyl alcohol and stearyl alcohol which may cause local skin reactions (e.g. contact dermatitis) as well as methyl parahydroxybenzoate and propylparahydroxy-benzoate which may cause allergic reactions (possibly delayed). Interactions: No interaction studies have been performed. Pregnancy and lactation: Women should not use Vaniqa whilst pregnant or breastfeeding. Ability to drive and use machines: Vaniqa has no or negligible effects on the ability to drive and use machines. Adverse Effects: These are ranked under heading of frequency using the following convention: very common (≥1/10); common (≥1/100 to <1/10); uncommon (≥1/1,000 to <1/100); rare (≥1/10,000 to <1/1,000); very rare (<1/10,000). Very common: acne. Common: pseudofolliculitis barbae, alopecia, stinging skin, burning skin, dry skin, pruritus, erythema, tingling skin, irritated skin, rash, folliculitis. Uncommon: bleeding skin, furunculosis. Rare: rosacea, skin neoplasm, skin cysts, vesiculobullous rash. Consult SmPC in relation to other adverse effects. Legal Category: POM. Marketing Authorisation Number(s): EU/1/01/173/003. NHS Cost: (excluding VAT). Tube containing 60g – £56.87. Marketing Authorisation Holder: Almirall, S.A. Ronda General Mitre, 151 08022 Barcelona, Spain. Further information is available from: Almirall Limited, 1 The Square, Stockley Park, Uxbridge, Middlesex, UB11 1TD, UK. Tel: (0) 207 160 2500.Fax: (0) 208 7563 888. Email: almirall@professionalinformation.co.uk. Date of Revision: 10/2015. Item code: UKEFL3336

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 Almirall Ltd.

Reproduced from Aesthetics | Volume 4/Issue 5 - April 2017

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Not understanding how SEO works

Common SEO Faults and How to Avoid Them Marketing consultant Adam Hampson discusses the importance of Google search optimisation strategies to ensure patients are directed to your website Good search engine optimisation (SEO) can make a positive difference to any aesthetics business. A high position in a search engine results page (SERP) should generate more traffic to your website (71.33% of clicks come from page one results)1, 2 and, consequently, increase the number of new customers.

As Google is one of the top search engines in the world with an estimated 1.6 billion3 unique monthly visitors, we will focus on Google optimisation in this article.

Organic vs paid-for search results Google SEO provides two methods for acquiring traffic to a web page: organic and paid-for search. Organic SEO refers to ‘the methods used to obtain a high placement or ranking on a SERP in unpaid, algorithm-driven results’.4 In other words, it’s when a page from your website appears in SERPs without you having paid Google to prioritise your listing.

However, it isn’t enough to have an organic presence anywhere on a Google SERP; the page and position are vital. A study from SEO specialists Moz in October 2014 reviewed previous data from numerous sources and conducted fresh research – the findings indicated that 71.33% of searches result in an organic click from the first page in Google and that the first five organic results on page one account for 67.60% of all clicks.2 Advanced Web Ranking also carries out ongoing research into clickthrough rates that supports these findings.5 This means that your goal should be for your web pages to appear in the top five organic positions on page one of Google for your chosen keywords/search terms.6 Alternatively, you can pay Google for an advert listing that appears in a prominent position on SERPs depending on the relevance of your advert to the user’s search. This is known as PayPer-Click (PPC) advertising, which you can create using Google AdWords.7, 8 PPC ads have a small symbol next to the URL to indicate that they are a paid-for listing. The best ads mirror the searcher’s end goal – giving visitors the end solution to what they are looking to achieve, e.g. ‘kill acne once and for all’, and put the focus firmly on the visitor by using ‘you’ and ‘your’ whenever possible, e.g. ‘fat freezing – say goodbye to your muffin top’ or ‘book your free consultation9 Both organic and paid-for listings have their benefits. A paidfor listing can help you to appear on page one of Google and is useful to increase awareness about your clinic in the shortest possible timeframe. You may choose to do this if you are conducting a time-sensitive marketing campaign. Conversely, more than 50% of people prefer to click on organic listings over paid-for ones because they recognise that the PPC ads have paid for a top spot rather than earned it organically.10 Data from the Advanced Web Ranking CTR Study5 even shows that 94% of searches result in a click on an organic listing.11 This means that organic Google optimisation should be a priority for any business wanting to generate website traffic. There are, however, common mistakes that you need to avoid.

New clients often tell us that ‘SEO is dead’, citing reasons such as the popularity of social media, and Google’s increasing ability to understand context and adapt search results to an individual’s location and search history.

SEO is far from dead, it’s just evolving.

Google’s algorithms use approximately 200 signals to decide how to rank pages in SERPs.12, 13 Although Google has never provided a definitive list of what they are, we know that they cover the following: • Website content: text and keywords, images, tags, meta data (a set of data that can be read by search engines to describe images, videos and webpages)14 • Website technicalities: page speed, Schema markup (a code put on a website to help search engines provide more informative results for users) and Hypertext Transfer Protocol (HTTPS)15 – an application of data communication for the World Wide Web and off-site SEO, such as social media and backlinks from other websites.

• Bounce rate and dwell time: the percentage of people who ‘bounce’ away from the page they land on without visiting any other pages,16 and the average dwell time (how long visitors spend on your site). Low bounce rates combined with high dwell times tell Google that yours is a site that people want to spend time on, which is likely to boost your rankings.

We know from experience that by improving your web content and technical SEO, it should improve where your web pages rank on Google. Where your web pages rank for a search will also depend on the searcher.

Google personalises search results,17 so if a searcher who lives near your clinic has visited your website before or follows your business on social media, it will influence whether your site appears in their search results. Google wants to return the most useful results so, in the case of a search for an aesthetics clinic, it will look for businesses in the searcher’s location first.12,13

Having unrealistic expectations Many businesses carry out a flutter of SEO activity and expect to leap-frog to page one of Google overnight. It’s more realistic to allow three to six months for your SEO efforts to positively affect your organic rankings, or even 12 months in more competitive areas, such as Central London. SEO is an ongoing process, not a ‘set and forget’ activity, meaning that you must commit to regularly

Reproduced from Aesthetics | Volume 4/Issue 5 - April 2017

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reviewing your Google optimisation at least once a month, if not more often. You also need to consider how much you will spend and whether your budget is realistic for what you want to achieve, and seek advice about this. There is no magic number for the perfect SEO budget but it will be influenced by the size of your website, the number of treatment pages, and the competitiveness of your local area; a clinic in a city will typically have to spend more over a longer time period than a rural clinic with one or two local competitors.

A good SEO strategy should focus on maximising your available budget, concentrating on optimising your most profitable treatments, but also set realistic expectations of what can be achieved.

Losing focus It’s important to pinpoint who you want to reach via Google, why you want to reach them and what you want them to do once they have seen the listing for your business.

Once you understand this, you can begin researching the keywords and phrases that your potential patients are using.

Each page of your website should have a unique and single focus.18 For example, if you have a page about non-surgical fat reduction, then everything on the page – from the copy and images to the titles, meta data and calls to action – should be about the non-surgical fat reduction methods that you offer and topic-specific information. Where some businesses go wrong is cramming too many unrelated keywords and search terms (as well as products and services) on to each page.

This is bad for user experience as much as search engines. Ideally, a person landing on any page of your website should be able to instantly see whether it addresses their query.

Eye-tracking research shows that people take just 2.6 seconds to scan a web page before focusing on a single element, so you need each element on a page to support one core message.19

Focusing on too many products and services Although you should pay attention to Google optimisation throughout your website, we believe that the best strategy is to identify your most profitable and/or most popular services and concentrate on that SEO first, especially in terms of wider optimisation activities such as blogging or social media content. For example, if chemical peels are your biggest seller, you might want to concentrate on writing blogs about the benefits of medical facials or information

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on social media that links to your website treatment page on chemical peels. This can help you to maximise your budget and enquiries. The danger with promoting too many products and services is that your website will seem chaotic, hard to navigate, and hard for customers and search engines to decipher.

Not optimising for local searches Another common mistake is failing to optimise a website for local searches.

As we’ve seen above, if someone is looking for a local service, Google will endeavour to return the highest-rated businesses situated as close as possible to the searcher. You can improve your local optimisation with simple, free steps such as listing your clinic on Google My Business,20 adding your address to the header or footer of your website, featuring Google reviews from your Google My Business page on your website, and writing longform content that mentions the local area.

Not understanding different searching methods In May 2015, Google announced that mobile searches were outstripping desktop searches in 10 countries including the US and Japan;21 this trend has continued. The popularity of mobile devices affects how we search, with the latest figures from the US indicating that more than half of teens and 41% of adults now use voice searches on a daily basis.22 It is therefore important to remember that your patients might be searching using this method. When people conduct a voice search, they tend to ask a question, such as ‘will dermal fillers hurt?’ or ‘how long will dermal fillers last?’ rather than typing in a keyword.23 As a result, many websites are able to increase their traffic by answering frequently asked questions and using questions in headers and body copy. In my experience, using conversational content such as questions also makes readers feel like you are talking to them personally, which can be more compelling and therefore increases website dwell time and lowers bounce rates.

Conclusion In the race to the top of Google’s organic search listings, a consistent and methodical approach is far more likely to win than a scatter-gun sprint.

For many businesses, the best approach is to combine organic SEO efforts with some

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PPC advertising. This can help you appear several times on page one of Google in multiple positions and increase your visibility while you fine tune your Google optimisation strategy. The key is to be patient, check the credentials of SEO professionals if you outsource your efforts, understand your audience and create content designed to appeal to them, and treat SEO as an ongoing process.

Adam Hampson is the founder and director of Cosmetic Digital, a web design and digital marketing agency in Nottingham that works with clients in the cosmetic medical sector. He is also a public speaker on aesthetics marketing and branding.

REFERENCES 1. Zero Limit Web Digital Marketing, ‘Part 1: Organic vs PPC in 2017: The CTR Results’, 2016, <http://www.zerolimitweb.com/ organic-vs-ppc-2017-ctr-results-best-practices/> 2. Moz, ‘Google Organic Click-Through Rates in 2014’, <https:// moz.com/blog/google-organic-click-through-rates-in-2014> 3. Search Engine Watch, ‘What are the top 10 most popular search engines’, 2017. < https://searchenginewatch.com/2016/08/08/ what-are-the-top-10-most-popular-search-engines/> 4. Techopedia, ‘Organic search engine optimisation definition’, <https://www.techopedia.com/definition/5184/organic-searchengine-optimization-organic-seo> 5. Advanced Web Ranking, ‘CTR Study’, 2017, <https://www. advancedwebranking.com/cloud/ctrstudy/> 6. Hubspot Academy, ‘Understanding keywords’, 2017, <https://knowledge.hubspot.com/keyword-user-guide-v2/ understanding-keywords> 7. Google AdWords, Overview, <https://www.google.co.uk/ adwords/> 8. Neil Patel, ‘Google AdWords Made Simple: A Step-by-Step Guide’, <http://neilpatel.com/what-is-google-adwords/> 9. WordStream, ‘7 Ways to Write Super-Effective AdWords Ads (with Real Examples)’, 2017, <http://www.wordstream.com/blog/ ws/2015/04/21/adwords-ads> 10. Pronto Marketing, Paid vs. Organic - The winning search strategy, April 2014, <https://www.prontomarketing. com/2014/04/paid-vs-organic-the-winning-search-strategy/> 11. Smart Insights, ‘Comparison of Google clickthrough rates by position [#ChartoftheDay]’, 2016, <http://www.smartinsights. com/search-engine-optimisation-seo/seo-analytics/comparisonof-google-clickthrough-rates-by-position/> 12. My Tasker, ‘205 Google Ranking Factors – Ultimate SEO Checklist for 2017’, 2016, < https://mytasker.com/blog/googleranking-factors/> 13. Backlinko, ‘Google’s 200 Ranking Factors: The Complete List’, 2016, <http://backlinko.com/google-ranking-factors> 14. Neil Patel, ‘SEO Made Simple – A Step-by-Step Guide’, <http:// neilpatel.com/what-is-seo/> 15. SEO+, ‘How website security and HTTPS could affect your SEO’, 2015, <https://www.seo-plus.co.uk/website-security-seo/> 16. Neil Patel, ‘13 Ways to Reduce Bounce Rate and Increase Your Conversions’, <http://neilpatel.com/blog/13-ways-to-reducebounce-rate-and-increase-your-conversions/> 17. Search Engine Land, ‘Google Now Personalises Everyone’s Search Results’, December 2009. <http://searchengineland. com/google-now-personalizes-everyones-searchresults-31195> 18. Yoast, ‘How to Choose the Perfect Focus Keyword’, 2016. <https://yoast.com/focus-keyword/> 19. Conversion XL, ‘10 useful findings about how people view websites’, 2013, <https://conversionxl.com/10-useful-findingsabout-how-people-view-websites/> 20. Google My Business, <https://www.google.com/business/> 21. Google Inside AdWords, ‘Building for the next moment’, 2015, < https://adwords.googleblog.com/2015/05/building-for-nextmoment.html> 22. Forbes, ‘2017 will be the year of voice search’, 2017, <http:// www.forbes.com/sites/forbesagencycouncil/2017/01/03/2017will-be-the-year-of-voice-search/#66b8a85b4f0d> 23. Search Engine Watch, ‘How to capitalise on voice search and the death of the keyboard’, 2016, < https://searchenginewatch. com/2016/02/10/voice-search-the-death-of-the-keyboard/>

Reproduced from Aesthetics | Volume 4/Issue 5 - April 2017

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that the KPI measures a consistent set of input information, as well as predictive, meaning that there is a direct relationship between the action of the data being measured and the desired outcome (see example in point 1 below).

To accurately determine the right KPIs to use, I would suggest you follow three steps, which I have developed from experience: 1. Define the objective

Performance Management Using KPIs In the second of a three-part series on ‘How to Maximise Clinic Performance’, global business executive Reece Tomlinson details how to utilise KPIs to boost clinic success

It is necessary to define the objective of the clinic, functional areas or initiatives. A clinic may choose, for example, that its objective is to grow sales. This chosen objective becomes the guiding principle behind all the KPIs of the clinic, functional areas or initiatives, which may include KPIs such as: year-to-date sales growth, re-booking rates and growth in average spend per customer etc. It is important to note, however, that the objective of the clinic needs to match the stated or implied strategy of the clinic in order to ensure it is moving closer to its goals.

2. Determine the ‘causal effect’ relationships of KPIs It is important that KPIs are related to the objective. With each KPI, you should identify whether it has ‘causal effect’, meaning it is correlated towards the achievement of the objective of the clinic. If the clinic, for example, has identified that growing sales is its core objective, then KPIs such as customer satisfaction, re-booking rates and number of complaints etc, could arguably be indicators that, when acted upon, will help lead the clinic towards achieving the clinic’s objective.

3. Run a test

Key performance indicators evaluate the performance of the clinic or a particular function or activity within it. The use of key performance indicators (KPIs) can help clinic owners, managers and employees effectively monitor the success of the various clinic functions and initiatives, which are essential to the achievement of the clinic’s objectives.

KPIs are a tool that any clinic can put into practice. Unlike simply receiving reports or analysing data from the various functions and initiatives of the clinic, KPIs are used to summarise relevant data and use the data to provide indicators of future performance. They offer the clinic the ability to review indicators which clinic owners, managers and employees can use to monitor success and, as importantly, make decisions.1 The best way to think of a KPI report is as a dashboard report, which is the visual representation of your clinic’s indicators. A dashboard report can represent the performance of the entire clinic or the performance of specific functions and initiatives. They typically use a combination of leading and lagging indicators, which will be explained later in this article, to paint a picture of where things are heading.1 Implementing KPIs into the clinic does not need to be complex and can be done with relative ease. Below are some tips on how to implement KPIs as efficiently and effectively as possible.

Determine the right KPIs The most influential KPIs are reliable at painting the picture between cause and effect. Michael J. Mauboussin, of Credit Suisse Group, a global financial services company, states that for KPIs to be effective they need to pass the test of being ‘persistent and predictive’.2 He asserts that a KPI needs to be persistent, meaning

Using the KPIs you have identified, run a test using historical data over a specific period, such as prior months or year. Using prior data to generate KPIs based on historical information, while being impartial, determine whether the KPIs would prove capable of indicating success as it relates to the chosen objective of the company.

Use a combination of lagging vs leading KPIs3 KPIs need to be a combination of lagging and leadings indicators.

It is important to have the right balance of leading and lagging KPIs so that the clinic can accurately gauge historical performance and predict future performance. Regardless of whether the KPIs are being used for clinic, functional or initiative purposes; when the right balance is achieved, performance can be both accurately measured and predicted. It is also important to ensure that KPIs

The best way to think of a KPI report is as a dashboard report, which is the visual representation of your clinic’s indicators

Reproduced from Aesthetics | Volume 4/Issue 5 - April 2017

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Leading indicators KPI

Description

Qualitative / Quantitative

New clients (patients)

Useful for gauging the number of new customers visiting the clinic.

Quantitative

Average customer visit value

Represents the average customer spend per visit, which if increasing or decreasing can help predict revenue potential (particularly with clinics that are operating close to capacity).

Quantitative

Complaints

Useful in determining if the clinic is experiencing quality-related issues.

Quantitative and Qualitative

Re-booking rate

If this KPI is increasing, it signifies that the clinic is providing value to the customer and can thereby be used as an indication that sales and the average customer visit value may increase. If it is decreasing, it is a warning sign that the clinic is not providing value and the customer could be going to a competitor’s clinic for their next treatment. A decreasing re-booking rate is a major red flag for the clinic and the cause of the decrease needs to be determined and addressed.

Quantitative

Average annual customer value

Useful in determining the average spend per customer over the course of a year to gauge whether this increases or decreases.

Quantitative

KPI

Description

Qualitative / Quantitative

Total customer visits

Helpful in identifying capacity and customer visit trends.

Quantitative

Clinic sales

Necessary to gauge past performance.

Quantitative

Sales growth

Useful in determining if sales are exceeding forecasts and prior year sales.

Quantitative

Operating profit

Very important for determining whether the clinic is generating profits.

Quantitative

Cost to acquire new customers

Useful to determine marketing effectiveness (marketing total spend/total new customers). This can be broken down per marketing channel spend as well.

Quantitative

Customer cancellations

Useful to determine booking success and capacity management.

Quantitative

Lagging indicators

Figure 1: Examples of KPIs in clinic. The first table provides examples of leading indicators, the second shows lagging indicators

are a combination of financial and numbers-based (quantitative) and non-financial or non-numbers based (qualitative) indicators.

Although I suggest using as much numbers-based data as possible; too much reliance on financial indicators can offer an incomplete view of the health of the clinic, which is important for sustainability.4 As a result, I suggest having at least one or two qualitative-based KPIs to be used within your dashboard report.

Lagging indicators Lagging indicators are necessary because they provide the clinic with achieved results. For example, ‘operational profitability’ is a lagging indicator because it only provides data based on historical performance. Therefore, operational performance as an indicator is not always helpful in determining future performance because one period of profit generation cannot guarantee the next period will remain profitable.

contained within the report that management needs to rely and act upon. In such situations, the clinic can create sub-dashboard reports for functional areas or specific initiatives.5

Benchmark performance Benchmarking performance against industry averages, which can be found at websites such as bizstats.com, and internal expectations is quintessential for monitoring whether an indicator is representing anything of value to the clinic. For example, if the clinic aims to grow sales by 10% for the year, the indicator of sales growth should clearly display whether the clinic is achieving the required sales growth for the period in which the indicator is measuring performance (weekly, bi-weekly, monthly, quarterly or yearly). In short, each KPI needs to be benchmarked against a set performance expectation.

Report format Leading indicators Leading indicators are important because they provide insight into where things should be heading. For example, ‘customer satisfaction’ is a leading indicator because it identifies how happy a customer was with their experience at the clinic. Accordingly, the higher the degree of customer satisfaction the higher the likelihood they will return for another treatment and likewise, the more people they will tell about it, which in theory, correlates to higher future revenues. ‘Customer rebooking rates’ can be considered another leading indicator because it should directly correlate to future revenue.

The right number of KPIs The number of KPIs being used in a dashboard should be no less than six and, in my opinion, no more than 15, however, I suggest aiming for eight to twelve KPIs. For the average clinic, it is important for the dashboard report to be simple, easy to follow and concise.

When the number of KPIs grows, the complexity of the report invariably grows, which can negate or hide the key information

There are two types of formats that I recommend the clinic can use for the dashboard reports containing KPIs. One format is an excel or table format and the other is a visual format.6 Excel or table format The excel or table format outlines the performance of each KPI in a very concise order while identifying whether the result has

Providing dashboard reports and KPIs to the company can be a great way of engaging employees

Reproduced from Aesthetics | Volume 4/Issue 5 - April 2017

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3

74%

Happiness

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4

Completion

2!

Overdue plans

User

Summary

Completion

Overdue

Mike

finished what he planned

70%

2

Ashton

doesn’t complete his plans

20%

8

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Problems

Progress, Plans and Problems 8 2

2 11

Happiness

1 4

Figure 3: Example of a visual format dashboard report

met or exceeded expectations (highlighted in green), is slightly lower than expectations (highlighted in yellow) or is below expectations (highlighted in red). Note, that each clinic may have their own definition of what meeting or exceeding, slightly lower than and below expectations actually means. To make it simple, I prefer to consider anything in green being meeting or exceeding expectations, anything highlighted in yellow to be between 9099.99% of expectations and anything highlighted in red to be below 90% of expectations. The table format is easy to create, easy to manage and may look something like the below report.

KPI New clients Average customer visit value Complaints Re-booking rate Clinic sales Sales growth (over prior year) Customer cancellations Add on sales (as a % of sales)

Meets or exceeds target

Monthly Target

January

February

15

15

18

£650

£500

£675

0

1

1

55%

54%

62%

£45,000

£40,000

£52,000

10%

-2%

21%

5 or less

8

4

5%

2%

4.80%

90-99.99% of target

90% or less of target

Figure 2: Example of an excel or table format dashboard report

Visual format The visual format outlines the performance of each KPI using visuals such as dials, gauges and graphs, and is typically more customised to be visually appealing. In fact, the term ‘dashboard report’ comes from the visuals often used in such reports, which appear similar to that of an automobile dashboard. Although it can be produced in Excel, this format is more difficult to create so some practitioners may choose to invest in third party technology companies such as; idashboards, Sisense and Notion. The benefits of using a third-party dashboard technology is largely tied around the ability to provide simpler-appearing reports, which are more visually appealing and easier for employees, at all levels of the organisation, to follow. An example of a visual dashboard report is below:

Management Managing KPIs does not have to be a complex undertaking. In many ways, the KPI report is an assimilation of data already produced by the clinic itself and should not add a huge amount of time to the clinic accounting manager or clinic manager. In situations where the clinic does not have an accounting manager or clinic manager, focus on producing only KPIs that are critical to success. I would recommend

producing weekly, monthly and quarterly reports, which should be reviewed with your management team on a regular basis to identify and act upon positive and negative indicators.

Providing dashboard reports and KPIs to the company can be a great way of engaging employees. When the dashboard reports contain KPIs, which are clearly linked to the stated strategy of the clinic, they can become a company-wide performance measurement tool, which every employee can clearly see, utilise and understand. It should be noted, that based on the degree of open book management within the clinic, certain KPIs such as sales, profitability and those associated with cash generation, should be left to higher level dashboard reports for management and clinic owners.7

Summary In summary, KPIs and dashboard reports offer the clinic the ability to increase the utilisation of data while providing a tool that allows data to become a means of regularly monitoring performance. Through taking action as a result of the KPIs and dashboard reports, they ensure a clinic’s success against its objectives. I would encourage clinic owners/managers to implement KPIs and dashboard reports as they can dramatically improve transparency and create a greater ease of understanding of what the data is telling you and your employees.

To read the first part of the series ‘How to Maximise Clinic Performance’ visit www.aestheticsjournal.com or see the March 2017 issue for ‘Increasing Employee Performance’.

Reece Tomlinson is the global CEO of Intraline Medical Aesthetics Ltd. He holds an MBA, is a chartered professional accountant and has completed extensive executive education. His areas of expertise include: executive leadership, strategy development and execution, international business management, negotiations, product commercialisation, business development, sales management, corporate finance and M&A. He spends his time between Kelowna, BC and London, UK. REFERENCES 1. F. John Reh, The Balance, The Basics of Key Performance Indicators (KPI) (2017) <https://www. thebalance.com/key-performance-indicators-2275156> 2. Michael J. Mauboussin, Harvard Business Review, The True Measures of Success, (2012) 3. Carlos Cardal, Leading, lagging, or lost? How to Find the Right KPIs for Your Sales Team, Geckoboard, (2016) <https://www.geckoboard.com/blog/leading-lagging-or-lost-how-to-findthe-right-key-performance-indicators-for-your-sales-team/#.WL_fLHecb6Y> 4. Monitoring Evaluation, Quantitative & Qualitative Indicators, (2016) <http://monitoringevaluation. weebly.com/quantitative--qualitative-indicators.html> 5. Dr. Matt, Clear Health Media, Key Performance Indicators and Your Practice’s Success, (2014) <https://www.clearhealthmedia.com/business/key-performance-indicators-practices-success/> 6. Duums.com, KPI Dashboard Example <https://www.google.ca/search?q=dashboard+report+format&biw=1536&bih=799&source=lnms&tbm=isch&sa=X&ved=0ahUKEwjA9d2a57rSAhVMDMAKHbKUAKsQ_AUIBigB#tbm=isch&q=excel+kpi+&*&imgrc=2DhvRWkPBB7bbM> 7. Juri Kaljundi, Be a better manager: the new team dashboard, (2017) <https://blog.weekdone. com/be-a-better-manager-new-team-dashboard/>

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Client JM’s Hair Journey with Viviscal, by Denise McAdam Before

After

Patient before and four months after taking Viviscal Professional Hair Growth Programme

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Aesthetics | April 2017

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creation and is generally considered not permissible but, even in this regard, there are some exceptions; for example surgery to correct congenital deformity or burns.4

Substances prohibited in Islam

Consulting Religious Patients Aesthetic practitioner Dr Sabba Janjua discusses consultation considerations for Muslim patients As aesthetic practitioners we may see patients from a wide variety of backgrounds, cultures and faiths. A patient’s religious viewpoint may well impact upon their decision to embark on a particular treatment. As such our approach ought to be sensitive and also supported by an awareness of the issues relevant to our patients. This article explores the topic of religion with a particular focus on consulting with Muslim patients and how to approach some of the concerns they may have.

Considering a patient’s personal values and beliefs When deciding whether or not to proceed with a particular aesthetic intervention, the individual considers multiple factors before forming a decision. Personal values and beliefs are themselves shaped by a number of variables; the society an individual has grown up in, the influence of their friends and family and, for some individuals, their religious identity. The frenetic pace of today’s life, coupled with the impact of print and digital media on societal perception of beauty, can increase the complexity of decision-making that our patients face whilst seeking to respect and adhere to tenets of faith.

Islamic faith In Islam there are five recognised categories for a hierarchy of acts ranging from permitted to non-permitted.1 These are:

‫( ضرف‬fard/wajib) – ‘compulsory/duty’ ‫( بحتسم‬mustahabb) – recommended, ‘desirable’ ‫( حابم‬mubaḥ) – neutral, ‘permissible’ ‫( هوركم‬makruh) – disliked, ‘hated’ ‫( مارح‬haram) – sinful, ‘prohibited’ The category of ‘haram’ has the highest status of prohibition within the Qur’an.

Examples include gambling, usury and eating certain foods such as pork and drinking alcohol. For some Muslim patients the use of non-surgical interventions raises the issue of whether these treatments are considered haram. An Islamic perspective advises that focusing on external beauty should not be a goal in itself. Inner beauty and behaviours reflective of this, such as kindness and good conduct towards others, are favoured.2

Beautification ideals in Islam The issue of beautification is addressed in the Qur’an and is one of moderation.2 Numerous methods of beautification including wearing jewellery and the application of creams, kohl and henna are permissible.2 Indeed it can be considered a form of ‘ibada’, an Arabic term for worship and is actively encouraged in some circumstances, for example, within marriage.3 According to the Qur’an, permanently changing one’s appearance could be viewed as changing God’s

Applying the above principle, hyaluronic acid (HA) dermal fillers and botulinum toxin could arguably be considered permissible given their temporary nature.

However, a prospective Muslim patient may well question whether HA fillers or botulinum toxin contain any substances that may be deemed haram, such as alcohol. It is therefore prudent to be aware of these concerns and to be able to discuss and address them appropriately, including discussing the ingredients of the substances used in these treatments.

HA fillers Hyaluronic acid is a substance found in the body’s cells and tissue fluids, and is a key molecule in maintaining dermal volume and elasticity due to its moistureretaining capacity.5 HA dermal fillers have structural properties similar to those of native tissue, excellent biocompatibility and good tissue integration.6 HA products may be derived from animal or bacterial sources. The HA fillers most widely used in clinical practice are non-animal HAs.5 To determine whether a HA filler is non-animal based, the ingredients in the product can be checked. Further information can be sought from a medical representative from the relevant company. Once the practitioner has checked that the HA filler that they use is non-animal based the patient can be reassured that it does not contain anything which could be considered haram.

Botulinum toxin Botulinum toxin is a highly purified protein refined from the bacterium clostridium botulinum that results in localised reduction of muscle activity by inhibiting acetylcholine release at the neuromuscular junction.7 The process of botulinum toxin A production begins with culturing Clostridium botulinum.

To provide the proper nutrients, the medium chosen for growth usually has animal or soy product.8 The manufacturing process for botulinum toxin involves growing the bacterium on agar plates comprising of a number of animal-derived (porcine and non-porcine) components. The bulk toxin then undergoes a comprehensive series of purification steps so that all the animalderived by-product is eliminated in the final

Reproduced from Aesthetics | Volume 4/Issue 5 - April 2017

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botulinum toxin type A product.9 Patients can therefore be reassured that the final product does not contain any animal-derived products. However, as always, patient should make the final decision on whether to go ahead with treatment and if necessary seek further advice. The Summary of Product Characteristics (SPC) document that is included with the product states how it should be used. It also provides details on all the substances contained within the product, including excipients, and is therefore a very helpful resource for practitioners. An excipient is an inactive substance that serves as the vehicle or medium for a drug or other active substance.10 The three commonly used botulinum toxins type A: Botox11, Azzalure12 and Bocouture13 all list human albumin as an excipient. Albumin is a protein that is defined as haram or halal depending on the source. Albumin obtained from blood is considered haram14,15 and this is therefore something patients should be informed of. It is then for the individual patient to decide whether to still go ahead with treatment.

Patient consultation In my practice I have seldom encountered Muslim patients wishing to specifically discuss the Islamic view-point of non-surgical aesthetic treatments, although on the few occasions the topic has arisen. The patients offered the following perspectives: • A 46-year-old female Muslim patient attended, as she noticed that her cheeks were looking hollow after losing weight.

She felt it made her appear older and wished to look as she did six months prior to the weight loss. During the consultation and examination she also commented that she was not happy with the bump on her nose and would next be considering having a non-surgical rhinoplasty. She told me she had undertaken some research on treatment with HA filler and felt treatment was permissible, as she was not making any permanent changes to her face. It is for this reason that she would not undergo a surgical rhinoplasty, as this would involve making permanent changes to her face, which did not sit comfortably with her. For this patient the issue of permanence was the most pertinent when considering the permissibility of treatments.

• A 34-year-old female Muslim patient attended to discuss lip filler treatment.

For many years she had noticed that the

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For some Muslim patients the use of non-surgical interventions raises the issue of whether these treatments are considered haram left side of her top lip was slightly thinner compared to the right side. She explained that as she was seeking only very subtle and natural results, she was not changing her features significantly and therefore felt her treatments would be considered permissible. She required 0.1ml of HA filler to help address the subtle asymmetry and was particularly pleased because she was certain other people would not notice which was important to her. For this patient, not deviating significantly from her original features and having a modest and natural approach was an important factor in determining whether her treatment was haram or not.

• A 28-year-old female Muslim patient requested treatment for hyperhidrosis with botulinum toxin. She had actively researched the acceptability of the treatment prior to attending and I also informed her that the substance used did contain human albumin. Ultimately she felt comfortable going ahead with treatment as she considered it a medical treatment rather than a means of beautification, and therefore felt her treatment was permissible from an Islamic perspective.

Although she felt happy having treatment with botulinum toxin for hyperhidrosis, she would not have had treatment to her face for rejuvenation purposes.

These cases reflect how some Muslim patients may feel comfortable with one particular treatment but not another and also demonstrates the variety of thoughts and views of different patients. When a patient of Muslim faith has presented to us in clinic one might reasonably assume their attendance itself suggests they are willing to consider a procedure. However when undertaking a consultation with patients, regardless of their religious beliefs, it is important to ascertain

whether they have any concerns about the procedure. Some patients may be worried about pain or side effects; others may cite confidentiality as a concern or worry about the results. They may also voice a concern as to whether the procedure is considered haram or not. It is important that each concern is addressed in turn.

Furthermore, patients may benefit from seeking advice from family, friends or even an Islamic scholar prior to having a treatment that they may later feel uneasy or guilty about. An Islamic scholar is someone who has spent many years studying the Qur’an academically and possesses a high level of knowledge in religious matters. They can be consulted at the patient’s local Islamic centre or mosque and they provide advice and information on a wide range of issues that affect individuals. Examples include advice on marriage, family life, financial issues and general guidelines on living as a Muslim. Often such queries are addressed in a group format so others also share in the knowledge, but if the query is of a sensitive nature or if an individual simply does not wish to disclose their issue in front of others, then confidentiality should be requested from the outset so that this can be respected.

Patient reassurance The patient should be reassured that the practitioner will do all they can to minimise any pain or discomfort. Having explained the side effects the patient should be informed of the rates of risk and complications including details of whom to contact in an emergency. With regard to confidentiality, the practitioner should reassure the patient that this will be guarded assiduously. Respecting confidentiality is an ethical but also a legal obligation on practitioners and the General Medical Council’s (GMC) confidentiality guidelines16 make it clear that patients have a right to

Reproduced from Aesthetics | Volume 4/Issue 5 - April 2017

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expect their personal information to be held in confidence by their doctors. A clear discussion should also take place on what can be realistically achieved in terms of results. The GMC guidance for doctors who offer cosmetic interventions17 states that all patients should be given all the time they may need so that they can make a voluntary and informed decision about whether to go ahead. While this should apply to all consultations, due to cultural and religious sensitivities it can be particularly important for some patients and this should be ascertained as early as possible.

Conclusion

Aesthetics

concerns and, as with any consultation, be prepared to not undertake the procedure if there is any hesitation or uncertainty from the patient about its religious acceptability.

If indeed the patient does have a concern, they ought to be reassured that there is no obligation to go ahead with a procedure and they should be given as much time as they require to decide.

By approaching concerns with sensitivity and appreciating there may be considerable differences amongst individuals, even those sharing the same faith, practitioners can aim to offer a successful consultation where the patient feels empowered in their decision making.

Dr Sabba Janjua is an aesthetic practitioner based in London. She qualified from Newcastle University and trained as a GP where she developed a special interest in dermatology.

She was awarded the Diploma of Practical Dermatology with distinction from Cardiff University and works exclusively within aesthetics and is a trainer for Skinviva Ltd.

REFERENCES 1. Adamec L, ‘Historical Dictionary of Islam’, 2009, pp. 102 2. Mission Islam, ‘The Muslim Woman and her Ownself’ , <https://www. missionislam.com/family/mwomanownself.htm> 3. Sarwar G., ‘Islam: Beliefs and Teachings’, 1989, 2, pp. 76 4. Shaykh Muhammad Saalih al-Munajjid, ‘Ruling on Cosmetic Surgery’ ,Islam Question and Answer, 1997-2017) <https://islamqa.info/en/47694> 5. MacReddy N, ‘Dermal fillers: focus on hyaluronic acid’, Medscape, 2008 <http://www.medscape.org/viewarticle/576776> 6. Newman J, ‘Review of soft tissue augmentation in the face’, Clinical, Cosmetic and Investigational Dermatology, 2009, 2, pp. 141-50. <https:// www.ncbi.nlm.nih.gov/pubmed/21436976> 7. Small R, ‘Botulinum Toxin Injections for Facial Wrinkles’, Amercian Family Physician, 2014, 3, pp. 168-175 <http://www.aafp.org/afp/2014/0801/p168. html> 8. Natalie Derise & Kristi Harrison et al., ‘Production of Botulinum Toxin A: BE 3340 Process Design Group 5’ , 2013, pp.5-11. http://nderise.weebly.com/ uploads/2/4/4/1/24410337/be_3340_process_report_final-_group_5.pdf 9. Allergan supplied data 10. American Pharmaceutical Review, ‘Pharmaceutical Excipients’, 2016 <http://www.americanpharmaceuticalreview.com/25335-PharmaceuticalRaw-Materials-and-APIs/25283-Pharmaceutical-Excipients/> 11. EMC, ‘BOTOX 50, 100 and 200 Allergan Units’ ,EMC, 2015 <https://www. medicines.org.uk/emc/medicine/11665> 12. EMC, ‘Azzalure’ ,2016. <https://www.medicines.org.uk/emc/ medicine/21990> 13. EMC, ‘Bocouture 50 Units Powder for Solution for Injection SPC, 2016, <https://www.medicines.org.uk/emc/medicine/23251> 14. ICWA Halal Guidelines, ‘The Islamic Council of Western Australia, ICWA’ 2017 <http://www.islamiccouncilwa.com.au/halal-certification/halalguidelines/> 15. Mursyidi, Achmad (2013), ‘Chemical Analysis Authentication Role in Halal and Food Pharmaceutical Products’, Journal of Food and Pharmaceutical Science, 2013, pp.1-4. <https://jurnal.ugm.ac.id/jfps/article/view/1823> 16. General Medical Council, ‘Confidentiality guidance: Principles’, 2009 <http://www.gmc-uk.org/guidance/ethical_guidance/confidentiality_6_11_ principles.asp> [ 17. General Medical Council, ‘Guidance for all doctors who offer cosmetic interventions’, 2016. <http://www.gmc-uk.org/guidance/news_ consultation/27171.asp>

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When it comes to a discussion around whether a certain treatment is haram or not I believe having awareness and understanding of what this term means is beneficial. It enables the practitioner to explore a patient’s religious concerns whilst assisting them thoughtfully and respectfully to make an informed decision as to their treatment of choice. The practitioner should be aware of the patient’s possible

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In Profile: The Ravichandrans

Dr Simon and Dr Emma Ravichandran detail their careers in aesthetics and explain how they have worked together to build a successful practice

“Always have the humility to accept you won’t get it right all the time and that there’s so much to learn” “Aesthetic medicine can be a lonely specialty, as a lot of people practice on their own,” says Dr Simon Ravichandran who established the Clinetix Medispa group in 2006 in Scotland with his wife, Dr Emma Ravichandran. The pair opened their first clinic in 2011, before opening a second in 2013. “Practitioners may have very little support in terms of a peer network – they certainly didn’t have one when I began my career in the aesthetics specialty – so it was really good that Emma and I could share this experience together,” he explains.

The Ravichandrans met at university in 1995. Dr Simon Ravichandran recalls their first encounter, “There was a communal telephone in the hallway of my student residence. Whilst on the phone to my mum, this girl walked past me, heading to the flat upstairs. I got off the phone, followed Emma and pestered her for about a year until she said she would marry me!”

After completing a Bachelor of Medicine and Bachelor of Surgery from the University of Glasgow in 2002, Dr Ravichandran spent several years in orthopaedic surgery, cardiothoracic surgery and accident and emergency surgery, before progressing to ear, nose and throat surgery. He notes, “It was always a specialty I wanted to do but I never thought I would manage to get into it, I got the job and eventually progressed to specialising in facial plastics.”

Whilst working as a doctor in the NHS, Dr Ravichandran attended an introductory botulinum toxin course at a dental practice in Glasgow in 2006. “The initial training was pretty basic but it motivated me to find out more and more about the topic,” he says, adding, “I found the whole sub-field of aesthetic medicine fascinating and found myself applying the principles I learned in aesthetic medicine to my ENT practice – both areas complemented each other tremendously.”

While Dr Emma Ravichandran worked as a dentist, the couple set up their practice and worked in clinics across Glasgow on a parttime basis alongside their general medical careers, where they offered treatments in botulinum toxin, dermal fillers and chemical peels. The practice flourished and developed more quickly than either of them expected. Dr Ravichandran explains, “We

became more involved in the education, learning, training and development of the aesthetic specialty, to the point where about a year ago, it became quite difficult to run both jobs at the same time. So with a heavy heart, I made the decision to leave my NHS practice and concentrate solely on medical aesthetics.”

The couple now run two Clinetix Medispas; one in the West End of Glasgow and the other in the Lanarkshire village of Bothwell.

Dr Ravichandran says their different backgrounds in dentistry and medicine enable them to combine their knowledge, to learn from each other and continually grow as practitioners. “Emma knew more about oral facial ageing than I did and there are some things that I knew more about. Constantly reflecting on our treatments and learning from each other has really helped drive us to become the practitioners that we are today,” he explains.

Discussing how they run their clinics, Dr Ravichandran says, “We see our patients and address them in a similar fashion – we are unfortunately very rarely in the same clinic at the same time unless we have a complex procedure which we both want to get involved with; in which case we’ll work together and have to organise a hierarchy of who is in charge and who holds the medical devices,” he jokes. Working together presents great benefits says Dr Ravichandran, noting, “If I am doing a large volume replacement treatment, combining threads with a laser or a deep chemical peel, there’s no better work colleague than someone who understands the treatment as well as Emma.”

For Dr Ravichandran, being an aesthetic practitioner is gratifying as he sees the significant impact that non-surgical treatments can have on his patients. “The improvements in the quality of life in our patients that we achieve with a minimally invasive, comfortable treatment with minimal downtime is tremendous. It really is phenomenal how much happier we can make people feel, how we can improve their self-esteem and confidence just by a few medical aesthetic interventions.”

What’s your industry pet hate?

I am concerned by the apparent commoditisation of the speciality. We are providing a professional medical service and I don’t think we should be ‘selling’ to customers.

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

Enjoy every day. If you don’t, then fix it or find something else to do – life is too short to something you don’t enjoy.

What aspects of medical aesthetics do you enjoy the most?

I enjoy meeting my patients at their follow-up consultations and hearing them descibe how their treatments have impacted their lives. That’s my biggest buzz from the work I do.

Is there anything you would have done differently?

One thing medical school didn’t teach me was how to run a business! We’ve made a few mistakes but, in the long run, we have learnt from them and become better because of it.

Reproduced from Aesthetics | Volume 4/Issue 5 - April 2017

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The need for continual learning and growth to improve on techniques is the part of aesthetics that Dr Ravichandran enjoys the most. He also says that it’s important to stay up to date and learn new treatments, “The one thing I enjoy right now is thread lifting, because it’s a new thing. This time last year I would have said laser treatments and maybe before that I would have said mesotherapy.”

Dr Ravichandran is also passionate about educating others, leading him to co-found the Association of Scottish Aesthetic Practitioners five years ago, which holds an annual conference to support the growing number of aesthetic clinicians practising in Scotland. In addition, he and Dr Emma Ravichandran run the Aesthetics Training Academy, Glasgow, for doctors, dentists and nurses to develop their skills and knowledge. He says that in their training academy, “All concepts stem from a simple question we ask ourselves, ‘if we were starting again from the beginning, how would we like to be trained ourselves?’”

The process of ongoing learning and training is something he encourages those hoping to build a career in aesthetic medicine to pursue. He says, “Once you have made that decision, train and go on every single course you can go on, spend time with other aesthetic doctors, dentists or nurses, and find out how they perform treatments. Always have the humility to accept you won’t get it right all the time and there’s so much to learn. No one has reached the top yet, we are still climbing that mountain, so just keep going.”

“I think if you enjoy it, working is not a job, it’s a lifestyle” For Dr Emma Ravichandran, becoming a practitioner and co-owner of a clinic dedicated to delivering nonsurgical aesthetic procedures was not part of her initial plan upon graduating as a dentist from the University of Glasgow in 2000. She explains, “My mum had toxin injections for my wedding and afterwards she absolutely loved it and said ‘Emma you can do this and you can do it for me!’ I was intrigued about this area of medicine, so I enrolled to do a course.

My mum still accredits my success to her requesting that glabella toxin all those years ago.”

Dr Ravichandran was working as a dentist in the NHS when she went on her first botulinum toxin course six months before her husband in 2006 and says that she found it very inspiring, “I took to it like a duck to water, but I just expected there to be one course.

I expected that training to be the end of it, but then I got inspired, started reading about more treatment modalities and went on an advanced training course and attended lots of conferences. I got absolutely hooked on the specialty!”

After practising aesthetics at various clinics in Glasgow and building a successful reputation alongside her husband, the pair opened their first clinic. Dr Ravichandran explains that for them, the challenge was that they were completely new to running a business, “We probably didn’t have the best business acumen

Aesthetics

at that time and it was a steep learning curve. It was really nervewracking from the beginning, but it was basically word of mouth that spread the popularity of the clinic.”

Dr Ravichandran says that she learnt that when opening a business, it is important to ensure that you are offering something unique, “The clinic was much more focused on the medical side of the specialty and, at that time in Glasgow, this was pretty unique.

The other choice we made was to put our clinic on the main high street because most other clinics were set back and were very private. We said let’s do something different – we also sold other treatments such as skincare, so people didn’t feel as though they had to be coming in just for non-surgical treatments.”

For those who are endeavouring to open their own clinic and become a successful aesthetic practitioner, Dr Ravichandran advises to, “Be enthusiastic and love the industry that you are in. People need to absolutely keep abreast of what is changing because it’s progressing so rapidly that you need to invest your time in learning and keeping on top of everything that’s coming out.” Above all, Dr Ravichandran advises, “Just enjoy the experience because it’s a fabulous, dynamic industry and you can make big changes to people’s lives with your treatments. I think if you enjoy it, working is not a job, it’s a lifestyle.”

As well as her clinical work, Dr Ravichandran has a huge passion for teaching others. “It was not a path that I actively pursued in my career, but teaching seemed to choose me,” she says. After establishing her aesthetic career, Dr Ravichandran was approached by training companies and conferences to share her knowledge. She explains that, although daunting at first, it is an important part of her success, “Teaching motivates me to always stay at the cutting edge of the latest developments. With this understanding, I gain the confidence to develop new, safe techniques to achieve the best results.” In addition, she notes that, “Teaching is always a two-way process. I love sharing knowledge and experiences and every day I learn from others to make me a better practitioner too.”

While reflecting upon her life, Dr Ravichandran says that her biggest achievement is in fact her husband and three children. “From a career point of view, however, my biggest achievement is establishing a really amazing workforce in Clinetix – we have employed staff with similar attitudes to ourselves, who really strive for delivering the best patient outcomes rather than being driven by financial gain. I think that we have created a really amazing team who are invested in the business and are really happy to be there!”

What is your top tip for success?

Absolutely love your job, have a good working environment and enjoy life!

Do you have a motto that you follow?

I truly believe that you shouldn’t do something unless you would do it for yourself if you were in that position.

What treatment to you enjoy giving the most?

I would still go back to dermal fillers as my favourite – I really enjoy the artistry of the treatment and that you can loose yourself in the project at hand.

How do you think the aesthetics industry will look in 10 years?

I think a lot of money will be invested into such a rapidly growing market. Regeneration treatments maybe the way forward, rather than corrective fillers. Autologous stem cell treatments would be exciting!

Reproduced from Aesthetics | Volume 4/Issue 5 - April 2017

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The issue is that not all practitioners may recognise that some conditions may appear in different ways according to individual patients and that patients may not show symptoms all at once, so a quick diagnosis can be difficult.

To help avoid such circumstances, I believe all practitioners offering aesthetic treatments should have extensive, compulsory psychological training and that they should conduct mandatory patient screening before offering aesthetic treatment to patients.

The Last Word Consultant plastic surgeon Mr Ibby Younis discusses the importance of psychological education and training for professionals working in the aesthetics specialty Cosmetic and aesthetic interventions in the UK are popular treatments. It is difficult to find current non-surgical statistics to reflect this; however, according to the British Association of Aesthetic Plastic Surgeons (BAAPS), 31,000 people went under the knife in 2016. Although this figure was significantly lower than 2015, with 40% more procedures, BAAPS acknowledges that this decrease could be attributed to the rising popularity of non-surgical cosmetic procedures.1 In addition, reports by GBI Research indicate that the global facial aesthetics market will experience rapid growth from $2.5 billion in 2013 to $5.4 billion by 2020, at a compound annual growth rate of 11%.2 Taking these significant developments into account, safety and duty of care have never been more important. However, it’s not just physical safety that should be a priority, but the mental wellbeing of patients too.

Prevalence of psychological concerns in patients It is not unusual for aesthetic practitioners to consult with patients who are showing the signs of depression, psychosis and body dysmorphic disorder (BDD). According to The Body Dysmorphic Disorder Foundation, surveys have suggested BDD affects about 2% of the population3 and studies have indicated that of individuals who seek aesthetic medical treatments, 5-15% suffer from BDD, suggesting that it is common for these types of patients to present for treatment at an aesthetic practice.4,5 It is also not uncommon for symptoms to go undetected until after procedures. According to the Foundation, there has been very little research on the treatment of patients with BDD, however, in a study of 265 surgeons, 84% reported having operated on a patient only to realise postoperatively that they had BDD.5,6 This could be because screening processes are not always rigorous enough and, in some cases, BDD might not be detected until after a number of consultations.

Problems that arise when psychological issues aren’t recognised Whilst procedures are designed to meet what patients consider as desirable aesthetic outcomes and may, in some cases, alleviate psychological suffering,5 more serious mental health conditions may worsen following intervention.

A small prospective study of cosmetic surgery patients who requested treatment for minimal defects found that the majority of those who had BDD received surgery (seven out of 10 patients) and, at follow-up, most continued to have BDD and had developed new appearance preoccupations.5,7 However, in contrast to this, in a study of 250 people with BDD, 66% of patients had received cosmetic treatment for BDD concerns had no change in BDD severity.8 It is important to note that more severe issues can occur when psychological conditions such as BDD are not recognised.

According to a 2007 study by Phillips, global rates of suicidal ideation, suicide attempts, and completed suicide appear markedly elevated in BDD sufferers.9 Current psychological education Medical degrees include compulsory psychology teaching and one of the required clinical rotations for medical students is psychiatry, but psychological issues are not always a huge focus of study. Nearly all nursing degree programmes include some psychology courses,10 whether a basic course in general psychology

I believe all practitioners offering aesthetic treatments should have extensive, compulsory psychological training and that they should conduct mandatory patient screening before offering aesthetic treatment to patients

Reproduced from Aesthetics | Volume 4/Issue 5 - April 2017

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or specialised courses in patient psychology that focus on the mental states of ill or injured people. Nurses who are working on an advanced degree will typically take more courses on psychology than those with basic training. I think a key issue is that psychological education, specifically BDD, is not a prioritised point of study in many courses, so when individuals move into their chosen professions, they may not be educated enough in BDD to know how to screen out patients with the condition.

I believe more compulsory psychological training should be provided at education level. There should also be a larger focus on training for such conditions when individuals start their professions and refresher courses offered throughout their careers, which will update professionals on new research and findings, so psychological education can remain as up-to-date as possible.

This would arm practitioners who are performing surgical and non-surgical cosmetic interventions with the knowledge needed to handle difficult consultations, with patients exhibiting poor mental health and BDD. It would also make them better equipped to spot certain behaviour ‘warning signs’ more quickly and easily, thus enabling practitioners to be more scrupulous about who they consider for treatment.

Enhancing the future of patient wellbeing Another option, which I believe would be beneficial, is for aesthetics professionals to introduce formal screening tools in clinics nationwide, a practice suggested by The University of the West of England’s Centre for Appearance Research.11 Psychiatric questionnaires can offer a way to protect patients from unwarranted medical treatment and to pre-emptively defend practitioners from legal and physical attacks, however I don’t think enough aesthetic practitioners are doing this.

Psychological screening can help to speed up the decision-making process, but as articulated by Norman Wright, a psychotherapist who works with cosmetic surgery patients, aesthetic practitioners ‘need to look at the person behind the patient’.12 Consequently, I believe screening is not the only answer. This is mainly because due to the secretive nature of BDD sufferers, some symptoms won’t present themselves until quite a way into the procedure process and may also not present themselves all at once, making it harder to diagnose the conditions. It is also likely that some patients may not be honest about their mental wellbeing, in anticipation of a practitioner refusing treatment. At the surgical clinic I practise at, MyBreast, we believe the more scrupulous, face-to-face time that surgeons and nonsurgical aesthetic practitioners have with the individual, the better.

The latest GMC guidelines highlight that all industry professionals must give patients time for reflection and that they need to have the time and information about risks, to decide whether to go ahead with a procedure.13 More guidance aimed specifically at surgeons recommends that they should implement a two-week cooling-off period before any surgery is carried out.14 At MyBreast, individuals are welcome to return to us for additional consultations at no additional cost, to ensure the surgeon and patient are ‘on the same page’ at the end of that journey. We charge a small fee for the first consultation, which we deduct from the overall cost if a patient decides to go ahead with a procedure. In our experience, two consultations suffice for 80% of cases, the rest may need three. However, it is very important not to waste a patient’s time during the process as well. If we think necessary, we may advise a patient that the treatment may not be for them, if after a certain number of appointments we cannot reach a satisfactory decision.

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If unsure about someone’s psychological wellbeing during consultations, all potential patients should be referred to a psychologist or psychiatrist for further evaluation. Of course, care should be taken to ensure the patient fully understands why you are referring them and how seeing a specialist will benefit their overall mental wellbeing. At MyBreast, we use a team of very experienced, fully accredited and highly trained psychologists who specialise solely in body image issues and work closely with surgeons in the NHS. Specialist cognitive behavioural therapy (CBT) has been demonstrated to be effective for those with BDD, which psychologists tend to specialise in.15 CBT is based on a structured programme to enable patients to learn to change the way they think and act.16 Summary Any procedure that can make someone feel better about how they present themselves to the world is worth considering. Part of that consideration, however, includes the risk/benefit ratio of the procedure. If practitioners who are conducting medical interventions all have sufficient psychological education, as well as effective screening, unlimited consultations and extensive face-to-face time, it will mean fewer patients with mental health problems will be missed and will receive the appropriate support and treatment they need.

Mr Ibby Younis is a consultant plastic surgeon specialising in breast reconstruction at MyBreast clinic.

He studied at the University of Wales, undertook his general surgical training in London and completed postgraduate studies at Queen MaryUniversity of London. Mr Younis is on the specialist register of the General Medical Council for plastic surgery.

REFERENCES 1. The British Association of Aesthetic Plastic Surgeons, ‘SUPER CUTS ‘Daddy Makeovers’ and Celeb Confessions: Cosmetic Surgery Procedures Soar in Britain, BAAPS, (2016) <http://baaps.org.uk/ about-us/press-releases/2202-super-cuts-daddy-makeovers-and-celeb-confessions-cosmeticsurgery-procedures-soar-in-britain> 2. GBI Research, ‘Press Release: Global Facial Aesthetics Market Value to Double by 2020’, (2014), <http://www.gbiresearch.com/media-center/press-releases/global-facial-aesthetics-market-value-todouble-by-2020-says-gbi-research> 3. Body Dysmorphic Foundation, ‘How common is BDD?’, <http://bddfoundation.org/helping-you/ about-bdd/#how-common-is-bdd> 4. D. B. Sarwer, and J. C. Spitzer, ‘Body Image Dysmorphic Disorder in Persons Who Undergo Aesthetic Medical Treatments’, Aesthet Surg J, 32 (2012), 999-1009.

5. Canice Crerand, William Menard, & Katharine Phillips, ‘Surgical and Minimally Invasive Cosmetic Procedures among Persons with Body Dysmorphic Disorder’, Ann Plast Surg, 2010, 65(1): 11–16, <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3083632/> 6. Sarwer DB, ‘Awareness and identification of body dysmorphic disorder by aesthetic surgeons: results of a survey of american society for aesthetic plastic surgery members’, Aesthet Surg J, 2002 Nov;22(6):531-5, 7. Poole, Nigel, ‘Consent to Cosmetic Surgery’, (2012) <https://nigelpooleqc.blogspot.co.uk/2012/07/ consent-to-cosmetic-surgery.html> 8. BAAPS, ‘The Bust Boom Busts’, (2017), <http://baaps.org.uk/about-us/press-releases/2366-the-bustboom-busts> 9. Phillips KA., ‘Suicidality in body dysmorphic disorder’, Primary Psychiatry. 2007;14:58-66.

10. NursingSchoolHub.com, ‘Your Educational Training’, <http://www.nursingschoolhub.com/why-ispsychology-important-for-nursing/ 11. Bristol UWE University, ‘New cosmetic screening tool explained at Appearance Matters 5 international conference’, July 3-4 2012, <https://info.uwe.ac.uk/news/uwenews/news. aspx?id=2300> 12. Hart-Davis, Alice, ‘What Motivates People To Go Under The Knife?’, (2014) <http://thewrightinitiative. com/what-motivates-people-to-go-under-the-knife-norman-wright-features-in-this-article-from-theraconteur/> 13. General Medical Council, ‘Tough new standards for doctors carrying out cosmetic procedures’, (2016) <http://www.gmc-uk.org/news/29042.asp 14. The British Association of Aesthetic Plastic Surgeons, ‘BAAPS Statement on GMC’s ‘Cooling Off’ Guidelines, <http://baaps.org.uk/about-us/press-releases/2113-baaps-statement-on-gmc-s-coolingoff-guidelines> 15. Body Dysmorphic Disorder Foundation, ‘Cognitive Behaviour Therapy’, <http://bddfoundation.org/ helping-you/getting-help-in-the-uk/#cognitive-behaviour-therapy> 16. Veale, D, ‘Cognitive-behavioural therapy for body dysmorphic disorder’, Advances in Psychiatric Treatment, 7(2001), pp. 125–132 <http://veale.co.uk/PDf/CBT%20for%20BDD.pdf>

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