Aesthetics August 2016

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Photodynamic Therapy CPD Anna Baker examines literature on PDT for non-melanoma skin cancer

Tattoo Removal

Treating Scars

Practitioners discuss how to safely and successfully remove unwanted tattoos using different lasers

Dr Salinda Johnson outlines the most common types of scars and details the treatments available

21/07/2016 16:07

Under Investigation

Naomi Di-Scala explains what practitioners should do if they are under investigation

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Contents • August 2016 06 News

The latest product and industry news

14 Conference Report

Aesthetics reports on the BAD Annual Meeting

16 News Special: The Impact of the EU Referendum

Aesthetics speaks to practitioners about how they think the Brexit vote could affect the aesthetics industry in the UK

CLINICAL PRACTICE 18 Special Feature: Tattoo Removal

Practitioners discuss how to safely and successfully remove unwanted tattoos

25 CPD: Using PDT

Aesthetic and dermatology nurse prescriber Anna Baker discusses the literature on topical photodynamic therapy for non-melanoma skin cancer

31 Treating Seborrhoeic Keratoses

Aesthetic nurse Mary White details her methods of treating seborrhoeic keratosis with long pulsed alexandrite lasers

35 Lip Augmentation

Dr Lee Walker details the relevant anatomy to consider for lip augmentation and explains patient selection for treatment

38 Botulinum Toxin: A New Look for Depression Treatment

Dr Michelle Magid, Dr Jason Reichenberg and Tyler Willenbrink discuss the use of botulinum toxin A in the treatment of depression

42 Body Contouring and LLLT

Dr Sarah Tonks explores the role of low level laser therapy in body-contouring treatments

47 Treating Scars

Dr Salinda Johnson outlines the most common types of scars and details some of the effective treatments available

51 Abstracts

A round-up and summary of useful clinical papers

52 What to do When Under Investigation

Naomi Di-Scala explains why aesthetic practitioners may find themselves under investigation and what to do in this situation

55 The Business of Skin

Sharon Cass examines the skincare market in the UK and advises practitioners how they can provide a more bespoke service to patients

58 Trade Marking in Aesthetics

Dr Daniel Sister and marketing director Jemma Patton discuss why practitioners might consider trade marking a treatment, protocol or product

60 Avoiding Burnout

Dr Kieren Bong explains what causes stress related burnout and advises how to best prevent and manage it

63 In Profile: Dr Kate Goldie

Dr Kate Goldie shares her path into aesthetics and discusses her passion for education and training

65 The Last Word

Dr Paul Charlson discusses the rise of mole apps and argues that they should never replace a full consultation

NEXT MONTH • IN FOCUS: Augmentation • Treating Henna Tattoo Complications • Writing a Blog Post

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Clinical Contributors Anna Baker is a dermatology and cosmetic nurse practitioner, running nurse-led topical PDT clinics for Galderma UK in conjunction with Ashfield Clinical. She works alongside Mr Dalvi Humzah as the coordinator and assistant tutor for Facial Anatomy Teaching.

Mary White has been an aesthetic nurse since 1993 and specialises in dermatology laser treatments and aesthetic injectable treatments. White owns and runs an aesthetic clinic in Worcestershire.

Dr Lee Walker is a former cosmetic dental surgeon who has more than 14 years’ experience in nonsurgical facial aesthetics. He is clinical director at B City Clinics in Liverpool and speaks at many industry conferences and lectures for Teoxane UK. Dr Michelle Magid is a psychiatrist in Austin, Texas. She is president of Austin Psychcare, PA, and a clinical associate professor for University of Texas, Dell Medical School. She is a leading researcher in using botulinum toxin for psychiatric illness.

Dr Jason Reichenberg is chief of dermatology for Seton Family of Hospitals and an associate professor for Dell Medical School at the University of Texas.

Dr Magid and Dr Reichenberg helped to edit the book Practical Psychodermatology.

IN PRACTICE

Special Feature Tattoo Removal Page 18

Tyler Willenbrink is a fourth year medical student at the University of South Carolina School of Medicine in Columbia South Carolina. Following graduation, he plans to pursue residency training in the field of dermatology.

Dr Sarah Tonks is an aesthetic doctor and previous maxillofacial surgery trainee with dual qualifications in both medicine and dentistry. Based at the Chelsea Private Clinic, she practices cosmetic injectables and hormonal based therapies.

Dr Salinda Johnson is an aesthetic practitioner and 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.

Book now for the Aesthetics Awards 2016 www.aestheticsawards.com Saturday December 3, London

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Editor’s letter August has arrived and finally we seem to be having some seasonal weather, so I am sure everyone is applying copious amounts of SPF! I don’t know about you but I am feeling somewhat unsettled of late, I don’t think we have Amanda Cameron ever had so much political change in such a short Editor period of time. So to continue with the political theme, this month we take a look at the impact of Brexit on our own aesthetic specialty to see what changes, if any, may occur. Turn to p.16 to read the experience and thoughts from a range of industry professionals. Are you thinking of adding another treatment option to your clinic offering? With continued demand for tattoo removal and ever-developing laser technology, laser tattoo removal could be a good investment for your clinic. Read our Special Feature on p.18 to discover the science behind how it works and take advice from experienced practitioners on how to manage patient expectations and achieve successful results.

This issue’s CPD article, written by aesthetic and dermatology nurse prescriber Anna Baker, is an interesting and in-depth analysis of the literature on photodynamic therapy for the treatment of non-

melanoma skin cancer. Turn to p.25 to read it in the journal and don’t forget to log learning on your online Aesthetics Training Record. If you aren’t already a member, join now by visiting www. aestheticsjournal.com/training to record all of your continued professional development. This month we are also delighted to include an article from our US-based colleagues, Dr Michelle Magid, Dr Jason Reichenburg and Tyler Willenbrink, who have kindly detailed their research into how botulinum toxin can have a positive influence on depression. Find out more about this innovative and interesting new treatment indication on p.38.

Planning for the Aesthetics Awards is coming along excellently and I for one can’t wait to celebrate the dedication, innovation and achievements of our industry in 2016. To stay up-to-date with the latest Awards news and ensure you have your table booked for the ceremony, visit www.aestheticsawards.com today!

At the journal we pride ourselves on offering the best we can in education to help grow your business and knowledge so we continue to provide a varied and comprehensive range of topics relevant to your practice. Please let us know your thoughts by tweeting us @aestheticsgroup or emailing editorial@aestheticsjournal.com

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

Talk #Aesthetics Follow us on Twitter @aestheticsgroup #Lasers Dr Joney Dr Souza @DrJoneyDeSouza In beautiful Berlin listening to Dr Mulholland on lasers #Customers Pam Underdown @AestheticGrowth Price is never the most important thing according to statistics and research. 14% of buying public only ever buy the cheapest #aesthetics #Training DH Clinical Teaching @facialanatomy Final preparations underway for #advancedinjectable #midface #lowerface @WigmoreTraining 6.7.16 @pdsurgery

#Teaching Dr Souphiyeh Samizadeh @drsamizadeh Thoroughly enjoyed training an enthusiastic group of healthcare professionals (Harley Street, London) #aestheticmed

#Dermatology Dr Justine Kluk @JustineKluk In #Birmingham for the @HealthySkin4All annual meeting #dermatology

#Association Barbara Jemec @bjemec Here with @DrAnneDancey and Mamta Shah keeping the female end and high standards up on BAPRAS Council #ilooklikeaplasticsurgeon #Injecting Dr Raj Acquilla @RajAcquilla Injecting with the wonderfully talented @DrPrager today in #London

Study suggests GPs leave acne patients on antibiotics too long A study presented at the British Association of Dermatologists Annual Meeting suggests that patients are exceeding the recommended time of antibiotic use for acne before being referred to a dermatologist.

The study reviewed the oral antibiotic duration for 928 patients with acne. The results suggested that the average duration of antibiotic use prior to a dermatologist referral was six and a half months, with the longest being 84 months.

The National Institute for Health and Care Excellence (NICE) recommends that unless acne improvement is seen, general practitioners should only continue to prescribe antibiotics for up to three months before referring the patient to a dermatologist.

In cases where patients are responding to treatment, NICE recommends it should continue for four to six months alongside topical treatments.

The study was conducted by Dr Alison Layton and the dermatology team at Harrogate and District NHS Foundation Trust, including Dr Heather Whitehouse, who said, “Antibiotics remain an important part of acne management, but given concerns about antibiotic resistance we should be using antibiotics judiciously as part of a treatment regime, limited to the shortest possible time period.”

Radiofrequency

Syneron Candela launches Profound device in the UK Aesthetic device company Syneron Candela has launched a bipolar radiofrequency-needling system to the UK market.

The Profound device produces temperaturecontrolled radiofrequency, aimed at delivering energy to the deep dermis to stimulate neoelastogenesis, neocollagenesis and hyaluronic acid deposition. It aims to treat skin laxity and improve skin quality in just one treatment and results can be seen between two to three weeks post treatment.

“With Profound, physicians deliver maximum results with minimum downtime, empowering the creation of younger, smoother skin with unprecedented outcomes,” said Amit Meridor, chief executive officer of Syneron Candela.

Reproduced from Aesthetics | Volume 3/Issue 9 - August 2016

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Industry

MedivaPharma partners with Institute Hyalual UK pharmaceutical supplier of facial aesthetic products MedivaPharma has announced it will now include Institute Hyalual products in its offering.

The company will supply a full range of cosmeceutical and injectable skin rejuvenation products for medical professionals.

Commercial manager at MedivaPharama said, “We are thrilled to be able to provide our UK clients with Institute Hyalual products. The products are top of the range and will complement our already extensive product offering.”

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

PRACTITIONER FINDER The BACN has launched a new ‘Practitioner Finder’ section on its website that allows members of the public to identify BACN members in their area by simply entering a postcode and distance criteria.

Profiles of BACN members in that category will then be displayed, providing contact details and outlining the areas of treatments they provide.

BACN AUTUMN CONFERENCE 2016

Botulinum toxin

Juvaplus launches Juvapen for botulinum toxin in the UK Swiss device manufacturer Juvaplus has launched the Juvapen for botulinum toxin injections in the UK. The device aims to administer botulinum toxin with less pain, side effects and downtime for the patient and to increase their trust in the procedure. According to Juvaplus, the device is accurate with less than 2% variation between doses, has a constant flow mode and six pre-set doses from 0.0125ml to 0.080ml, and is also cordless and light. A clinical study that evaluated the precision, pain and patient satisfaction of injection indicated that out of the 25 patients injected with the Juvapen, the device had a 97% degree of symmetry and a 98% patient satisfaction rate. The authors concluded that, “In the patient group in which we perform the injection with the Juvapen, the perceived pain during the procedure was significantly inferior in comparison with the standard one.”

This was shown with a mean level of pain registered immediately after the procedure as 3 compared to 8, with 10 being the highest level of pain. The company also stated that the device is compatible with all FDA and CE-approved botulinum toxins.

The BACN has now finalised the programme for its annual aesthetic conference, taking place on September 17 in Birmingham. Interest has been huge, with virtually all exhibition space sold, and members signing up to attend in droves. This year’s event will feature the usual latest treatment demonstrations, as well as a new business and training hub, and a social gathering for delegates and exhibitors the night before on September 16. Bookings can be made via the BACN website.

BACN GOES INTERNATIONAL The BACN has now concluded agreements with leading aesthetic practitioner organisations in the Republic of Ireland and the Philippines to become ‘Affiliated Associations’. The BACN will share a range of services, expertise and support with these partners to promote best practice in aesthetic treatments, training and products.

DATES FOR YOUR DIARY 17th Sep: BACN Autumn Conference, Birmingham 11th Nov: Wales and South West Meeting, Bristol 14th Nov: London, East Anglia & South East Group

Meeting, London 21st Nov: South Coast Group Meeting, Southampton 25th Nov: North West Group Meeting, Manchester 28th Nov: Ireland Group Meeting, Dublin 2nd Dec: Central Group Meeting, Birmingham 5th Dec: Scotland Group Meeting, Edinburgh

MEET A MEMBER

Skincare

Sesderma introduces the C-Vit range Clinical skincare and aesthetics company Sesderma has introduced the C-Vit range to its product portfolio. The products utilise a combination of nanotechnology and ethyl ascorbic acid and includes: the Liposomal Serum, which aims to boost skin radiance and luminosity; the Radiance Glowing Fluid, for the nourishment of skin, intending to even out skin tone and reduce the appearance of pigmentation; and the Eye Contour Patches, which aim to protect and strengthen the resistance of skin as well as fade dark circles and reduce the signs of fatigue. Sesderma claims the C-Vit products further improve results because they contain the ‘Antiox Booster system’, which is a combination of ingredients, including ginkgo biloba extract, quercetin and pterostilbene.

Andrew Rankin is an independent nurse prescriber, vice chair of the BACN and chair of the BACN education committee.

He has represented the BACN at the Health Education England consultations as well as being instrumental in developing the new Joint Council of Cosmetic Practitioners. Along with his wife Angela, Rankin is joint owner of Regenix Medical Aesthetic Clinic in Worcestershire and Birmingham. Rankin has taught extensively both nationally and internationally.

This column is written and supported by the BACN

Reproduced from Aesthetics | Volume 3/Issue 9 - August 2016

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Collagen

Comedian Hal Cruttenden to entertain at the Aesthetics Awards Stand-up comedian Hal Cruttenden is to entertain guests with a comedy set at the Aesthetics Awards 2016. Cruttenden, who has appeared on Mock the Week, Live at the Apollo and Have I Got News For You, will perform his set before hosting the presentation of the Awards. The evening of celebration will also feature a drinks networking reception, a three-course sit down dinner and, following the presentation of the winner’s trophies, music and dancing late into the night. Of last year’s Aesthetics Awards, aesthetic practitioner Dr Kuldeep Minocha said, “The Aesthetics Awards 2015 was a wonderfully glamorous event; the comedian was a star, and all were very worthy winners.” This year’s event will take place on December 3 at the Park Plaza Westminster Bridge Hotel, London. Finalists for the Awards will be announced in the September issue of Aesthetics journal.

To find out more and to book tickets visit www.aestheticsawards.com.

Psoriasis

LEO Pharma releases Enstilar for psoriasis Global pharmaceutical company LEO Pharma claims it has launched the first fixed-combination foam spray for the treatment of plaque psoriasis in the UK. Enstilar foam combines calcipotriene hydrate and betamethasone dipropionate and, according to the company, should be applied once a day for four weeks on patients aged over 18.

LEO Pharma claims that in clinical trials, 81% of patients using Enstilar reported improvements after four weeks, with more than 70% seeing a reduction in itch-related sleep loss.

Professor Chris Griffiths, foundation professor of dermatology at the University of Manchester, said, “Enstilar foam spray represents a welcome new choice of topical therapy for people with plaque psoriasis, particularly those who wish to explore new options with their GP and/or whose next step would be a referral, to consider transitioning to systemic therapy.”

Vida Aesthetics launches Linerase Collagen Booster Aesthetic distributor Vida Aesthetics has introduced the Linerase Collagen Booster to its product offering.

The Linerase Collagen Booster aims to reduce the appearance of wrinkles by regenerating and reconstructing tissues by stimulating the production of new fibroblasts, producing collagen. The treatment comes in the form of a lyophilised collagen powder and is administered through intradermal infiltration injections.

According to the company, Linerase is safe, has no reported side effects, is hypoallergenic and can be used as a body and facial chronological ageing and photoageing treatment.

Acne

FDA approves full prescriptionstrength Differin Gel for overthe-counter acne use Galderma Laboratories has announced that its full prescription-strength Differin Gel has been approved by the FDA for an over-the-counter (OTC) treatment for acne.

According to the company, the approval of Differin Gel (adapalene gel 0.1%) makes it the first and only OTC acne product containing a full prescriptionstrength retinoid and is the first new, FDA-approved active ingredient to be introduced to the OTC acne category in more than 30 years.

“We believe bringing Differin Gel over-the-counter will be a game-changer for consumers and for the acne category,” said Miles Harrison, president and general manager of Galderma Laboratories. “We’re excited to deliver this new level of efficacy without a prescription to consumers. As the research and development leader of medically proven dermatologic solutions, Galderma is proud to announce this innovation will be available for people with skin health needs.”

Skincare

Medik8 introduces new Hydr8 Eye 360 eye cream Global skincare brand Medik8 has added the Hydr8 Eye 360 to its skincare collection. The eye cream features SPF 30, 5-star UVA protection and advanced infrared protection, which aim to help protect the delicate eye area from pigmentation, loss of collagen and the formation of fine lines and wrinkles.

The Hydr8 Eye 360 contains L-carnosine, which is said to fight the glycation process; hesperidin and caffeine, which aim to stimulate microcirculation to improve puffiness and dark circles around the eyes; and antioxidant tetrahexyldecyl ascorbate, which helps to fight UV damage caused by free radicals.

Reproduced from Aesthetics | Volume 3/Issue 9 - August 2016

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Skincare

House of Famuir Beauty launches new products House of Famuir Beauty has introduced the SkinMate Light Mask and MC Cosmetics range to its product offering.

The SkinMate Light LED Mask uses a combination of facial toning and phototherapy to stimulate the deeper skin tissue for facial lift and rejuvenating effects. The mask can be used for a variety of different skin treatments, such as skin rejuvenation and repair, acne and anti-inflammatory treatments. It also has three programmes: Face Lift and Rejuvenation, Promote Lymph Circulation and Relaxing and Massage. Also being launched is MC Cosmetics, a programme that aims to provide bespoke treatments to treat a variety of conditions on the face and body such as ageing skin, localised fat, skin spots, hair loss, flaccid skin, cellulite and stretch marks. The company claims the application of the products cause the cell membrane micropores to temporarily open, allowing for the active ingredients to enter via the epidermis to be absorbed by the body.

Men

Study highlights male body image concerns A study from The University of Sydney has indicated that men are more likely to suffer psychologically when they are dissatisfied with their body image compared to women. The Australian research consisted of 966 males and 1,031 females who provided information about their body dissatisfaction, mental health, physical health-related quality of life and eating disorder symptoms. The results of the research suggested that, for both sexes, increased levels of body dissatisfaction was associated with poorer mental and physical health-related quality of life and great physiological distress. The results also indicated that these associations were more pronounced for males than females.

Lead researcher Dr Scott Griffiths said the stigma associated with males suffering from what tends to be seen as a female problem is concerning, and that their research suggests that men with body image issues are up to four times more likely than females to be undiagnosed.

“Although our data suggests that, overall, the burden of body dissatisfaction is borne disproportionately by females, males with body dissatisfaction may be a particularly high-risk group,” said Dr Griffiths.

He added, “The additional stigma towards men is that they are less masculine by virtue of suffering from a stereotypically female problem.

In addition, men report feeling less worthy if they need to ask for help, and this has been associated, in our research, with an increased likelihood of men with eating disorders remaining undiagnosed – four times more likely in our study.”

Aesthetics

Vital Statistics More than half of acne sufferers have experienced verbal abuse from friends, family and other people they know due to their skin condition (British Skin Foundation, 2015)

19% of US smartphone owners have at least one health app on their phone. Exercise, diet, and weight apps are the most popular types (Pew Internet & American Life Project’s Mobile Health survey, 2012)

The average age someone gets their first tattoo is 21 (YouGov, 2015)

A survey among members of RealSelf.com found that 70% of women claimed to have a more satisfying sex life after breast augmentation (RealSelf, 2012)

Research by Mintel suggests 50% of UK men believe facial skincare products with natural ingredients are better for their skin (Mintel, 2016)

47% of 595 people surveyed said they would trade their life savings to stop hair loss (Survey of 595 International Society of Hair Restoration Surgery (ISHRS) website visitors, 2012)

A study in the US found that only 56% of men know that there’s no such thing as a healthy tan, compared to 76% of women (AAD survey of 1,020 people, 2016)

Reproduced from Aesthetics | Volume 3/Issue 9 - August 2016

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Events diary 17th September 2016 British Association of Cosmetic Nurses Annual Conference and Exhibition, Birmingham www.bacn.org.uk

22nd September 2016 Royal Society of Medicine, Safety and Risk in Healthcare, London www.rsm.ac.uk

24th September 2016 British College of Aesthetic Medicine Conference 2016, London www.bcam.ac.uk

23rd - 25th November 2016 British Association of Plastic Reconstructive and Aesthetic Surgeons Winter Scientific Meeting 2016, London www.bapras.org.uk

3rd December 2016 Aesthetics Awards, London www.aestheticsawards.com

31st March - 1st April 2017 Aesthetics Conference and Exhibition, London www.aestheticsconference.com Submetal fat

Allergan receives ‘positive opinion’ for BELKYRA Global pharmaceutical company Allergan has received a ‘positive opinion’ from the Swedish Medical Products Agency (MPA) for BELKYRA. BELKYRA (deoxycholic acid) – also known as Kybella in the US – is aimed at treating submental fullness. It will be the first prescription medicine to be licensed in Europe for the treatment of a double chin when the presence of submental fat has a psychological impact on the patient. “We are delighted to receive the ‘positive opinion’ from the MPA for BELKYRA, which provides men and women who are bothered by submental fullness with a new minimally-invasive treatment option,” said David Nicholson, chief research and development officer at Allergan. “Because of the extensive evidence behind the product, we see BELKYRA as a breakthrough treatment that will complement other aesthetic treatments.” According to the American Society for Dermatologic Surgery in 2015, fat under the chin/neck topped the list of most troublesome conditions for patients, with 67% reporting being concerned or bothered about the condition.

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Dermal filler

Vida Aesthetics launches iALUGEN ESTEEM Aesthetic supplier Vida Aesthetics has introduced the iALUGEN ESTEEM range to its product offering. iALUGEN ESTEEM is a hyaluronic acid dermal filler that, according to the manufacturers, is obtained by bacterial fermentation and is derived from an advanced cross-linking process of butanediol diglycidyl ether (BDDE) that is below the limit of detection (<50 ppb). The range comes in four different types: iALUGEN Volume, for deep wrinkles, facial contour and volumising; iALUGEN Intense, for deep wrinkles and facial contouring; iALUGEN Global, for facial intermediary wrinkles and lip contouring and iALUGEN Soft, for lip contouring and increasing volume. The filler is manufactured by French Laboratoires Genevrier and is available from Vida Aesthetics.

Supplements

MINERVA Research Labs launches GOLD COLLAGEN RX Aesthetic supplement manufacturer MINERVA Research Labs has launched the GOLD COLLAGEN RX. The new professional supplement is an oral liquid collagen treatment aimed at boosting natural production of collagen, elastin and hyaluronic acid in the dermis, to treat the visible signs of ageing. GOLD COLLAGEN RX has been developed to be used as a standalone antiageing treatment or in conjunction with aesthetic procedures to enhance their effects. MINERVA claims that the new product is a more powerful formulation than the original GOLD COLLAGEN supplement, as it contains advancements such as hydrolysed elastin and astaxanthin. “I’ve spoken to scores of aesthetic practitioners who are looking for a healthy skin partner product they feel confident they can recommend to their patients,” said Dr Martin Godfrey, head of research and development at MINERVA Research Labs. He continued, “To answer this clear need, MINERVA has now developed an innovative product based on the combination of clinically-proven bioactive collagen peptides together with hydrolysed elastin and best in class antioxidants for therapist-only dispensing. We believe this represents a significant breakthrough for patients undergoing cosmetic procedures.”

Industry

Novus Medical to distribute Wontech devices Aesthetic laser supplier Novus Medical has announced it will distribute devices by Wontech in the UK. Wontech produces medical laser and ultrasound HIFU equipment, which Novus Medical believes will perfectly complement its product offerings. “The products are very well made, the whole heritage of their business has been developing research and producing high quality lasers and HIFU equipment,” said director of Novus medical Jim Westwood. He continued, “They have a very nice HIFU technology device for face lifting and they have also developed a HIFU treatment for body contouring, which are extremely good so they have a full range of products.”

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Scarring

Research indicates blunt-blade subcision is effective in acne scar treatment A new study published in Dermatology Surgery indicates that a blunt-blade subcision procedure was effective in treating atrophic acne scars with mild adverse effects. Researchers studied 18 patients with moderate-to-severe bilateral atrophic facial acne scars considered eligible for subcision between September 2012 and March 2013. Local anaesthesia was a tumescent solution of 50ml 1% plain lidocaine, 1ml 0.1% epinephrine, and 10ml 8.4% sodium bicarbonate solution in 1L of normal saline, injected subdermally. A blunt stainless steel subcision blade, in 6cm or 13cm length and 1.5mm width, with gradually narrowing edges and a rounded blunt tip, was used for the subcision. Marked improvement was noted in nine patients (50%) and moderate improvement in six patients (33.3%) within six months of the procedure. Twelve patients (66.7%) reported high satisfaction with results, while five patients (27.8%) reported moderate satisfaction and one patient reported no change.

Psoriasis

FDA advisory committee backs psoriasis treatment brodalumab An FDA-assembled panel has approved brodalumab for adult patients with moderate-to-severe plaque psoriasis. Brodalumab, manufactured by Valeant, is a novel human monoclonal antibody that targets the interleukin-17 receptor.

Valeant CEO Joseph Papa said, “Brodalumab has the potential to improve the lives of many patients suffering from this chronic, debilitating disease.” During clinical trials, six suicides were recorded, and fourteen of the 18 panelists voted for riskmanagement restrictions. The committee were also said to be ‘leaning toward’ a black-box warning – the FDA’s most serious – and a Risk Evaluation and Mitigation Strategies (REMS) programme, although they unanimously agreed that brodalumab was highly effective and that its benefits outweighed its risks. FDA approval will be decided by November 16.

Branding

Survey suggests more than a third of women are not loyal to one cosmetic brand A study by cosmetic surgery company MyBreast has indicated that 41% of women do not have loyalty to one brand of cosmetics. The survey also suggested that 82% of women have changed their makeup brand over the years, with 24% of respondents saying they have changed brand depending on their age. Price came out as the top factor for changing brand (39%), followed by the range of products (29%) and the company’s animal testing policy (14%). Advertising was only chosen by 3% of those surveyed. General manager of MyBreast, Adrian Baxter, said, “People seem more aware of the brands they use these days and are conscious of what they are putting on their skin. It is interesting reading the findings of the survey to see that price and the product range are the top reasons when deciding on the brand of your choice. However, people seem more informed these days and therefore are not so loyal to one particular brand but are willing to try different brands and products depending on their lifestyle changes and choices.”

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Danny Large, managing director of DSL Consulting What’s your industry background?

I started my career in aesthetic sales about six years ago, working for the Consulting Room, where Ron Myers, Martyn Rowe and David Hicks gave me the opportunity to develop and enhance my business skills. Two and a half years ago I decided to establish my own company, offering sales and marketing support to clinics and distributors. I also specialise in event consultancy; helping to set up and run conferences and product-user meetings. I now work with clients that include BTL Aesthetics, the British Association of Cosmetic Nurses and the Association of Scottish Aesthetic Practitioners.

What services does DSL Consulting provide?

DSL Consulting (www.dslconsultingltd.co.uk) offers what I call Simple Solutions, which is a basic sales and marketing strategy that can be incorporated and personalised to any clinic or distribution business. While aesthetic practitioners excel in their clinical skills, they can sometimes find business development more challenging. DSL therefore provides basic level advice on managing a marketing budget and utilising communication strategies, such as using social media and sending e-newsletters. All the marketing protocols we offer are quantifiable, allowing clients to adapt to the methods that work best for their business. We also offer practical sales advice, teaching clinic owners how to effectively sell products and treatments to patients, as well as build valuable and profitable relationships for fututre business development.

How do you support education in aesthetics?

DSL offers a range of services; from organising venue hire and ensuring health and safety protocols are followed, to helping shape agendas and booking exhibitors. Working with clinics and distribution companies ensures we understand the wants and needs of both delegates and exhibitors, allowing us to create a professional, educational event that appeals to everybody.

What’s the future for DSL Consulting?

We want to continue to support the business development of the industry and become an industry leader in sales and marketing services.

Personally, I want to be at the forefront of the growth of the market and help support the safe regulation of aesthetic practice.

This column is written and supported by

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Industry

Wigmore Medical announced as distributor for Viveve Aesthetic distribution company Wigmore Medical has become the exclusive distributor for a new-to-market sexual wellness treatment. Viveve aims to provide a pioneering approach to tightening vaginal tissue post childbirth. The treatment works at a cellular level using patented radiofrequency, which aims to work by cooling and gently heating the vaginal tissue to stimulate the formation of new collagen fibres.

Only one 30-minute treatment is needed and the collagen restoration process is said to take place over time, usually between 30-90 days after the procedure.

An independent, third-party research house, commissioned by Viveve, surveyed more than 400 women to learn more about vaginal laxity affecting women post childbirth. More than half of the women surveyed felt ‘vaginal looseness’ was a concern post childbirth, but only 20% discussed the condition with a medical professional.

Hair removal

Lynton Lasers launches the Duetto MT EVO Aesthetic technology manufacturer Lynton Lasers has introduced a new hair removal system. The Duetto MT EVO is a ‘mixed technology’ laser that delivers two laser wavelengths – alexandrite (755nm) and Long Pulsed Nd:YAG (1064nm). The two wavelengths are aimed at treating fine and fair hairs on all skin types, including tanned skins. Lucy Billane, aesthetician at MediZen clinic, who has been using the device, said, “Having worked with many hair removal systems over the years we feel that the Lynton Duetto MT EVO stands out head and shoulders above the rest. Our clients have been delighted with how quick and comfortable the treatments are and the results have been fantastic even on stubborn, fine hairs.”

Beauty

New study reveals women’s attitudes towards beauty Global research conducted by Allergan suggests that almost half of women think building self-confidence is equally as important as improving sagging skin when seeking aesthetic treatment. The Changing Faces of Beauty: A Global Report, captured the opinions of beauty and ageing from 7,700 women and, according to Allergan, is one of the largest of its kind, including online interviews with women aged 18-65 from 16 different countries. The study suggests that 42% of women would seek treatment to boost their self-confidence, which is the same amount as those seeking it to improve sagging skin. When it comes to injectables, the study suggests that 65% of women agree that facial fillers are more socially acceptable than they were five years ago, and 57% feel they can look natural, but 21% are still concerned about having a ‘frozen’ facial expression. “What is especially exciting about this new research is the discovery that women around the world are united by an increasing desire to control how their looks evolve with time,” said Caroline Van Hove, senior vice president, International Medical Aesthetics at Allergan, adding, “And whether through photography filters, makeup or aesthetic procedures, investing in beauty is their way of positively influencing their image.”

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News in Brief PSA accredits Save Face Save Face has been accredited by The Professional Standards Authority (PSA), allowing for it to be officially recognised by the government as an Accredited Register.

The announcement means that Save Face has met the authority’s standards in governance, setting standards, education and training, managing the register, providing information and complaints handling.

Training academy launches new accredited BTEC laser courses Mapperley Park Aesthetics Training Academy has launched three accredited BTEC qualifications for ‘credible, quality training and development in lasers’. The new courses include: BTEC L4 award, L5 award and L5 Certificate in Laser and Light Therapies. Glenda Bailye-Bray, head of learning and development at the academy, said, “In a continually evolving industry, our suite of courses in laser and injectable training provide practitioners of every level with the training required to be at the forefront of the industry, using the latest technology and techniques.”

Dr Daniel Sister releases PRP textbook Aesthetic practitioner Dr Daniel Sister has released a new book about the use of plateletrich plasma (PRP) in aesthetic treatments.

PRP: Platelet Rich Plasma – a New Frontier in Regenerative and Aesthetic Medicine, by Dr Sister and co-writer Jemma Patton, aims to educate practitioners on PRP. Dr Sister said, “I realised that a multidisciplinary medical textbook would have real value and benefit and I am immensely proud of the result.”

Syneron Candela announces new global brand ambassador World swimming champion and 11-time Olympic medallist Ryan Lochte has become global ambassador for Syneron Candela’s Gentle Laser Hair Removal system.

Amit Meridor, chief executive officer of Syneron Candela said, “Gentle Laser is not only permanently reducing hair, its also fast and virtually painless. When we started working with Ryan, one of the first things he mentioned was how much time he spent shaving. With Gentle Laser Hair Removal, Ryan can spend that time focused on what he does best – swimming.”

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Skincare

BTL Aesthetics launches new academy Aesthetic device manufacturer BTL has launched a new one-day meeting to educate users of their devices. The BTL Academy will incorporate a recap of existing techniques with their BTL Exilis Elite technology, as well as including the latest techniques, advanced protocols and a practical demonstration of the treatment. Speakers at the meeting will include clinical director of BTL International, Tomas Boleslavsky, UK training manager, Jaye Bird and managing director Lee Boulderstone. “This is a very exciting time in BTL,” said Boulderstone, who continued, “with quality trainers such as Tomas Boleslavsky and Jaye Bird, it will be a fantastic day for delegates to learn and develop their skills.” The Academy meeting will take place at the Royal Society of Medicine in London on October 10.

Murad launches Eye Lift Firming Treatment Skincare company Murad has released a new treatment aimed at making eyes look more youthful. The Eye Lift Firming Treatment, the first in the Murad Professional treatment (a range of professional-strength formulas), features surface-filling ‘spheres’ designed to reduce the appearance of fine lines and wrinkles. Ingredients of the product include: encapsulated hyaluronic acid spheres, to attract moisture deep into the skin’s surface; firming polymers and oat kernel extract, to lift and tighten; and vitamin E, myrtle extract, zinc and amino acids to condition the skin. Murad claims results are visible within 10 minutes, but improve with continued use of the product two to three times a week. The treatment is available from September 1.

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The British Association of Dermatologists Annual Meeting, Birmingham Aesthetics reports on the highlights of this year’s annual BAD meeting The International Convention Centre played host to the 96th Annual Meeting of the British Association of Dermatologists (BAD) in Birmingham on July 5-7. What was described by dermatologists and cosmetic dermatologist Dr Simon Zokaie as, “Probably one of the best meetings they have had,” the event consisted of an extensive agenda of dermatology focussed sessions along with aesthetic and cosmetic agendas.

Highlights included the British Dermatology Cosmetic Group ‘facial rejuvenation’ agenda; which discussed how to join the cosmetic and aesthetic industry, with discussions of establishing a clinic and relevant courses, training, learning and development

by Dr Nisith Sheth. Threadlifting for facial rejuvenation was a new topic for the BAD meeting, and was presented by Dr Bav Shergill, who discussed complications and results. Dr Zokaie said, “It seemed like threadlifting was a new thing to talk about at BAD, it’s normally devices like lasers and injectables but it was an excellent presentation.” Dr Sweta Rai presented on the side effects of aesthetic procedures and according to consultant dermatologist Dr Justine Kluk, the presentation, “Gave a very good round-up of the most common complications to be aware of for injectable treatments and body sculpting treatments.”

Skin cancer was also greatly discussed at the meeting, which Dr Zokaie said is important to have on the agenda to educate delegates on the latest advancement and research for melanoma treatments.

Throughout the event several noteworthy studies and research were also presented. Dr Alison Layton’s talk on acne and

antibiotic prescriptions was a popular topic among delegates and discussed her new research, which suggests that patients are exceeding the recommended time of antibiotic use for acne before being referred to a dermatologist. Dr Zokaie said it was, “A hot topic because many practitioners put acne patients on antibiotics for a long time without actually switching them around – it’s important for people to be aware of.”

A talk by Dr Sally Ibbotson discussed daylight photodynamic therapy for treating pre-cancerous skin lesions and suggested that it is as effective as conventional photodynamic therapy, but is much less painful with higher levels of patient satisfaction. Ibbotson discussed research which indicates that the cream that is applied can be effective without the need of exposing the patient to the specific photodynamic therapy lamp, and instead patients can use ordinary daylight exposure, making the treatments easier.

Dr Kluk found this research particularly interesting, explaining that there is potential for this technology to be applied to acne and skin rejuvenation as well as precancerous skin conditions in due course, as has been done with conventional PDT.” The event also included an exhibition, which, according to delegates, had a diverse range of dermatology and cosmetic companies. Speaking about the conference as a whole, Dr Kluk said, “I thought the meeting was absolutely fantastic this year – the topics presented were very relevant. The correct balance was struck between conveying the latest scientific research findings and delivering useful tips and clinical pearls that can be applied directly to patients.”

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The Aesthetics Industry Post-Brexit

Aesthetics speaks to practitioners about how they think the Brexit vote could impact the industry in the UK On June 23, more than 30 million people voted on the UK’s future within the European Union (EU). 1,2 After 52% of these voters opted to leave, many economists have argued that Brexit will have an impact on the British economy, affecting a wide range of industries. In a poll conducted by the Financial Times, economist Panicos Demetriades said, “There is no doubt that Brexit is a factor that will weigh heavily on the prospects of the UK economy and beyond.”3 ‘Remain’ campaigners argued that one of the biggest benefits of staying is the ability to be included in the ‘single market’ allowing for the free movement of goods, services, money and people within the EU.1 Exiting the EU could mean that the UK no longer has access to this, which may impact import prices and EU registration and could also affect the movement of people and information within the industry.3 With a new prime minister in place, Theresa May is likely to soon initiate the process for exiting the EU by invoking Article 50 of the EU Treaty, which allows two years to negotiate the terms of withdrawal.

She said in a statement, “Brexit means Brexit, and we are going to make a success out of it.”5 Since the vote, professionals in all sectors have discussed the potential implications it could have for their industry. So, what are the concerns surrounding the aesthetics industry?

And how do some think that this vote might impact the current UK market?

Trade and currency European import costs and the value of the British Pound have been noted as a significant worry for some UKbased distributors. Lorna Bowes, an independent nurse prescriber and director of AestheticSource, explains, “We have a business model that relies on importing skincare brands from America and Europe – so the immediate effects of ‘out’ will be a really hard hit on our margins due to the value of the

Sterling versus the US Dollar and Euros, so that is my immediate concern.”

Some practitioners are also predicting increased costs, and are worried they might have to pass this on to the consumer. Medical director of Linia Skin Clinic, Dr Simon Zokaie, says, “Products that are manufactured in Europe may increase in price and, because of the current exchange rates, UK distributors may also increase their new stock prices to clinics.” The chair of the British Association of Cosmetic Nurses, Sharon Bennett, says a heightened product price could cause further problems, prompting, “People to look elsewhere for cheaper and potentially substandard products. I hope that the manufacturers here decide that keeping the products competitively priced is of strategic interest to them and we won’t see any change.” Bowes believes this will be the case for many distributors. “From the industry side of aesthetics we have a choice – we either put our prices up, or, as AestheticSource will do, we absorb the margin change ourselves.

I don’t think the practitioners will carry the burden of the costs, I think the distributors and the manufacturers will carry it.”

Registration and cosmetic directive Another major concern being discussed in the industry is the uncertainty surrounding the fate of the European Commission’s (EC) CE Mark and its EU Cosmetic Directive.

Bowes explains, “We have products that are CE Marked and products that are registered

under the EU Cosmetics Directive. Both of these are European law and so, by exiting Europe, we don’t know how we will be affected.” Consultant reconstructive and aesthetic surgeon Mr Dalvi Humzah says, “What’s the point of having a CE Mark if we are not in the EU community? After Brexit the CE Mark could have no standard in the UK and anything produced in the UK is likely to have to conform to a different mark to the EU.” Dr Zokaie adds, “The CE Mark applies to the EU! So this is a concern, what would it mean to us? Will it have any meaning to the UK?” The CE Mark is issued by an authorised third party Notified Body and appears on products to show that it adheres to the EC’s relevant Directives, a form of legislation that sets out requirements that products must meet in order to sell them in Europe.6 Brexit could mean that UK products would not be able to claim automatic entitlement to market medical devices in the EU and would have to go through the same, lengthier process as other countries outside the EU.8 The British Standards Institutions (BSI) is an EU medical devices Notified Body and said in a statement, “We anticipate that products already certified and those certified while the negotiations progress, will continue to be accepted by the EU authorities and member states of the EU.”7 The EU Cosmetic Directive mainly concerns the regulatory framework for market access, international trade relations and regulatory

“I hope that the manufacturers here decide that keeping the products competitively priced is of a strategic interest to them and we won’t see any change” Sharon Bennet, chair of the BACN

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convergence for cosmetic products.9,10 For products coming into the UK, as the UK will no longer be a part of Europe, practitioners are wondering if we will create our own Mark or Directive for companies to sell products in the UK. Bowes says, “This could be a benefit, but I would strongly urge the government, if it is going to have a UK cosmetics directive and our own device registration process, to mirror what we have currently got.”

Information Mr Humzah comments that he is particularly concerned about the impact Brexit will have on the sharing of information, techniques and medical developments between Europe and the UK. He says if there are restrictions on the freedom of movement it may impact the amount of people moving to the UK to set up clinics.

Although many might see this as a positive factor resulting in less competition, Mr Humzah sees it as a negative. “I think this would be a bad thing – we learn from each other by having a lot of people in the UK doing things slightly differently. I think we would lose out by not having them practising in our community.”

Although Bennett agrees, she argues that Brexit may discourage people who are not medically trained from coming to practise in the UK, explaining, “At present, anyone can treat here in the UK, and also any non-medical practitioner can come into the UK and practice who might ordinarily be unable to do so in their own country, where regulations are in place. Without a regulatory body for these individuals, tightening the laws on who can work in the UK could be beneficial to patient safety.”

Aesthetics

Something to think about Although the two-year process for initiating Brexit is yet to begin, 1 practitioners argue that it is important to start considering the potential implications it will have on the aesthetic industry. Bennett says, “The BACN is closely monitoring any future changes that Brexit may have which could impact our members’ future practice. For now, we see no foreseeable significant change in our aesthetic practice and we are working closely with manufacturers, the DoH, MHRA and other stakeholders ensuring we are well informed.” Speaking on the Brexit as a whole, Mr Humzah says, “Whatever our opinions were before the vote, now it’s time for us all to work together to develop a strong aesthetic community that will benefit our patients.”

REFERENCES 1. Wheeler B & Hunt A, ‘The UK’s EU referendum: All you need to know’, BBC, (2016) <http://www.bbc. co.uk/news/uk-politics-32810887> 2. Chris Giles & Emily Cadman ‘Economists’ forecasts: Brexit would damage growth,’ Financial Times, (2016) <https://next.ft.com/content/1a86ab36-afbe-11e5-b955-1a1d298b6250> 3. Irwin G, ‘BREXIT: the impact on the UK and the EU,’ Global Council, (2015) <https://www.global-counsel. co.uk/sites/default/files/special-reports/downloads/Global%20Counsel_Impact_of_Brexit.pdf> 4. BBC Politics, ‘PM-in-waiting Theresa May promises ‘a better Britain’, BBC, (277016) < http://www.bbc. co.uk/news/uk-politics-36768148> 5. Department for Business, Innovation & Skills, CE marking, <https://www.gov.uk/guidance/cemarking#products-that-need-ce-marking> 6. Knobbe Martens Olson & Bear LLP, The Brexit Effect on Medical Devices <http://www.lexology.com/ library/detail.aspx?g=1b80b9f8-35fc-46bc-b694-4fc960dd69e3> 7. British Standards Institutions, EU referendum result, <http://www.bsigroup.com/en-GB/about-bsi/ media-centre/EU-referendum/> 8. European Commission, Cosmetics, (2016) <http://ec.europa.eu/growth/sectors/cosmetics_en> 9. British Standards Institutions, CE Marking and EU Directives, (2016) <http://www.bsigroup.com/en-GB/ our-services/product-certification/ce-mark/ce-mark-frequently-asked-questions/>

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with particles of a foreign matter; which can include pencil led, dirt, sand, grease, paint, grass, metal, gunpowder, wood and asphalt.

The skin then heals over the particles and results in what is known as a traumatic tattoo.4 So with a high and steady demand for tattoo removal in the UK, aesthetic practitioners may be tempted to add this procedure to their clinic’s treatment offering. However knowing where to start, what devices to invest in and how to safely treat patients can be a challenge; which is why, this month, Aesthetics explored these issues with leading professionals in the field.

Tattoo Removal Practitioners discuss how to safely and successfully remove unwanted tattoos Irish-American tattooist Samuel O’Reilly first patented the twin-coil electromagnetic tattoo needle in New York in 1891, paving the way for modern inking and the continued popularity of tattoos.1 In 2015 it was reported that almost one in five (19%) of the UK population now has a tattoo, however 14% of those regret getting inked.2 Based on the UK’s estimated 64.6 million population,3 those figures suggest that there are approximately 1.7 million people living in the UK who are unhappy with their tattoo.

This is not surprising, according to professionals interviewed for this article, who report seeing huge numbers of patients for tattoo removal consultations and treatments on a regular basis. Head of medical education at sk:n, which has 40 clinics nationwide, Lisa Mason, says, “I know that in a year we do about 14,000 treatments; the fact that we don’t convert all consultations to treatments suggests we probably offer around 15,000 consultations a year.”

Group medical director at sk:n, consultant dermatologist Dr Firas Al-Niaimi adds that he personally sees approximately 10-20 tattoo removal requests a week, further highlighting the demand. For Juliette John, a medical micropigmentation specialist who practises in what she describes as a ‘small suburban clinic’ in Ipswich, the demand is equally as high, with 98% of the 2,800 laser tattoo removal consultations offered in her clinic in 2015 going ahead.

Overseas in Israel, board-certified dermatologist and director of the Friedman Skin & Laser Center, Dr David Friedman, also reports that he conducts high numbers of tattoo removal treatments.

He comments that approximately 80% of 200 consultations he conducted last year followed through to treatment; adding, “My patients pay for the consultation and are highly motivated to get treatment; they’ve thought about it, they’ve read about it and done their research. I haven’t experienced buyer’s regret where someone has said they wished they’d thought about it more.”

Reasons for tattoo removal are as expected, with practitioners reporting bad designs, an ex partner’s name and general embarrassment with the artwork of choice being the most common.

Alternatively, some patients request treatment for ‘traumatic tattoos’, which are caused by the forceful penetration of the skin

Consultation “As with any treatment, the most important part of the consultation is setting realistic expectations,” says Dr Friedman, commenting, “People have to understand that although we can usually achieve excellent results, it’s impossible to promise exactly how much of an improvement there will be or whether they will be able to see anything afterwards.” Mason explains that the consultations for tattoo removal at sk:n are the longest of any type of treatments on offer to ensure that patients fully understand the risks, benefits, time and potential cost involved. “We would never treat a patient on the same day as a consultation; we might offer a small test patch on the tattoo on the day and then we would wait at least two weeks before treatment to give them time to think about it. This allows time to have a look at what the test patch looks like and think about the pain aspect of having their tattoo removed,” she says.

During the consultation, practitioners should take a comprehensive medical history to establish any contraindications to treatment such as, amongst others, malignancy, vitiligo, multiple sclerosis, MRSA and certain medications such as Roaccutane.5 John explains, “This drug can cause dermatitis, dryness and heightened skin fragility.”

She adds, “We also don’t treat people who are taking St John’s wort for depression, as this is highly photosensitive and can cause a reaction.6 In addition, patients on blood-thinning medication should consult with their doctor before undergoing treatment.” Other risks to be aware of are discussed later in the article in more detail. John adds that, in her clinic, “After the initial consultation a cooling-off period is a must; a large amount of information has been delivered in a 30-minute consultation and patients may need to adjust to a more realistic expectation of the results that can be achieved.”

Mechanism of action The two main mechanisms which have been proposed in laser tattoo removal are thermal and acoustic,7 which is further supported by a paper from Welch et al.8 GY Ho and Leok Goh outline in the Journal of Cutaneous and Aesthetic Surgery that laser tattoo removal treatment is based on the concept of selective photothermolysis, where laser light of different wavelengths is preferentially absorbed by different chromophores.9 They explain that the target chromophore is heated for no longer than its thermal relaxation time (the time required for the target to lose 50% of its heat), then selective destruction of these chromophores – which, in the case of tattoos, is the exogenous ink – can be achieved. As the tattoo pigment is very small, rapid heating with very short pulse durations – in the nanosecond or picosecond range – is required to cause photoacoustic injury and rupture the ink particles.9 The tattoo pigment is then removed in a process called phagocytosis, where the tattoo fragments are packaged for lymphatic drainage and further scavenged by dermal macrophages, fibroblasts, and mast cells, leading to lightening of the tattoo. Transepidermal elimination accounts for a small fraction of tattoo clearance too.9

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pigments.” John also advocates using the Er:YAG 2940 nm in combination with her Q-switched laser as she claims it boosts pigment clearance, shortens recovery time, helps the skin to repair and evens out texture.

Treating colour As already mentioned, the chromophore that is targeted by the laser is the exogenously-placed ink of a tattoo. Successful destruction of the ink Figure 1: Before and after tattoo removal treatment on Fitzpatrick skin type VI with the PicoWay. will depend upon the application of the correct Images courtesy of Dr David Friedman. wavelength, which is chosen based on the colour Choosing a device of the tattoo, as certain colours have complementary colours that Safe tattoo removal with laser requires the use of a Q-switched device, they absorb. “For example,” explains Dr Al-Niaimi, “green light is best of which there are three types: the Nd:YAG, ruby and alexandrite absorbed by red colour, which is why the best wavelength to treat a lasers which exist in three wavelengths; 532, 755 and 1064 nm. red tattoo is a Q-switched 532 nm.” He continues, “We know black Q-switched lasers produce a very short laser pulse in the nanosecond absorbs all light so, effectively, any of the wavelengths in the visible range; which is widely reported to be a much safer method than lasers spectrum will work. But, because you want to minimise damage to the or IPL systems that emit energy in the millisecond range.10 Dr Al-Niaimi epidermis you try to use a wavelength that is the least absorbed by says, “I am aware of people who have used IPL or long-pulse lasers, the epidermis – this is why we prefer the 1064 nm.” All practitioners which is very dangerous and can increase the risk of scarring, as you interviewed agree that yellow is the most difficult colour to treat, with will deliver the heat for too long for such small ink particles, which will Mason noting that patients may end up with a patchy tattoo if the then diffuse to the surrounding epidermis.” This is supported in the yellow can’t be entirely removed. literature, with reports of incomplete results and scarring.7,9,10,11 Mason notes that practitioners should be aware that patients could More recently, the introduction of picosecond technology has offered have had cover-up tattoos over other tattoos so there may be practitioners an enhanced treatment modality for tattoo removal. Ross competing colours. She says, “You have to remember that you don’t et al8 first compared the use of nanosecond and picosecond lasers always know what colours are making up that ink so if you’re not for the treatment of black tattoos, with all other parameters being getting anywhere with that wavelength then you can test patch on equal, and reported tattoo removal to be more effective with the another area to see how that goes.” She adds, “You should also be picosecond pulse duration. Further studies have since supported this, aware that every colour has a different shade which may effect results; with research confirming the efficacy of the first commercially available some blues can be a dark blue or have a bit of a green tinge, or be picosecond laser in 2013.9 “Picosecond is the new generation more turquoise.” because you get more photomechanical effects because the pulse duration is so short, which is much safer on the dermis and epidermis, Which wavelength for which colour?12 as you’re less likely to generate lots of heat and therefore get quicker and better removal,” says Dr Al-Niaimi. Dr Friedman agrees, noting, “There’s no question in my mind that picosecond technology works magnificently; it’s more efficient [than nanosecond technology] and uses less energy for less side effects and better results.”

Dr Friedman uses the PicoWay picosecond laser from Syneron Candela in his practice. He explains that the device now has fractionated capabilities, produced with the use of an add-on holographic handpiece called Resolve, which uses both 532 nm and 1064 nm wavelengths. In fact, Dr Friedman has recently had success removing a red tattoo on Fitzpatrick skin type VI with the device, which he claims has never been done before (Figure 1).

Dr Al-Niaimi does note, however, that because you are shattering the ink to smaller particles more quickly than a Q-switched laser, most of the results are seen within the first three to five treatments and may begin to plateau after that.

The evolution of picosecond lasers does not mean Q-switched lasers are outdated; Dr Al-Niaimi says that he has a Q-switched Nd:YAG 532 nm to treat red tattoos, a Q-switched 1064 for black tattoos, a Q-switched ruby for green tattoos and picosecond laser for resistant tattoos or those that aren’t fading fast with the Q-switched. John stocks a similar range of Q-switched lasers, preferring to use the Harmony XL Pro platform from ABC Lasers. She says, “The high power Q-switched Nd:YAG 1064 nanometre (nm) laser is great for treating blue-black tattoo inks and micropigmentation pigment, while the 532 nm wavelength is more effective on red, orange and red/brown ink and

• 1064 nm: black inks • 694 nm or 755 nm: blue and green inks • 532 nm: red and warm-toned inks (i.e. browns, oranges, yellows) Treatment Each practitioner interviewed agrees that the first thing to do prior to treatment is examine the patient’s Fitzpatrick skin type and check it is free from infection and inflammation. Although not a contraindication, darker skin should be treated with particular care, as it is more likely to encounter pigment changes. “One of the complications is hypopigmentation,” says Mason, who explains that this is often referred to as ‘ghosting’ because, while the ink may have been removed, the patient is left with a faint outline of the shape. This will of course become more prominent when a patient tans. Dr Friedman then says he decides upon the appropriate pain relief options for the patient, which ranges from cold air to direct intralesional injection with lidocaine. Tattoo removal is notoriously painful, with patients anecdotally reporting it as equal to or sometimes more painful than having the tattoo itself. Dr Friedman comments, “I’d say 80% of people get by with just cold air, 15% use topical anesthetic and 5% get injected.”

Practitioners then choose the appropriate wavelength for the colour of the pigment, as well as a suitable spot size, and then safely begin

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treatment. Choosing a spot size is important, Plexr: an alternative tattoo removal treatment explains Dr Al-Niaimi, noting that if you use a small spot size, you will generate a lot of While the use of laser is regarded as the most common method of removing unwanted concentration of light high in the epidermis, tattoos, a new treatment modality has recently emerged. The Plexr ‘soft surgery’ which can increase the risk of epidermal system utilises the plasma energy generated from the ionisation of atmospheric gas injury. “Therefore, in darker skin, it’s advisable between the Plexr probe and the skin.19 Dr David Jack, who offers Plexr treatments for to use a larger spot size,” he says. Dr facial rejuvenation and tattoo removal to his patients, explains that this injures the skin, Friedman agrees, explaining, in general, “If creating access to the dermis where the tattoo ink is located. A hypertonic dressing is you use a larger spot size you get greater then applied over the tattoo, which influences an osmotic response that aims to soak penetration of the skin using less energy, up the pigment and remove the tattoo. Patients can go home with the dressing and are which is more efficient and more effective.” advised to change it every 24 hours for approximately two days. Dr Jack explains that Following the first session, John explains that the benefit of this treatment method over laser is that it can remove any colour of tattoo. she recommends that patients apply an ice He says,“Because you’re not targeting the pack to the treatment site in order to minimise pigment by virtue of colour, like you are with the risk of blistering and scabbing. She also laser which is targeting a chromophore, any advises patients to avoid smoking, as it may colour of tattoo ink can be removed with inhibit results,13 and to stay out of the sun as it Plexr.” He does note, however, that if the may influence pigmentation changes.10 pigment has been injected very deep into the The amount of treatments needed varies skin, it makes it a lot more difficult to remove Figure 2: Before and after treatment with based on a number of factors, mainly the and laser may be more effective. Treatment Plexr. Images courtesy of Fusion GT. size of the tattoo, the colour(s) of the tattoo usually lasts 30 to 40 minutes and, as with and the level of professionalism as to how laser removal, repeat Plexr treatments are necessary. Dr Jack explains that between it was applied. “The more professional a six and eight treatments are usually needed, with results reviewed monthly, however tattoo, the more difficult it is to remove,” this varies depending on the size of the tattoo and the patient’s satisfaction with results. says Dr Friedman, while Dr Al-Niaimi adds He adds that, anecdotally, the procedure is relatively painless with the use of local that, if professionally applied with a specific anaesthetic blocks, although it may be slightly sore with topical anaesthetic. According machine like a gun, the tattoo may be placed to Dr Jack, prolonged redness is the main side effect that can occur with Plexr treatment. more deeply and have many colours that are He says, “Although it may not be too much of an issue for tattoo removal patients until densely packed so, more difficult to treat. most of the ink has been removed, it is important to be aware of prolonged redness, Mason comments that practitioners at sk:n which is fairly persistent in a small proportion of patients.” Dr Jack also adds that it is usually advise, “Professional tattoos typically essential to undergo thorough Plexr training before offering treatment. need between eight and twelve treatments, depending on the size and colour, however they can take up to 20 sessions.” For amateur tattoos or traumatic time between treatments is more effective, as the ink continues to be tattoos, Mason notes that she has seen these removed in as little as broken down and absorbed during that time,”9 says Mason, adding, four to six sessions. “anecdotally, if you leave at least eight to twelve weeks between The locationw of the tattoo can also be a factor. John says, “Tattoos treatments you still see fading in that time.” Dr Al-Niaimi adds, “Two to on the torso respond well to removal, whereas those on the ankles or four weeks is too short so it’s not advisable.” feet can be more difficult to treat.” It has been suggested that this may be because these areas have a lower vascular supply than other parts Risks and side effects of the body.17 As with all laser procedures, there is a significant risk of side effects In her practice, John uses the Kirby Desai scale to help determine and complications occurring during and after treatment. Most how many sessions a removal will take, which aims to provide a commonly, side effects can include pain, itching, swelling and some good assessment of the anticipated number of treatments needed, bleeding. More serious complications include blistering and crusting, based on the patient’s skin type, the location of the tattoo, the colours, which can lead to dispigmentation and scarring.10 As such, Dr Al-Niaimi 11 amount of ink, scarring and tissue change, and layered tattoos. highlights the importance of taking into consideration the depth All practitioners interviewed agree that the interval between of penetration of the laser wavelength and the interaction of other treatments is ideally relatively long compared to many other chromophores, namely, the melanin in the surface of the skin. He treatments, as you rely on the macrophage clearance, which can take explains, “You want to try and minimise absorption of the laser light many weeks. “There is evidence to suggest that leaving a longer by the melanin in the epidermis because, if that happens, you will heat the epidermis and influence the occurrence of Before After crusting, scabbing or blistering, which can lead to secondary infection with subsequent scarring.” Dr Friedman notes that scarring is not only unsightly, but it can also impede further improvement in the laser removal. Practitioners explain that this unintentional collateral damage to the surrounding skin can also influence pigmentation changes, which are highlighted as a predominant concern. They emphasise that Figure 3: Before and after eight tattoo removal sessions, eight weeks apart, with the Harmony XL Pro. Images courtesy of Juliette John. understanding how different Fitzpatrick skin types will

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appropriate, depending on the location of the tattoo, and is likely to result in a scar.

Adding laser tattoo removal to your clinic offering Before offering laser tattoo removal to patients, practitioners need to ensure they are competent to treat and have Figure 4: Before and after treatment with the Harmony XL Pro. Images courtesy of Juliette John. completed their Core of Knowledge training, in line with the Medicines and respond to wavelengths and how to safely treat is therefore imperative Healthcare products Regulatory Agency’s syllabus.16 Practitioners to successful results. For patients who are likely to tan in between should also ensure they meet the requirements set out by Health treatments, for example, if they are going on holiday, the treatment Education England on qualifications and training, which recommends area should be entirely covered with a good dressing. “If we don’t that practitioners offering tattoo removal treatment with lasers think there is any change of colour when they return, we would treat (excluding treatments within the periorbital rim) should meet the Level them,” says Mason. Another complication that can occur is swelling, 5 requirements, equivalent to a foundation degree level.17 Mason which could happen, for example, if a practitioner attempts to treat the says that practitioners should have a really good understanding of whole circumference of a full-arm sleeve tattoo. “This is a complete no- laser-light tissue interaction, commenting, “If you don’t have that no,” says Mason, explaining, “you can get so much swelling it almost basic knowledge then you don’t have the insight into getting the best results and managing complications.” To conclude, Dr Friedman warns Before After practitioners to ensure they are using the most appropriate device for the tattoo they are treating. He adds, “You need to understand which inks respond to which wavelengths as well as under promise and over deliver to manage patients’ expectations.” Mason adds that practitioners can get really good job satisfaction from removing tattoos, especially if the tattoo may be causing psychological distress to the patient. Considering the continued popularity in people having tattoos, there is a very strong likelihood that there will also be a continued increase in demand for tattoo removal in the UK. And with Figure 5: Before and after 12 treatments with the RevLite. Images courtesy advancements in laser technology progressing steadily, tattoo removal of sk:n. is certainly an interesting skill to consider adding to your repertoire. acts as a tourniquet around the arm so it’s not advisable to treat large REFERENCES tattoos like that in one session.” Another complication, which Mason 1. Jon Henley, The rise and rise of the tattoo, (UK: The Guardian, 2010) https://www.theguardian. com/artanddesign/2010/jul/20/tattoos says is not as common, is that the tattoo becomes blurred following 2. William Jordan, Myth busted: people do NOT regret getting tattoos in later life, (UK: YouGovUK, treatment, as though someone has smudged it. She explains, “We 2015) https://yougov.co.uk/news/2015/07/14/myth-busted-people-do-not-regret-their-tattoos/ 3. Office for National Statistics, Overview of the UK population: February 2016, (UK: Office think it’s because, rather than being shattered, the ink particles move for National Statistics, 2016) <http://www.ons.gov.uk/peoplepopulationandcommunity/ deeper into the dermis. You can usually remove it but it does become populationandmigration/populationestimates/articles/overviewoftheukpopulation/february2016> 4. Tattoo Removal Laser Clinic, Accidental/Traumatic Tattoo Removal, (US: Tattoo Removal Laser more challenging to treat.” Mason adds that practitioners should also Clinic, 2016) <https://www.trlaser.com/services/accidental-tattoo-removal/> find out if the patient had an allergic reaction to ink when they had 5. 14 key factors than affect laser tattoo removal (UK: Andrea Catton Laser Clinic, 2014) <http:// www.andreacatton.co.uk/2014/02/14-factors-affect-laser-tattoo-removal/> the tattoo, as they may have another reaction as the ink is broken up.

6. St. John’s Wort and Depression: In Depth (US: NIH, 2016) <https://nccih.nih.gov/health/ She explains, “We don’t know what the tattooist may have put in their stjohnswort/sjw-and-depression.htm 7. Sardana K et al., ‘Optimising Laser Tattoo Removal’, J Cutan Aesthet Surg, 8 (1) (2015), pp.16-24. ink – most aren’t FDA-approved or approved by any organisation – 8. Welch AJ, Van Gemert MJ., ‘Optical-thermal response of laser-irradiated tissue’, Plenum Press, some inks contain cadmium sulfide [added to help brighten tattoos] or (1995), pp.561-60.

9. Stephanie GY Ho and Chee Leok Goh, ‘Laser Tattoo Removal: A Clinical Article’, J Cutan Aesthet cinnabar [used in greens], which can cause reactions.”18 Surg, 8 (1) (2015), pp.9-15. <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4411606/> Practitioners should also be aware of the risk of paradoxical darkening. 10. Bernstein E, ‘Laser Tattoo Removal’, Seminars in plastic surgery, 21 (2007), pp.175-192. <http:// www.ncbi.nlm.nih.gov/pmc/articles/PMC2884836/> Dr Al-Niaimi explains that cosmetic tattoos, such as eyebrow and 11. Ross V, Naseef G, Lin G, Kelly M, Michaud N, Flotte TJ, Raythen J, Anderson RR., ‘Comparison of lip liner tattoos, tend to have iron or titanium in them, which can responses of tattoos to picosecond and nanosecond Q-switched neodymium: YAG lasers’, Arch Dermatol,134(2) (1998), pp.167-71. oxidise when heated and therefore darken. He says, “You need 12. Why laser wavelengths matter for removing tattoos (US, Astanza, 2016) <http://info.astanzalaser. to do a test spot prior to treatment and gain experience in treating com/blog/why-laser-wavelengths-matter-for-removing-tattoos> 13. How smoking affects tattoo removal success (UK: Sk:n, 2014) <https://www.sknclinics.co.uk/ cosmetic tattoos. They can still be treated but should be done so by about-skn/news-and-blog/blogs/2014/feb/how-smoking-affects-tattoo-removal-success> someone experienced.” Finally, there is of course a risk that results 14. 14 key factors than affect laser tattoo removal (UK: Andrea Catton Laser Clinic, 2014) <http:// www.andreacatton.co.uk/2014/02/14-factors-affect-laser-tattoo-removal/> are unsuccessful. “My advice would be, if you’re not seeing any 15. cinnabar and calcium sulfide improvement at all, you need to stop and rethink what you’re doing,” 16. Gov.uk, Lasers, intense light source systems and LED, (UK, Gov.uk, 2015) <https://www.gov.uk/ government/publications/guidance-on-the-safe-use-of-lasers-intense-light-source-systems-and-leds> says Mason. She adds, “You need to say to the patient, ‘I don’t think 17. HEE, Part One: Qualification requirements for delivery of cosmetic procedures: non-surgical we’re getting anywhere with this’ rather than keep going and getting cosmetic interventions and hair restoration surgery (UK, HEE, 2016) <https://www.hee.nhs.uk/ sites/default/files/documents/HEE%20Cosmetic%20publication%20part%20one%20update%20 nowhere.” She also emphasises the importance of documenting the v1%20final%20version.pdf> conversation you have during the consultation, so you can ensure 18. Tattoo-associated skin reactions (New Zealand: DermNet NZ, 2016) < http://www.dermnetnz.org/ reactions/tattoo-reaction.html> the patient has been told that there are people who do not respond 19. Plexr Soft-Surgery (UK: Dr David Jack, 2016) < http://drdavidjack.com/treatment/plexr-softto treatment. In such cases where patients don’t respond, Mason surgery-blepharoplasty-london/> suggests they can opt for surgical removal, however this is not always

Reproduced from Aesthetics | Volume 3/Issue 9 - August 2016

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Using PDT Aesthetic and dermatology nurse prescriber Anna Baker discusses the literature on topical photodynamic therapy for non-melanoma skin cancer with methyl aminolevulinate (MAL) Introduction Topical photodynamic therapy (PDT) is a widely used non-invasive treatment for certain non-melanoma skin cancers, permitting treatment of large and multiple lesions with a high safety and efficacy profile as well as excellent cosmesis. This paper will allude to the increasing burden of non-melanoma skin cancer, as well as the licensed indications using MAL PDT for treating actinic keratosis, squamous cell in situ (Bowen’s disease), superficial and nodular basal cell carcinoma, and some of the emerging dermatological indications.

Skin cancer prevalence Non-melanoma skin cancer occurs most often on areas of skin that have been exposed to the sun. Whilst skin cancer in England is less common in people living in the most deprived areas,1 around 98,400 cases of non-melanoma skin cancer were registered in 2011 in the UK. Registration is incomplete, however, with an estimated 30-50% of basal cell carcinoma (BCC) and around 30% of squamous cell carcinoma (SCC) going unrecorded.1 Furthermore, approximately 72,100 new cases of non-melanoma skin cancer were reported in the UK in 2013, though it is likely that this underestimates a true incidence.1 Equally, challenging myths on sun exposure and motivating patients to change unhealthy sun behaviour is an important role and responsibility in clinical practice.2 The new NICE guidance on sun exposure, released this year,3 gives evidencebased public information to help prevent skin cancer, and to also ensure the public understand that sensible sunlight exposure is important for vitamin D production.

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the application of a photosensitizing drug to a lesion, which is converted by the haem biosynthetic pathway predominantly to protoporphyrin IX (PpIX) and activated by light of an appropriate wavelength to produce reactive oxygen species, in particular singlet oxygen, which results in apoptosis and necrosis of target tissue.5 PDT can decrease expression of p53, a marker of early skin cancer,6 supporting its preventive indication in carcinogenesis.6 Methyl aminolevulinate 160mg/g MAL (Metvix) cream is licensed for thin, non-hyperkeratotic actinic keratoses (AKs), Bowen’s disease (BD), superficial and nodular BCCs (sBCC & nBCC),8 and is supported by NICE interventional procedure guidance (IPG155).7 MAL is contraindicated in individuals with a hypersensitivity or allergy to arachis oil, soya, as well as those with a history of porphyria.8 It is not indicated for treatment of morpheaform basal cell carcinoma.8 AKs require one treatment, followed by specialist review at three months,4 whereas BD, sBCC and nBCC require two treatments with a seven-day interval and subsequent specialist review at three months.4 Prior to topical application of MAL to the affected lesion/area, it is necessary to remove overlying scales and crusts from the lesion and to slightly roughen the surface to enhance penetration of the photosensitizer.9 This can be performed with a ring curette or scalpel in a manner insufficient to cause pain and thus not requiring local anaesthesia.9 MAL is applied to a depth of approximately 1mm thickness and surrounding 5/10mm of skin, which is then covered with an occlusive dressing and photo-protective dressing for three hours. This is to prevent exposure to ambient light during the three-hour incubation period, which may lead to increased activation of PpIX superficially, and potentially reducing deeper photosensitizer penetration before photoactivation.10 The dressings are then removed and the lesion cleaned with saline. The use of a Wood’s lamp following the three-hour application time of the photosensitizer can assist in delineating the boundaries of the lesion by demonstrating photofluoresence; this also indicates the level of uptake of MAL in the lesion, which can be visualised as a coral pink appearance.11 The lesion is then subjected to red narrowband, which matches the 630/635nm activation peak of PpIX with improved tissue penetration9 to provide a total dose of 37j/cm2. A Wood’s lamp may also be utilised at the end of illumination to assess the extent of photobleaching, (which occurs when MAL has been taken up during the illumination phase of treatment).10 Tyrrell et al (2010) indicate that the extent of

Approximately 72,100 new cases of non-melanoma skin cancer were reported in the UK in 2013

MAL topical photodynamic therapy PDT for dermatological indications was first described more than 20 years ago.4 Topical photodynamic therapy involves

Reproduced from Aesthetics | Volume 3/Issue 9 - August 2016

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photobleaching during PDT, as opposed to photofluoresence, is predictive of the level of lesion clearance.11 Pain and burning sensation during the illumination component of PDT is widely reported in the literature.10,12 The sensation can widely vary in intensity and can be influenced by a number of factors, including skin type and anatomical location, as well as the size of lesion (isolated or large area).10,12 The mechanism behind the discomfort with MAL PDT has not been definitively proven and it has been hypothesised that possible nerve stimulation and/or tissue damage by reactive oxygen species may be the principle cause.13,14 In addition, the second treatment of a two-therapy cycle may be more uncomfortable.15 A number of studies analysing the benefit of topical anaesthetics (tetracaine gel and morphine gel) have not been shown to reduce pain significantly during PDT.16,17,18 Cold-air analgesia and cool water spray are frequently adopted to minimise discomfort during illumination,10,19 as well as nerve blocks for large field treatments.20 Erythema and oedema are common post PDT, with crust formation and healing taking place between two to six weeks following treatment,10 with localised sensitivity that can persist for up to 48 hours post treatment and MAL-induced PpIX clearing from normal skin within 24-48 hours.21 Actinic keratosis AKs are keratotic lesions occurring on chronically light-exposed adult skin.22 They represent focal areas of abnormal keratinocyte proliferation and differentiation that carry a low risk of progression to invasive SCC.23 A spectrum of histology can be seen but the poignant feature of an AK is epithelial dysplasia, which may be restricted to the basal layer or may extend to full-thickness atypia, at which point differentiation from BD can be difficult.12 Histological variants of AK have been described, including hypertrophic, bowenoid, Iichenoid, acantholytic and pigmented.22 AKs are widely considered to be premalignant lesions with low individual potential for invasive malignancy and higher potential for spontaneous regression.24 They present as discrete, sometimes confluent, patches of erythema and scaling on predominantly sun-exposed skin, usually in middle-aged and elderly individuals, and may be

Efficacy for PDT on acral sites has been shown to be reduced by approximately 10% for face/scalp lesions

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single or multiple in presentation. Chronic exposure to ultraviolet light induces mutations in key genes associated with skin cancer formation, including p53 and deletion of the gene coding for p16 tumour suppressor protein.25 In addition, UV light also causes immunosuppression which appears to increase human papilloma virus (HPV) expression.1 Organ transplant recipients as well as those who have been exposed to arsenic are also at a higher risk of developing AKs.26 Diagnosis of AKs is frequently made on clinical appearance alone, but as the differential diagnosis can include superficial BCC, BD, as well as SCC, a skin biopsy should be performed in cases where there is clinical doubt or suspicion of invasive malignancy.27 Current European consensus endorses PDT as effective for both lesion and field directed treatment for AKs and suggests that PDT has an especially useful role where AKs are multiple or confluent, at sites of poor healing, or where there has been a poor response to topical therapies.22 Serra-Guillen et al, (2011) undertook a randomised comparison of patient tolerance to MAL-PDT against topical imiquimod for multiple face/scalp AKs and concluded that a significantly higher level of satisfaction was observed following PDT.28 In addition, a large randomised intraindividual study of face/scalp AKs of 199 patients compared MAL PDT with cryotherapy, which demonstrated that PDT cleared more lesions following the first cycle (87% vs. 76%), but with equivalent outcome after non-responders were retreated (89% vs. 86%).29 Efficacy for PDT on acral sites has been shown to be reduced by approximately 10% for face/scalp lesions, potentially due to a higher proportion of less-responsive thicker lesions on these sites.10 Skin field cancerization, the presence of multiple non-melanoma skin cancers, AK, dysplastic keratinocytes in sunexposed areas, reflects the presence of multilocular clinical and subclinical cancerous lesions.10 Field therapies, including PDT, are most appropriate for treating field cancerization.19 A growing body of current literature reinforces the safety and efficacy of MAL daylight PDT, licensed for thin and non-hyperkeratotic AKs.30 This licensed clinical protocol utilises daylight to activate PpIX instead of narrowband red light. Following at 24-week randomised, controlled, investigator-blinded study comprising 100 subjects, Rubel et al., (2015) concluded that daylight-mediated PDT was not inferior in efficacy to MAL PDT, better tolerated, nearly painless and more convenient for patients.31 Consensus literature concludes that in view of the reduced accumulation of protoporphyrin IX (PpIX), this results in a significantly lower incidence of pain.31 Superficial and nodular basal cell carcinoma Basal cell carcinoma is a slow-growing, locally invasive malignant epidermal skin tumour which frequently affects Caucasians.32 The tumour infiltrates in a three-dimensional manner, through an irregular growth of subclinical finger-like outgrowths which remain contiguous with the tumour mass.33,34 Metastasis is rare, and morbidity results from local tissue invasion and destruction, particularly on the face, head and neck.35 Clinical appearances and morphology are diverse, and include nodular, cystic, superficial, morphoeic (sclerosing), keratotic and pigmented variants.32 Common histological subtypes include nodular (nBCC), superficial (sBCC) and pigmented forms, in addition to morphoeic, micronodular, infiltrative and basosquamous variants, which are particularly associated with aggressive tissue invasion and destruction.36 In the context of the licensed indications for MAL PDT, nBCC and sBCC will be the focus of this paper.

Reproduced from Aesthetics | Volume 3/Issue 9 - August 2016

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Chronic exposure to ultraviolet light induces mutations in key genes associated with skin cancer formation

BCC is the most common cancer in Europe, Australia and the US, and is showing a worldwide increase in incidence.32,10 Inconsistent data collection does not allow for accurate figures pertaining to the incidence of BCC in the UK.32 The age shift in the population has been accompanied by an increase in the total number of skin cancers, with a continued rise in tumour incidence predicted up to the year 2040.37 The most significant aetiological factors appear to be genetic predisposition and exposure to ultraviolet radiation.9 The sun-exposed areas of the head and neck are the most commonly involved sites.33 Sun exposure in childhood may be particularly relevant and increasing age, male sex, fair skin types (Fitzpatrick I and II), immunosuppression and arsenic exposure are other recognised risk factors, as well as a diet with a high fat intake.38,39 Multiple BCCs are a feature of basal cell naevus (Gorlinâ&#x20AC;&#x2122;s) syndrome.34 Following development of a BCC, patients are at a higher risk of developing subsequent BCCs at other sites.32 Clearance rates are reported as 92-97% for sBCC when treated with MAL PDT,10,40 with recurrence rates reported at 9% during the first year following two cycles of treatment.40 Clearance at three months of 91% of primary nBCC following MAL PDT is reported with 76% clearance consistent at five years.10 Comparison of MAL PDT with cryotherapy for sBCC were achieved with 96% clearance, with superior cosmesis to cryotherapy.10 MAL PDT was equivalent to surgery (92% vs. 99%) initial clearance, and 0% recurrences at one year for sBCC, but inferior to surgery for nBCC when recurrence rates were compared (91% vs. 98% initial clearance, 14% and 4% recurrences at five years).40 Cosmetic outcome was superior following PDT compared with surgery.10 Topical PDT is best considered for nodular lesions where surgical excision is relatively contraindicated, or where patient preference, reflecting past therapy history, comorbidities and/or cosmetic considerations result in a willingness to accept higher risk of recurrence.10 It is currently recommended that patients receiving topical PDT for nodular BCC are reviewed for evidence of recurrence for at least one year.10 Squamous cell in situ (Bowenâ&#x20AC;&#x2122;s disease) BD is a form of intraepidermal (in situ) SCC, originally described in 1912.41 It clinically presents as a gradually enlarging, well demarcated, erythematous and hyperkeratotic plaque with an irregular border,42 characterised by full-thickness epidermal dysplasia on histology.9 An annual incidence of 15 per 100,000

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has been suggested in the UK; which has been previously based on US data, which may reflect a higher incidence due to greater sun exposure.9 In the UK, the peak age group for BD is the 70th decade, with approximately 75% of cases occurring on the lower leg predominantly in women (70-85% of cases).42,43 More recent data indicates the most commonly affected sites are the head and neck (29-54%).44,45 Lesions are usually solitary but are multiple in approximately 10-20% of patients.46 Less common sites or variants include pigmented BD, subungual/periungual, palmar, genital, perianal and verrucous SCC in situ.42 In cases of clinical diagnostic doubt, a punch biopsy can be performed to establish the full thickness of the epidermis and dermis to ascertain the presence of any invasive disease amounting to a cutaneous SCC.9 Aetiological factors of BD include: irradiation (ultraviolet radiation, solar iatrogenic and sunbeds) and radiotherapy, carcinogens (arsenic), immunosuppression (particularly therapeutic), viral (there is an association between human papillomavirus HPV, especially HPV16, and the development of anogenital SCC in situ).9 Current literature indicates clearance of 86-93% of BD lesions, three months beyond two cycles of MAL PDT using red-light, with sustained clearance at 24 months of 68-71%, equivalent to conventional therapy, but with superior cosmesis.9,10 Therapy guidelines recommend PDT as the treatment of choice for both large and small plaques of BD on poor healing sites, representing the majority of lesions, and a good choice for larger lesions in good-healing sites.9 Novel indications PDT has been studied extensively in acne, yet a consensus protocol has yet to be determined. Follicular obstruction and congestion may be reduced by enhanced epidermal turnover promoted by PDT.10 Propionibacterium acnes (p.acnes) naturally produce small amounts of endogenous porphyrins47 yet, the literature is mixed in determining a consistent reduction, or temporary reduction in p.acnes following PDT. A decrease in sebum excretion has been more consistently noted.47 Red light has been shown to possess greater potential in sebaceous gland destruction, when compared to blue and pulsed light, but treatment was noted to be more painful using a conventional MAL protocol of a three-hour application time.12 A growing number of studies increasingly acknowledge the potential photorejuvenation component of PDT, with findings indicating observed improvement in fine wrinkles, mottled hyperpigmentation, roughness and sallowness, as well as upregulation of collagen production and increased epidermal proliferation.48,49 Conclusion The current license(s) for MAL PDT only extend to the indications previously discussed; it is not recommended for thick/nodular BCC or SCC. Treatment is contraindicated for morpheaform BCC, porphyria and in individuals with a peanut allergy due to the arachis oil. PDT is most efficacious in lesions that have been well prepared with excess keratin removed/softened to allow for optimum absorption of MAL. MAL topical PDT provides a safe and efficacious treatment modality for certain non-melanoma skin cancers. The procedure can be repeated as often as required and may be especially suitable for patients with large areas/field cancerization. The novel and licensed indications discussed are by no means exhaustive and continue to expand, demonstrating the evolving potential for this innovative treatment. The future is bright for topical PDT!

Reproduced from Aesthetics | Volume 3/Issue 9 - August 2016

@aestheticsgroup Anna Baker is a dermatology and cosmetic nurse practitioner, running nurse-led Topical PDT clinics for Galderma UK in conjunction with Ashfield Clinical. She works alongside Mr Dalvi Humzah as the coordinator and assistant tutor for Facial Anatomy Teaching.

Baker has a post-graduate certificate in applied clinical anatomy, specialising in head and neck anatomy.

REFERENCES 1. Skin cancer incidence statistics (UK: Cancer Research UK, 2016) <www.cancerresearchuk.org/ health-professional/cancer-statistics-by-cancer/typeskin-cancer> 2. Thompson A., Onselen J.V., ‘A Summary of new NICE Guidance on Sunlight Exposure: Encouraging Behavioural Change in Photoprotection’, Dermatological Nursing 15(2) (2016) Supp:s10-s13.

3. National Institute for Health and Care Excellence-Sunlight exposure: risks and benefits. NICE guidance NG34 (2016) <www.nice.org.uk/guidance/lifestyle-and-wellbeing/sunlight-exposure> 4. Morton C.A., Szeimies R.M., Sidoroff A., Braathen L.R., ‘European guidelines for topical photodynamic therapy part 1: treatment delivery and current indications-actinic keratosis, Bowen’s disease, basal cell carcinoma’, Journal of the European Academy of Dermatology and Venereology, 27(5) (2012), pp.536-544.

5. Kennedy J.C., Pottier R.H., Pross D.C., ‘Photodynamic therapy with endogenous protoporphyrin IX: basic principles and present clinical experience’, J Photochem Photobiol, 6 (1990), pp.143-148.

6. Bagazgoitia L., Cuevas Santos J., Juarranz A., Jaen P., ‘Photodynamic therapy reduces the histologic features of actinic damage and the expression of early oncogenic markers’, British Journal of Dermatology, 165 (2011), pp.144-145.

7. Photodynamic therapy for non-melanoma skin tumours (including premalignant and primary non-metastatic skin lesions) (UK: NICE, 2016) <https://www.nice.org.uk/guidance/IPG155/ chapter/2-The-procedure> 8. Metvix 160 mg/g cream (UK: emc, 2016) <https://www.medicines.org.uk/emc/medicine/11913> 9. Morton C.A., Birnie A.J., Eedy D.J., ‘British Association of Dermatologists’ guidelines for the management of squamous cell carcinoma in situ (Bowen’s disease) 2014’, British Journal of Dermatology, 170 (2014), pp.245-260.

10. Morton C.A., Szeimies R.M., Sidoroff A., Braathen L.R., ‘European guidelines for topical photodynamic therapy part 2: emerging indications-field cancerization, photorejuvenation and inflammatory/infective dermatoses’, Journal of the European Academy of Dermatology and Venereology, 27(6) (2012), pp.672-679.

11. Tyrrell J.S., Campbell S.M., Curnow A., ‘The relationship between protoporphyrin IX photobleaching during real-time dermatological methyl aminolevulinate photodynamic therapy (MAL-PDT) and subsequent clinical outcome’, Lasers Surg Med, 42 (2010), pp.613-619.

12. Braathen L. R., Szeimies R.M., Basset-Seguin N., Bissonette R., Foley P., Pariser D., Roelandts R., Wennberg A.M., Morton C., ‘Guidelines on the use of photodynamic therapy for nonmelanoma skin cancer: An international consensus’, J Am Acad Derm 56(1) (2007), pp.125-143.

13. Grapengiesser S., Ericson M., Gudmondsson F., ‘Pain caused by photodynamic therapy of skin cancer’, Clin Exp Dermatol, 27 (2002), pp.493-497.

14. Sandberg C., Stenquist B., Rosdahl I., ‘Important factors for pain during photodynamic therapy for actinic keratosis’, Acta Derm Venereol, 86 (2006), pp.404-408.

15. Arits A., Van De Weert M., Nelemans P., Kelleners-Smeets N., ‘Pain during topical photodynamic therapy: uncomfortable and unpredictable’, Journal of The European Academy of Dermatology and Venereology, 24 (2010), pp.1452-1457.

16. Holmes M., Dawe R.S., Ferguson J., Ibbotson S.H., ‘A randomized, double-blind, placebocontrolled study of the efficacy of tetracaine gel (Ametop) for pain relief during topical photodynamic therapy’, British Journal of Dermatology, 150 (2004), pp.337-340.

17. Langan S.M., Collins P., ‘Randomized, double-blind, placebo-controlled prospective study of the efficacy of topical anaesthesia with a eutectic mixture of lignocaine 2.5% and prilocaine 2.5% for topical 5-aminoleluvinic acid-photodynamic therapy for extensive scalp actinic keratosis’, British Journal of Dermatology, 154 (2006), pp.146-149.

18. Skiveren J., Haedersal M., Philipsen P.A., ‘Morphine gel 0.3% does not relieve pain during topical photodynamic therapy: a randomized controlled double-blind, placebo controlled study’, Acta Derm Venereol, 86 (2006), pp.409-411.

19. Braathen L.R., Morton C.A., Basset-Seguin N., Bissonnette R., Gerritsen M.J., Gilaberte Y., Calzavara-Pinton P., Sidoroff A., Wulf H.C., Sziemies R.M., ‘Photodynamic therapy for skin field cancerization: an international consensus. International Society for Photodynamic Therapy in Dermatology’, Journal of the European Academy of Dermatology and Venereology, 26(9) (2012), pp.1063-1066.

20. Halldin C.B., Paoli J., Sandberg C., Gonzalez H., Wennberg A.M., ‘Nerve blocks enable adequate pain relief during topical photodynamic therapy of field cancerization on the forehead and scalp’, British Journal of Dermatology, 160 (2009), pp.795-800.

21. Angell-Peterson E., Christensen C., Mullet C.R., Warloe T., ‘Phototoxic reaction and porphyrin fluorescence in skin after topical application of methyl aminolevulinate’, British Journal of Dermatology, 156 (2006), pp.301-307.

22. De Berker D., McGregor J., Hughes B.R., ‘Guidelines for the management of actinic keratosis’, British Journal of Dermatology, 156 (2007), pp.222-230.

23. Salasche S.J., ‘Epidemiology of actinic keratosis and squamous cell carcinoma’, J Am Acad Dermatol, 42(1 pt 1) (2000), pp.4-7.

24. Callen J.P., Bickers D.R., Moy R.L., ‘Actinic keratoses’, J Am Acad Dermatol. 36 (1997) pp.650-653.

25. Nelson M.A., Einsphar J.G., Alberts D.S., Balfour C.A. Wymer J.A., Welch K.L., ‘Analysis of the p53 gene in human precancerous actinic keratosis lesions and squamous cell cancers’, Cancer Lett, 85(1) (1994), pp.23-29.

26. Ormerod A.D., Recommendations in British Association of Dermatologists guidelines, (2005).

27. Feldman S.R., Fleischer A.B., ‘Progression of actinic keratosis to squamous cell carcinoma revisited: clinical and treatment implications’, Cutis 87(4) (2011), pp.201-207.

28. Serra-Guillen C., Nagore E., Hueso L., ‘A randomized comparative study of tolerance and satisfaction in the treatment of actinic keratosis of the face and scalp between 5% imiquimod cream and photodynamic therapy with methyl aminolevulinate’, British Journal of Dermatology, 164 (2011), pp.429-433.

29. Morton C., Campbell S., Gupta G., ‘Intraindividual, right-left comparison of topical methyl aminolevulinate-photodynamic therapy and cryotherapy in subjects with actinic keratoses: a multicentre, randomized controlled centre study’, British journal of Dermatology, 155 (2008), pp.1029-1036.

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30. Morton C.A., Wulf H.C., Szeimies R.M., Gilaberte Y., Basset-Seguin N., Sotirou E., Piaserico S., Hunger R.E., Baharlou S., Sidoroff A., Braathen L.R., ‘Practical approach to the use of daylight photodynamic therapy with topical methyl aminolevulinate for actinic keratosis: a European consensus’, Journal of the European Academy of Dermatology and Venereology, 29(9) (2015), pp.1718-1723.

31. Rubel D.M., Spelman L., Murrell D.F., See J.A., Hewitt D., Foley P., Bosc C., Kerob D., Kerrouche N., Wulf H.C., Shumack S., ‘Daylight photodynamic therapy with methyl aminolevulinate cream as a convenient, similarly effective, nearly painless alternative to conventional photodynamic therapy in actinic keratosis treatment: a randomized controlled trial’, British Journal of Dermatology, 171 (2015), pp.1164-1171.

32. Telfer N.R., Colver G.B., Morton C.A., ‘Guidelines for the management of basal cell carcinoma’, British Journal of Dermatology, 159 (2008), pp.35-48.

33. Diffey B.L., Langtry J.A., ‘Skin cancer incidence and the ageing population’, British Journal of Dermatology, 153 (2005), pp.679-680.

34. Braun R.P., Klumb F., Giard C., ‘Three-dimensional reconstruction of basal cell carcinomas’, Dermatol Surg, 31 (2005), pp.562-566.

35. Randle H.W., ‘Basal cell carcinoma: identification and treatment of the high risk patient’, Dermatol Surg, 22 (1996), pp.255-261.

36. Motley R.J., Gould D.J., Douglas W.S., Simpson N.B., ‘Treatment of basal cell carcinoma by dermatologists in the United Kingdom. British Association of Dermatologists Audit Subcommittee and the British Society for Dermatological Surgery’, British Journal of Dermatology. 132 (1995), pp.437-440.

37. Goodwin R.G., Holme S.A., Roberts D.L., ‘Variations in registration of skin cancer in the United Kingdom’, Clin Exp Dermatol, 29 (2004), pp.328-330.

38. Zak-Prelich M., Narbutt J., Sysa-Jedrzejowska A., ‘Environmental risk factors predisposing to the development of basal cell carcinoma’, Dermatol Surg, 30 (2004), pp.248-252.

39. Kuijpers D.I., Thissen M.R., Neumann M.H., ‘Basal cell carcinoma: treatment options and prognosis, a scientific approach to a common malignancy’, Am J Clin Dermatol, 3 (2002), pp.247259.

40. Szeimies R., Ibbotson S., Murrell D., ‘A clinical study comparing methyl aminolevulinate photodynamic therapy and surgery in small superficial basal cell carcinoma (8-20mm), with a 12 month follow-up’, Journal of European Academy of Dermatology and Venereology, 22 (2008), pp.1302-1311.

41. Bowen J.T., ‘Precancerous dermatoses: a study of two cases of chronically atypical epithelial proliferation’, J Cutan Dis 30 (1912), pp.241-255.

42. Cox N.H., Eedy D.J., Morton C.A., ‘Guidelines for management of Bowen’s disease: 2006 update’, (2006).

43. Arlette J.P, ‘Treatment of Bowen’s disease and erythroplasia of Queryat’, British Journal of Dermatology, 149(Suppl. 1) (2003), pp.13-15.

44. Hansen J.P., Drake A.L., Walling H.W., ‘Bowen’s disease: a four-year retrospective review of epidemiology and treatment at a university centre’, Dermatol Surg, 34 (2008), pp.878-883.

45. Leibovitch I., Huilgol S.C., Selva D., ‘Cutaneous squamous carcinoma in situ (Bowen’s disease): treatment with Mohs micrographic surgery’, J Am Acad Dermatol, 52 (2005), pp.997-1002.

46. Bell H.K., Rhodes L.E., ‘Bowen’s disease-a retrospective review of clinical management’, Clin Exp Dermatol, 24 (1999), pp.338-339.

47. Sakamoto F.H., Lopes J.D., Anderson R.R., ‘Photodynamic therapy for acne vulgaris: a critical overview from basics to clinical practice Part I Acne: when and why consider photodynamic therapy?’, J Am Acad Dermatol, 63 (2010), pp.195-211.

48. Kohl E., Torezan L.A.R., Landthaler M., Sziemies R.M., ‘Aesthetic effects of topical photodynamic therapy’, Journal of the European Academy of Dermatology and Venereology, 24 (2010), pp.1261-1269.

49. Dover J., Bhatia A.C., Stewart B., Arndt K.A., ‘Topical 5-aminolevulinic acid combined with intense pulsed light in the treatment of photoaging’, Arch Dermatol, 141 (2005), pp.1247-1252.

Reproduced from Aesthetics | Volume 3/Issue 9 - August 2016

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Treating seborrhoeic keratoses As the lesions are not cancerous and cause no symptoms, there is no immediate need for treatment or removal. However, most people dislike them as they can be unsightly, can itch, catch on jewellery and bleed if scratched or knocked.

Historically seborrhoeic keratoses were treated using several methods, including: 8

Treating Seborrhoeic Keratoses Aesthetic nurse prescriber Mary White discusses her methods of successfully treating seborrhoeic keratosis with long pulsed alexandrite lasers I have noticed that patients complaining about seborrhoeic keratoses and requesting removal are becoming more frequent in aesthetic and laser clinics today. I believe this is due to more historic sun damage. Years ago, being tanned was considered to be a sign of ‘lower class’ as it meant you were an outside/manual worker.

During the 60s and 70s, celebrities like Coco Chanel made foreign travel and suntans popular, and people started to consider that being tanned was now a desirable feature. I believe we are now seeing the damage that was done decades ago, when sun protection was not widely used. Whilst seborrhoeic keratoses can occur in areas of the body that have not been exposed to sun damage, they are more commonly seen in patients who have a long history of sun exposure, and are less common in patients with Fitzpatrick skin types IV-VI.1 Diagnosis Seborrhoeic keratoses are sometimes referred to as basal cell papillomas, seborrhoeic warts, or senile warts, which are all misnomers as their etiology is not from the wart virus, human papillomavirus (HPV) 2,3 and they are becoming far more prevalent in younger generations. For example, a study of a British population found that seborrhoeic keratoses were present in people younger than 40 years (males,

• cryotherapy – freezing them with liquid nitrogen • electrocautery – burning the lesion using an electric current • curettage – a shave excision, typically performed under local anaesthetic These methods successfully remove the lesions, but are no longer funded on the NHS as they are considered to be cosmetic and usually cause some form of scarring or hypopigmentation.8 The advent of advances in technology with medical lasers means treating seborrhoeic keratoses is now commonplace in many aesthetic and laser clinics. Lasers are useful in treating this condition because the principle of selective photothermolysis makes the incidence of scarring less likely with lasers, as opposed to the other methods, which are non selective and work by ablation.

8.3% and females, 16.7%).2 Seborrhoeic keratoses are warty in appearance, which aids their diagnosis in clinic. Usually raised and sometimes crusty and proliferated, they are similar to a scab or wart/verruca, and their colour varies from very light tan to dark brown and sometimes almost black. They Using laser for destructive therapy of are usually round or oval and symmetrical seborrhoeic keratoses and can vary in size and diameter with some All lasers have unique characteristics, which larger ones growing to more than 2cm determine the outcome of treatment, what wide.4 Seborrhoeic keratosis is a build up condition a specific laser can effectively of keratinocytes (ordinary skin cells). In the treat, and how the laser light interacts UK by the age of 40, 30% of the population with the target and influences the clinical is affected by seborrhoeic keratosis, while outcome. Most lasers that can effectively by the age of 70 this number increases treat seborrhoeic keratoses fall into the to 75%. They are not infectious and do visible range (range that is possible to see not become malignant.7 The diagnosis with the human eye) of the electromagnetic of seborrhoeic keratoses must not be spectrum, as they are epidermal lesions. confused with anything more sinister. Whilst Lasers in the visible range that are used they are classed as benign skin tumours, they can also be present in association with other skin conditions, typically basal cell carcinoma.6 The differential diagnosis is melanoma, although they are not related to melanoma, and this must not be excluded at consultation and diagnosis. The gold standard of diagnosis is achieved following a biopsy of the Figure 1: Patient with untreated seborrhoeic keratoses lesion.6

Reproduced from Aesthetics | Volume 3/Issue 9 - August 2016

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to treat these lesions include pulsed dye lasers, long pulsed alexandrite, Argon, KTP and Q-switched ruby.

Other lasers that can be used are erbium:YAG (Er:YAG) and carbon dioxide (CO2). These are not in the visible range but are infrared (IR). Er:YAG is near IR and CO2 is far IR. Near IR means it has a lower wavelength to the visible spectrum, such as 750-900nm. Far IR means it is further away from the visible spectrum, such as 1000-1400nm. They are ablative lasers that vapourise tissue and are useful for destructive therapy of many dermatological lesions.9 When lasers are used in dermatology, it is on the theory of selective photothermolysis, which states that in order to destroy a selected target, while sparing the surrounding tissue, three basic parameters are necessary.10 First of all, the colour of laser light (wavelength) chosen must be one that is absorbed by the target and poorly absorbed by the surrounding tissue. This spares the surrounding tissue from being damaged at the same time by the laser. Secondly, the length of time that the laser beam interacts with the target, that is the pulse duration, must be long enough to destroy the target and is determined by the size of the target.

And finally, in order to destroy or alter the target, it must be heated to a high enough temperature to cause permanent damage to that target. Therefore, enough energy must be applied and absorbed for an effective temperature rise.10 Unless you are using the IR lasers for ablation and vapourising, the chromophore (target) for treatment is melanin. Melanin is well absorbed by wavelengths in the visible range of the electromagnetic spectrum.10 Care must be taken when using laser that the competing chromophore of melanin in the surrounding â&#x20AC;&#x2DC;normalâ&#x20AC;&#x2122; tissue is unaffected.

Another influencing factor when choosing a laser to treat seborrhoeic keratoses is the depth of penetration of the laser into tissue.

This is dependent upon the wavelength

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of the laser and also the spot size, with larger spot sizes penetrating deeper than smaller ones.10 As seborrhoeic keratoses are epidermal lesions, the clinical endpoint of treatment is the destruction of the lesion.

A spot size must be selected that does not penetrate too deeply into tissue, but also must be large enough to make the treatment practical, as some of the lesions can grow to be large.4 Different lasers have different pulse durations. Pulse duration is the amount of time over which the laser pulse is delivered into the chromophore, in this case the melanin in the epidermis. In order for laser treatment to be effective, the pulse duration must be selected in consideration with the thermal relaxation time (TRT) of the chromophore. The pulse duration must be shorter than the TRT of melanin, but not too short that it causes unwanted side effects, such as hyper/hypo pigmentation or even scarring from ablation. 10 If the pulse duration is longer than the TRT of melanin, then the target chromophore is not damaged and the energy simply dissipates into the surrounding tissues causing damage there instead.10 Treating seborrhoeic keratoses with long pulsed alexandrite laser The laser in my clinic that is used for the destructive treatment of seborrhoeic keratoses is the long pulsed alexandrite laser by Syneron Candela, which operates at a wavelength of 755 nm and is just in the visible IR part of the spectrum.

There are other lasers available such as those manufactured by Lynton Lasers and Cynosure, however I do not have experience using these devices. I have chosen to use an alexandrite laser because it is the latest technology available, the older lasers, such as Argon lasers, have a different wavelength and carry more unwanted side effects such as scarring and hypopigmentation.11 The laser I use delivers a burst of energy using long pulse durations in the remit of milliseconds. Using longer pulse durations delivers the energy in a Figure 2: Large seborrhoeic keratosis lesion treated with a long pulsed alexandrite laser and the immediate crusting after treatment.

Treatment parameters were: 755 nm, 8mm spot size, 3ms pulse duration and fluence of 65J/cm2.

Post-treatment cooling with ice was applied.

Before

After

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more controlled and gentle manner than very short durations, such as the acoustic type nanosecond pulse durations delivered with Q-switched lasers.9 Alexandrite laser at 755 nm is delivered into the skin to target melanin lying in the epidermis. When using long pulsed alexandrite laser for treatments such as hair removal, it is vital to protect the epidermis against heat damage by cooling the area either during or immediately before treatment. When treating epidermal lesions such as seborrhoeic keratoses, the target chromophore is the epidermal melanin that needs to be destroyed. We therefore do not pre-cool the skin when using the laser for this particular treatment, as protecting the epidermis by cooling would mean the target is not destroyed. Energy from the laser is absorbed by the epidermal melanin and causes damage to the lesion, which is visible by darkening of the lesion, often with an immediate white eschar. The lesion forms a thickened crust, which flakes off in around 10-14 days. The excess pigment falls away as part of the damaged crust.

My personal experience is that usually one treatment session is enough for most seborrhoeic keratoses, but as the treatment is reliant on absorption into melanin, the lesions that respond best are the ones containing more target chromophore â&#x20AC;&#x201C; the darker ones.10 Through my experience treating patients, I have noticed that lighter lesions may respond to higher fluences, but may take more than one treatment session. Repeat sessions should be spaced at eight week intervals because it can take around two to three weeks for the lesion to heal and it is important to wait for the surrounding tissues to settle completely before retreating. The treatment sensation is hot and the skin may be cooled afterwards manually, either by icing, cool air or the application of aloe vera gel. With long pulsed alexandrite laser therapy, the lesions are immediately more visible than before treatment. It is important to explain this thoroughly to the patient at consultation, as it will have social implications.

Normal sequelae of treatment includes immediate darkening (sometimes to almost Figure 3: Typical seborrheoic keratosis lesion before treatment and after test patch, the complete removal six weeks later. Treatment parameters were: 755 nm, 8mm spot size, 3ms pulse duration and fluence of 70J/ cm2. Post-treatment cooling with ice was applied.

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black), crusting and oedema. From my own observations, these immediate side effects usually disappear after 24-48 hours, but the crusting and scabs will last up to 10-14 days.

It is important to let the patient know that picking the scab may cause atrophic scarring – similar to picking chicken pox lesions.

Complications of destructive laser therapy using long pulsed alexandrite lasers In experienced hands, laser therapy is usually safe and effective for the destructive removal of most seborrhoeic keratoses. However, complications do sometimes occur, and the risk of scarring is generally from poor healing of the tissues after treatment, rather than from the laser treatment itself. Practitioners should be aware that there is a slight risk of permanent hypopigmentation in darker skin types, or those people who are tanned.9 The only other small risk is infection post treatment, which can be managed with oral antibiotics if necessary. After treatment, the risk of the seborrhoeic karatoses reoccurring is slim and rare, but the patient is likely to develop new ones as they are due to historical sun damage.

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Conclusion Seborrhoeic keratoses can be safely and effectively removed using alexandrite laser therapy. The treatment is cost-effective as it usually takes just one session to clear most lesions. The cosmetic perception of improvement after treatment is high – whilst some permanent hypopigmentaton may remain in certain patients, it is my experience that they dislike the rough, crusty feel of the lesions more than the lesion itself. The smooth, flat result is the desired clinical outcome for most people, even if some slight pigmentary changes remain.

Mary White has been an aesthetic nurse since 1993 and specialises in dermatology, laser treatments and aesthetic injectable treatments. White has been the clinical trainer for two leading suppliers of medical lasers in the UK and has trained many practitioners to safely use and deliver laser treatments. She also founded Outline Clinic in Worcestershire, which received Highly Commended in the 2015 Aesthetics Awards for Best Clinic North England.

REFERENCES 1. Yeatman JM, Kilkenny M, Marks R (Sep 1997), ‘The prevalence of seborrhoeic keratoses in an Australian population: does exposure to sunlight play a part in their frequency?’ Br J Dermatol 137 (3): 411–4.

2. Gill D, Dorevitch A, Marks R, ‘The prevalence of seborrheic keratoses in people aged 15 to 30 years: is the term senile keratosis redundant?, Arch Dermatol 136(2000), 759–62.

3. Reutter, JC, Geisinger, KR, Laudadio, J, ‘Vulvar Seborrheic Keratosis,’ Journal of Lower Genital Tract Disease 18(2014), pp.190–4.

4. Hafner, C; Vogt, T, ‘Seborrheic keratosis,’ Journal der Deutschen Dermatologischen Gesellschaft 6(2008), pp.664–77.

5. James, WD, Berger, Ti G, et al., ‘Andrews’ Diseases of the Skin: Clinical Dermatology,’ Saunders Elsevier, 12(2016) 6. Fusco N, Lopez G, Gianelli U, ‘Basal Cell Carcinoma and Seborrheic Keratosis: When Opposites Attractn,’ International Journal of Surgical Pathology 23(2015), p.464.

7. British Association of Dermatologists Fact Sheet (2014) <http://www.bad.org.uk/shared/get-file. ashx?id=231&itemtype=document> 8. Kenny T, Knott L, What are seborrhoeic warts? Patient, (2013) <http://patient.info/health/seborrhoeic-warts-leaflet> 9. Lanigan SW, ‘Lasers in dermatology: an introductory guide.

Springer-Verlag, London,’ (2000).

10. Anderson RR, Parrish JA, ‘Selective Photothermolysis: Precise microsurgery by selective absorption of pulse irradiation,’ Science, 220(1983), pp.524-527.

11. DermNetNZ, Lasers in dermatology (2016) <http://www. dermnetnz.org/procedures/lasers.html>

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Clinical analysis of the ageing lip

Lip Augmentation In the first of a two-part article, Dr Lee Walker details the relevant anatomy to consider for lip augmentation and explains patient selection for treatment Lip augmentation can be a clinical challenge. Clinical outcomes are defined by injection technique, the patient’s unique anatomy and the type and amount of filler used. The key to achieving and maintaining attractive and appealing lips is strongly related to understanding and respecting anatomy, aesthetics and associated challenges.1 Furthermore, a thorough knowledge of the ageing process is essential in appreciating what we need to focus on to achieve more ‘beautiful’ and youthful lips.2

Clinical analysis of the youthful lip In youthful Caucasian patients, the upper lip is usually narrower than the lower. The upper lip to lower lip ratio is approximately 40:60.

In the Afro-Caribbean ethnic group this ratio is 50:50.3 A youthful lip will show the skin

Figure 1: The white mark shows where the lip demonstrates a small central depression and the blue dots indicate two lateral protrusions

immediately above the vermillion border to have a smooth appearance without any visible rhytides. There are sharply defined philtral columns and a well-defined cupid’s bow centrally. The upper lip has a prominent medial tubercle with bilateral depressions.

The lower lip has a corresponding small depression centrally and two lateral protrusions (Figure 1).2 On lateral profile, the upper cutaneous ‘white’ lip should be short with a concavity approaching the ‘red’ lip.4 The upper lip should project slightly further than the lower (around 2mm).4 According to a study, attractive female lips tend to have an increased vermillion height, increased nasolabial angle and an increased mentolabial angle (Figure 2).3

Figure 2: Example of an ‘attractive’ female lip on a lateral profile

The ageing lip is characterised by:5-7 • Loss of fullness and projection (Figure 3) • Development of rhytids • Reduction in vermillion border • Inversion of lower lip • Reduction in show of upper teeth • Increased show of lower teeth • Flattening of cupid’s bow • Flattening of philtral columns • Lengthening of cutaneous upper lip (Figure 4) • Reduction in nasolabial angle • Reduction in mentolabial angle • Reduction of vermillion pigmentation These features are further accentuated by a perioral ‘collapse’. This collapse is due to resorption of the craniofacial skeleton,5 hyperkinetic activity of the orbicularis oris6 coupled with fat atrophy.7 Lip deflation is not due to overall volume loss in the lip. The loss of ‘pouting’ is attributed to a redistribution of thickness of the lip towards length. This means that this ‘virtual’ volume loss is simply just a loss of elasticity with resulting ptosis.8 There is no volume loss in the lip.8

Lip anatomy The lips are not only an important part of the central facial triangle, but they also play an essential role in facial expression, articulation of speech, masticatory competence, maintaining oral seal and defining soft tissue boundaries for the teeth. Shape and thickness differs between the upper and lower lip, and varies significantly between individuals and ethnic groups.

Orbicularis oris muscle The orbicularis oris muscle consists of two parts; a lower and an upper part joined to the modiolus. These two parts are composed of two distinct portions, the pars marginalis and the pars peripheralis, which differ in location and function (Figure 5).9,10 The pars marginalis is located in the

Figure 3: Patient with loss of fullness and projection

Figure 4: Patient with lengthening of cutaneous upper lip

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Patient alignment checklist There should be a synchronisation of patient and practitioner expectations and the patient should be aware of and understand: • All treatment options available • Informed consent • Immediate and late post-procedure outcomes • Number of syringes and costs • Type of filler used • Longevity of product used • Repetitive and temporary nature of treatment • Adverse events • Post-procedural care

vermillion and acts as a sphincter. The pars peripheralis is located in the cutaneous lip and has a dilatory function. The fibres of the pars marginalis and the pars peripheralis come from the modiolus but are directed differently and are not within the same plane. The pars marginalis is located in front of the pars peripheralis, which gives the lips its curved shape.9,10 Arterial blood supply There is huge variability in the number, course, diameter and location of the arterial supply to the lips.

The superior labial artery originates from the facial artery and is at most times superior or at the same level of the labial commissure, however it can occasionally be inferior to

it. The diameter of the superior labial artery at its origin ranges from 1-1.8mm.11-18 The superior labial artery travels forward to the upper lip, passing deep to the zygomaticus major muscle. The superior labial artery is usually larger and more tortuous in its course than the inferior one. Into the upper lip, it enters the orbicularis oris muscle and travels between the muscle and the mucosa, along the edge of the upper lip.11-18 The inferior labial artery is also branched from the facial artery, generally below or at the level of the labial commissure and seldom above it. Its mean diameter in its origin ranges 1.2-1.4mm. As with the superior labial artery, the point at which the inferior labial artery branches from the facial artery

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and the distance between its origin and the labial commissure exhibit a high variability ranging 0.5-4cm with a mean distance of 2-2.5cm (Figure 6). After branching from the facial artery, it runs tortuously upward and forward deep to the depressor anguli oris muscle in its course to the lower lip. The artery penetrates the orbicularis oris muscle and runs tortuously along the edge of the lower lip lying between the muscle and the mucous membrane.11-18

Patient selection and considerations The patient should be medically fit and well. If the patient is susceptible to herpes simplex, pre-treatment antiviral medication may be prescribed, and treatment should not take place if herpes simplex is visible.

Awareness of medications that predispose to bruising is essential (pain relief medication, non-steroidal anti-inflammatory drugs, anticoagulant medication, vitamin E).

Informed written consent must also be signed, dated and initialled on every page.

Pre-operative and post-operative photographs in frontal and lateral views are critical. These photographs will highlight any asymmetry, which must be relayed to the patient prior to commencement of treatment.

They will also serve as a ‘non-biased second opinion’ if the patient returns weeks later saying their lips look ‘no different’ or they are

Columellar a.

Orbicularis oris m: upper pars peripheralis upper pars marginalis

Superior labial a.

Inferior labial a.

Labial artery Orbicularis oris m: lower pars marginalis lower pars peripheralis

Mental a.

Labiomental a.

2cm

Chin muscles Submental a. (terminal part)

Chin fat compartment

Figure 5: The anatomy of the lip21 -150%

Figure 6: Anatomy showing the arterial blood supply21

-50%

50%

125%

Figure 7: Example of lip dimensions used to educate patients – % increases in surface area of the lips19

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200%

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Summary Achieving treatment goals with lip augmentation requires an in-depth knowledge of lip anatomy and clinical assessment of lip function. The best results are when the practitioner accentuates the patient’s existing lip architecture.

The practitioner should understand the considerations and undergo appropriate measures for patient selection.

Most attractive lip ratios by rank

1st place: 1:2 2nd place: 1:3 3rd place: 1:1

Ranking of each photo

1st place: 1:2

4th place: 2:1

2nd place: 1:3

This article is the first of two on lip augmentation by Dr Lee Walker. His next article will detail the treatment side of lip augmentation including a discussion of technique and products.

3rd place: 1:1

4th place: 2:1

Lip adjustment Figure 8: Most attractive lip ratios by rank. Facial attractiveness is highest with an average of +53% enhancement.19

‘uneven’. Identifying patient expectations and treatment goals at the consultation stage is one of the crucial stages in lip augmentation. Patients often ask for augmentation of the upper lip only, however this approach can lead to a ‘duck lip’ appearance, which is not usually considered aesthetically pleasing. I often use laminated photographs of lip dimensions related to facial beauty (Figures 7 & 8) to educate and counsel the patient.18 A study published in The Laryngoscope suggests that a larger upper lip (duck lip) is the most unattractive ratio.19 It also suggests that facial attractiveness is highest when

thin, non-treated lips are enhanced by 53%.

This is useful when patients are requesting large volumes of filler. It therefore aids the practitioner in preventing overfill in the demanding patient.

When it comes to considerations, it is also vital to discuss post-operative outcomes, which can include swelling and bruising.

The emphasis must be placed on social downtime ranging from two to 10 days.

Patients should be made aware that this treatment may be difficult to hide from partners or colleagues. A patient alignment checklist is a useful tool to ensure the patient is a suitable candidate for lip augmentation.20

Identifying patient expectations and treatment goals at the consultation stage is one of the crucial stages in lip augmentation

Dr Lee Walker is a former cosmetic dental surgeon with more than 14 years’ experience in non-surgical facial aesthetics. He is clinical director at B City Clinics in Liverpool. Dr Walker regularly presents and lectures at conferences and aesthetic training events, and in 2014 founded the Northern Aesthetics Practitioners’ Group.

REFERENCES 1. Byrne PJ, Hilger PA, ‘Lip augmentation,’ Facial Plast Sur, 20(2004), pp.31-8.

2. Patrick Trevidic, MD, E2e Anatomy & Lip enhancement, 4(2013), pg.9.

3. Jacono AA, ‘A New Classification of Lip Zones to Customize Injectable Lip Augmentation,’ Arch Facial Plast Surg, (2008), pp.25-29 4. Penna V, Stark B, ‘Classification of the aging lips: A foundation for an integrated approach to perioral rejuvenation,’ Aesth Plast Surg, 39(2015), pp.1-7.

5. Vleggar D, Fitzgerald R, ‘Dermatological implications of skeletal aging: a focus on supraperiosteal volumization for perioral rejuvenation,’ J Drugs Dermatol, 7(2008), pp.209-20.

6. Sarnoff DS, Saini R, Gotkin RH, ‘Comparison of filling agents for lip augmentation,’ Aesthetic Surg J, 28(2008), pp.556-563.

7. Klein AW, ‘The art and science of injectable hyaluronic acids,’ Plast Reconstr Surg, 117(2006), pp.335-375.

8. Iblher N, ‘Changes in the aging upper lip – a photomorhometric and MRI – based study (on a quest to find the right rejuvenation approach),’ J Plast Reconstr Aesth Surg, 61(2008), pp.1170-6.

9. Crouzet C, ‘Anatomy of the arterial vascularization of the lips,’ Surg Radiol Anat, 20(1998), pp.273-8.

10. Patrick Trevidic, MD, E2e Anatomy & Lip enhancement, 4(2013), pg.29.

11. Park CG, Ha B, ‘The importance of accurate repair of the orbicularis oris muscle in the correction of unilateral cleft lip,’ Plast Reconstr Surg, 96(1995) pp.780-8.

12. Crouzet C, ‘Anatomy of the arterial vascularization of the lips,’ Surg Radiol Anat, 20(1998), pp.273-8.

13. Magden O, Cadaveric study of the arterial anatomy of the upper lip, Plast Reconstr Surg, 114(2004), pp.355-9.

14. Pinar YA, ‘Anatomic study of the blood supply of perioral region.’ Clin Anat, 18(2005), pp.330-9.

15. Loukas M, ‘A detailed observation of variations of the facial artery, with emphasis on the superior labial artery,’ Surg Radiol Anat, 28(2006), pp.316-24.

16. Schulte DL, ‘The anatomical basis of the Abbé flap,’ The Laryngoscope, 111(2001), pp.382-6.

17. Edizer M, ‘Arterial anatomy of the lower lip: a cadaveric study,’ Plast Reconstr Surg 111(2003), pp.2176-81.

18. Al- Hoqail RA, ‘Anatomic dissection of the arterial supply of the lips: an anatomical and analytical approach,’ J Craniofac Surg, 19(2008), pp.785-94.

19. Popenko N & Wong B, ‘Analysis of Lip Dimensions and Facial Beauty: A Novel Method to Quantify Ideal Lip Size,’ The Laryngoscope, 121(2011) p.223.

20. Luthra A, ‘Shaping the lip with fillers,’ J Cutan Aesthet Surg, 8(2015), pp.139-142.

21. Plastic Surgery Key, Lip and Chin, Department of Anatomy, Medical School Democritus University of Thrace, Greece <plasticsurgerykey.com/lips-and-chin>

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Botulinum Toxin: A New Look for Depression Treatment Dr Michelle Magid, Dr Jason Reichenberg and Tyler Willenbrink discuss the use of botulinum toxin A in the treatment of depression Depression is the leading cause of disability worldwide and is a major contributor to the overall burden of disease, according to the World Health Organisation (WHO).1, 21 An estimated 350 million people of all ages suffer from depression.1 Depression varies from person to person, with some experiencing mild changes in mood and energy and others experiencing a significant sense of hopelessness, worthlessness, and helplessness. Signs and symptoms of depression include feelings of sadness, loss of interest in daily activities, loss of ability to feel pleasure, changes in sleep and eating behaviours, loss of energy, poor concentration, and in extreme cases, suicidal thoughts. It is still unclear exactly what causes depression; leading researchers believe it may be due an imbalance of hormones or chemicals in the brain (i.e. serotonin, dopamine, norepinephrine, testosterone, cortisol), or perhaps due to a dysregulated inflammatory or autoimmune response that is attacking the nervous system.22 The mainstay of treatment remains behavioural therapy and medication, but if remission is not achieved with these forms of therapy, few alternatives exist.2 Despite the myriad of antidepressants found on the market today, only 30% of patients experience symptomatic remission of their depression while taking first line medication.3 Up to a third may not achieve remission of their symptoms despite multiple medication trials.4 One, seemingly unlikely, solution has emerged as a viable option in this battle against depression: botulinum toxin A (BTA, onabotulinumtoxin A).

Rating Scale), the level of depression measured at 12 weeks was decreased by 54% in the group suffering from MDD. The selfesteem scores of the subjects also increased by more than 20% (P=0.004). In the patients without depression, their depression and self-esteem scores did not fluctuate during the study. The pooled analysis, in particular, indicated with high statistical power that the results of the prior studies were valid.10 This study consisted of 134 males and females from three randomised controlled trials who either received BTA (n=59) or placebo (n=75) into their glabellar region. The results indicated a decrease in depression scores by 45.7% in the group with depression, versus a 14.6% decrease in the placebo group. This corresponds to a 54.2% response rate and a 30.5% remission rate in the group with MDD (Figure 1).

Injection technique The injection technique for all studies involves a series of five injections of BTA into the glabellar region. Females are injected with a total of 29 units of BTA, while males are injected with 39 units.7 For females, seven units are injected into the centre of the procerus muscle, six units into the medial corrugator muscles and five units into the lateral corrugators bilaterally. For males, two extra units in each area are given to account for their increased muscle mass (Figure 2). This technique was established by Eric Finzi, who Placebo vs Botulinum Toxin A: Change in Depression Scores

45.69%

50%

A case study was performed in 2006, which indicated a reduction in depressive symptoms in nine out of 10 patients with major depressive disorder (MDD) when treated with botulinum toxin A.5 Since that time, another case series,6 three randomised controlled trials,7,8,9 a pooled analysis10 and a meta-analysis11 have all supported the findings that BTA can be effective in the treatment of depression.

The second case series, conducted in 2013, studied a group of 50 women, half of whom were diagnosed with depression.6 Using validated depression scales (Hamilton Depression Rating Scale and the Montgomery-Asberg Depression

Figure 1: Meta-analysis data: At the end of six weeks, patients who received botulinum toxin (n=59) vs. placebo (n=75) had a 45.69% vs. 14.60% change in mean depression score, respectively. The scales used were the Hamilton Depression Rating Scale and the Montgomery-Asberg Depression Rating Scale, both validated and widely used in psychiatry.

40%

Percentage

The evidence

30%

20%

14.60%

10%

0% Placebo

BTA

% change in mean score

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did the first case series on BTA for depression5 and replicated it in subsequent studies to allow for easier inter-study comparisons.

Botulinum toxin A is sold in three main forms: Botox/Vistabel (onabotulinumtoxinA), Xeomin/Bocouture (incobotulinumtoxinA), and Dysport/Azzalure (abobotulinumtoxinA).

These studies all used Botox/Vistabel (Cosmetic, Allergan) 100U dissolved in 1ml of 0.9% NaCl saline solution. Injections were made using 0.3ml insulin syringes.

How does it work?

Look better, feel better?

Despite the success of BTA in the treatment of 9U 8U 7U 6U 5U depression in the clinical Figure 2: Women received 29 units into the studies mentioned, glabellar region and men received 39 units into the glabellar region. Images courtesy of the reason behind its Dr Michelle Magid and Tyler Willenbrink. success is still under debate. Although it may seem logical, the idea that ‘looking better will make you feel better’ does not seem to be the case for improved mood. One study by Magid et al (author) indicated that the psychotropic effects of BTA injection persisted for at least 24 weeks, which was the full length of the trial.8 The paralytic effects of BTA last only 12-16 weeks, which makes it unlikely that cosmetic improvement is the sole cause of the improvement in mood. Another study by Lewis and Bowler compared the effects of BTA treatment in the glabella versus other cosmetic treatments including glycolic peels, laser treatments, dermal fillers and BTA in other locations.12 This study indicated comparative levels of cosmetic improvement between the two study groups, but the group receiving BTA in the glabellar region scored consistently lower in irritability, depression, and anxiety scores (P=0.003) after the treatment. Furthermore, one of the double-blinded trials showed a patient who actually disliked the cosmetic results of his treatment but experienced full remission of his MDD.7 Finally, and most importantly, a follow up meta-analysis of the previous BTA trials looked specifically at the correlation between improvement in wrinkle scores and improvement in mood. There was no correlation between the two, indicating that firstly, patients don’t necessarily need to have severe frown lines to be a candidate for the treatment and secondly, cosmetic improvement is not how BTA is exerting its mood-lifting effects.13 Thus, there are likely other factors in play.

Facial feedback hypothesis The facial feedback hypothesis is considered by many experts on BTA therapy to be the most prominent player in BTA’s effects on depression. First postulated by Charles Darwin in 1872, this hypothesis hinges on the idea that facial expression serves as a stimulus for human emotion.2 A study by Adelmann and Zajonc suggested that study subjects who were asked to smile while watching a cartoon rated the cartoon as funnier.14 Thus, smiling at a joke can make the comedian seem funnier, while frowning at a party can make it seem less fun. Emotions that are common in depression, such as fear, sadness and anger, result in contraction

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of the muscles in the glabellar region. By paralysing these muscles, the ability to form facial expressions associated with negative emotions is inhibited, making it harder for patients to maintain these emotions.12 Behavioural theory Behavioural theory postulates that individuals who physically appear unpleasant or angry are perceived in a negative light by their peers.

In response, their social interactions are generally more negative.7 This can create a vicious cycle, which may lead to feelings of worthlessness and depression, caused primarily by a disagreeable facial expression. By inhibiting the actions of the corrugator and procerus muscles, the patients’ more pleasant facial expressions can serve to break the cycle and steadily improve their social interactions and feelings of self worth.

Neurochemical changes A third theory supports the idea that BTA itself causes neurochemical changes in the brain, specifically the amygdala. The amygdala is responsible for emotional memory and is especially active in those who have experienced trauma.2 A hyperstimulated amygdala can lead to a fear response that is out of proportion to the stimulus, which predisposes the patient to depression and anxiety. BTA has been shown by functional MRI to reduce the amygdala response to negative stimuli.15,16 The reason for this is not well understood, but may be a result of decreased facial feedback from the trigeminal nerve to the amygdala, which would lend additional support to the facial feedback hypothesis mentioned above.2

Safety and cost The safety record of BTA injections to the glabellar region of the face is impressive.17 In the pooled analysis, the only notable side effect from BTA treatment was temporary headache, which was seen following injection in 13.6% of BTA subjects and 9.3% of the placebo group (not statistically significant).10 In comparing costs, a study was conducted by Beer to assess how the costs of BTA treatment would stack up compared to typical treatment of depression.18 This analysis showed that the annual costs for a patient in the US would be between $1,050 and $1,600 (£741 and £1,129) for BTA. In patients who respond to a generic antidepressant, the cost of BTA may be prohibitive. However, in patients with difficultto-treat depression who may be using a combination of branded

Although it may seem logical, the idea that ‘looking better will make you feel better’ does not seem to be the case for improved mood

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medication ($800-$2,400/£560-£1,690 annually) plus weekly psychotherapy ($2,000-$5,000/£1,410-£3,530 annually), BTA treatment may ultimately be the more cost effective option.2,18

Further studies Timing The effects of BTA have been indicated to attenuate depression in patients as early as two weeks and have lasted up to six months.7,8 Further studies are needed to determine if the onset of action is even less than two weeks. It will also be valuable to study the optimum time of maintenance of BTA treatments, including assessment of whether adherence would improve if the injections were less frequent (i.e. twice a year).

Injection The vast majority of evidence in support of BTA treatment uses evidence found with similar dosing strategies in the glabellar region of the face. Currently, larger studies are underway to provide further support of the most recent research.19 Going forward, further studies identifying whether a higher dose could create an even greater response could be valuable. Furthermore, looking into other facial regions for injection, such as the depressor anguli oris, may prove fruitful and also give us insight into the mechanism of action.2 Borderline personality disorder A recent study has indicated that botulinum toxin may be effective, not only in depression, but other psychiatric disorders, such as borderline personality disorder.20 The study followed six consecutive cases where patients showed a reduction in symptoms between 49-94%. The idea rests on the fact that BTA treatment may cause a global attenuation of negative emotions. Borderline personality disorder is the prototype psychiatric disease of excessive negative emotion and thus may be a perfect candidate for BTA injections. A randomised controlled trial will be valuable to assess the validity of these initial findings.

Conclusion Botulinum toxin A is currently being studied for the treatment of depression and other psychiatric disorders. For now, if patients seek ‘the botulinum dose used for depression’, we recommend 29 units for females and 39 units for males in the configuration outlined above. The ambitious and curious provider may want to track patients’ depression scores before and three to six weeks after treatment. For this purpose, we recommend using the Patient Health Care Questionnaire nine (PHQ-9), a simple and validated nine-question survey that can be filled out in five to 10 minutes by the patient in the waiting room. Botulinum toxin is currently not FDA approved for these indications, but if further studies uphold previous studies, it may become a standard treatment in the future.

Given that depression in a chronic illness, often with concomitant morbidity, the aesthetic practitioner should not be the primary provider for depression. A prerequisite to BTA treatment in our practice is that the patient has an established psychiatrist.

A possible course of action for the aesthetic practitioner is consultation with the patient’s primary provider (i.e. general practitioner or psychiatrist) prior to proceeding, and letting the patient know that any issues relating to depression should be discussed with their primary provider.

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Dr Michelle Magid is a psychiatrist in Austin, Texas.

She is president of Austin Psychcare, PA, and a clinical associate professor for University of Texas, Dell Medical School. Dr Magid is a leading researcher in using botulinum toxin for psychiatric illness.

Dr Jason Reichenberg is chief of dermatology for Seton Family of Hospitals and an associate professor for Dell Medical School at the University of Texas. Dr Magid and Dr Reichenberg helped to edit the book Practical Psychodermatology, an international collaboration written to help dermatologists’ and psychiatrists’ clinical practice.

Tyler Willenbrink is a fourth year medical student at the University of South Carolina School of Medicine, in Columbia, South Carolina. Following graduation, he plans to pursue residency training in the field of dermatology.

Disclosure: As a result of her research, Dr Michelle Magid is a consultant for Allergan Pharmaceuticals and a speaker for Ipsen Innovation. Tyler Willenbrink and Dr Jason Reichenberg have no conflicts of interest to disclose.

REFERENCES 1. World Health Organization (WHO), Fact sheet on depression, WHO Website, (2016) <http://www.who. int/mediacentre/factsheets/fs369/en/> 2. Magid, M, Reichenberg JS, ‘Botulinum toxin for depression? An idea that’s raising some eyebrows.’

Current Psychiatry, (2015) November; 14(11):43,46,51-56.

3. Warden D, Rush AJ, Trivedi MH, Fava M, Wisniewski SR, The STAR*D Project results: a comprehensive review of findings. Curr. Psychiatry Rep. 9(6), 449–459 8 (2007).

4. Gaynes BN, Warden D, Trivedi MH, Wisniewski SR, Fava M, Rush AJ, What did STAR*D teach us?

Results from a large-scale, practical, clinical trial for patients with depression. Psychiatr. Serv. 60(11), 1439–1445 (2009).

5. Finzi E, Wasserman E. Treatment of depression with botulinum toxin A: a case series. Dermatol Surg (2006); 32: 645–649.

6. Hexsel D, Brum C, Siega C, et al, ‘Evaluation of self-esteem and depression symptoms in depressed and nondepressed subjects treated with onabotulinumtoxina for glabellar lines. Dermatol Surg.

(2013);29(7): 1088-1096 7. Wollmer MA, de Boer C, Kalak N, et al. Facing depression with botulinum toxin: a randomized controlled trial. J Psychiatr Res. (2012);46(5):574–581.

8. Magid M, Reichenberg JS, Poth PE, et al, Treatment of major depressive disorder using botulinum toxin A: a 24-week randomized, double-blind, placebo-controlled study, J Clin Psychiatry, (2014);75(8):837-844.

9. Finzi E, Rosenthal NE, Treatment of depression with onabotulinumtoxinA: a randomized, double-blind, placebo controlled trial. J Psychiatr Res, (2014);52:1-6.

10. Magid M, Finzi E, Kruger TH, et al, Treating depression with botulinum toxin: a pooled analysis of randomized controlled trials, Pharmacopsychiatry. (2015);48(6):205-210.

11. Parsaik A, Mascarenhas S, Hashmi A, et al, Role of botulinum toxin in depression: a systematic review and meta-analysis, J Psychiatr Pract. (2016) 12. Lewis MB, Bowler PJ, Botulinum toxin cosmetic therapy correlates with a more positive mood, J Cosmet Dermatol. (2009);8(1):24–26.

13. Reichenberg JS, Hauptman AJ, Robertson HT, et al, Botulinum toxin for depression: Does patient appearance matter? Journal of the American Academy of Dermatology; 74(1): 171-3.e1 14. Adelmann PK, Zajonc RB, Facial efference and the experience of emotion, Ann Rev Psychol (1989);40:249–80.

15. Hennenlotter A, Dresel C, Castrop F, et al, The link between facial feedback and neural activity within central circuitries of emotion—new insights from botulinum toxin-induced denervation of frown muscles, Cereb Cortex, (2009);19(3): 537-542.

16. Kim MJ,Neta M,Davis FC, et al, Botulinum toxin-induced facial muscle paralysis affects amygdala responses to the perception of emotional expressions: preliminary findings from an A-B-A design, Biol Mood Anxiety Disord, (2014);4:11 17. Brin MF, Boodhoo TI, Pogoda JM, James LM, Demos G, Terashima Y, et al, Safety and tolerability of onabotulinumtoxinA in the treatment of facial lines: a meta-analysis of individual patient data from global clinical registration studies in 1678 participants, Journal of the American Academy of Dermatology, (2009);61: 961e970.e1-11.

18. Beer K, Cost effectiveness of botulinum toxins for the treatment of depression: preliminary observations, Journal of Drugs in Dermatology (2010);9:27e30.

19. Botulinum toxin and depression, ClinicalTrials.gov. <https://clinicaltrials.gov/ct2/ results?term=botulinum+toxin+and+depression&Search=Search. Accessed June 1, 2016> 20. Kreuger THC, Magid M, Wollmer MA, “Can Botulinum Toxin Help Patients with Borderline Personality Disorder? “ American Journal of Psychiatry, In Press.

21. World Health Organization (WHO), Health topics, Global burden of disease, WHO, (2016) <http://www. who.int/topics/global_burden_of_disease/en/> 22. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (DSM-5®), Washington: American Psychiatric Publishing, (2013), P.155-188 <http://UTXA.eblib.com/patron/ FullRecord.aspx?p=1811753>

Reproduced from Aesthetics | Volume 3/Issue 9 - August 2016

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anaesthesia.3 This article will seek to clarify which methods are commonly available in the UK at the moment and introduce a new treatment modality for non-surgical body contouring which also has some interesting endocrine effects, in the form of a low-level light green laser.

Modes available

Body Contouring and LLLT Dr Sarah Tonks explores the role of low level laser therapy in body-contouring treatments French surgeon Mr Charles Dujarier first introduced the concept of lipoplasty in the 1920s. He attempted to remove the subcutaneous tissue from a dancer’s calves, but unfortunately ultimately caused gangrene and the death of the patient.1 The appetite for non-surgical body contouring has fuelled the development of non-invasive, comfortable and safe solutions for the reduction of fat and improvement of the silhouette. Liposuction successfully reduces fat and improves contour in a predictable fashion, nevertheless there is still a continuous demand for non-surgical and non-invasive methods that may be less dramatic and immediate, and come without the same level of risk and side effects.

The number of minimally invasive procedures increased by 137% from 2000

to 2012 in the US.2 These treatments are sometimes referred to as ‘lunch-time procedures’ because they have minimal down time and can often be completed in less than two hours.

Patients who are time-poor and do not have the opportunity to recuperate following surgery may select a non-invasive alternative in order to fit with lifestyle factors, or the patient may dislike the idea of having a surgical procedure. Cost can also be a factor; although when larger areas are treated it can often be just as cost effective to undergo liposuction rather than a non-surgical method due to the number of treatment sessions that may be needed.

Periprocedural morbidity can be reduced by the use of non-invasive methods such as a reduction in infection, scarring and

There is still a continuous demand for non-surgical and non-invasive methods that may be less dramatic and immediate

Cryolipolysis, high intensity focused ultrasound, radiofrequency and low level laser are common treatment modalities available on the market in the UK.4 In a 2015 study it was indicated that both cryolipolysis and ultrasound cavitation are safe and effective for body contouring and decreasing abdominal adiposity. Both significantly reduced excess subcutaneous adipose tissue from the abdomen, as shown in the decrease in waist circumference and skinfold measurements. There was no significant difference between the two techniques with regard to reduction of fat thickness.3

Method of action Cryolipolysis, radiofrequency and ultrasound cavitation methods involve apoptosis or necrosis causing cell death, which reduces subcutaneous fat thickness and can all be achieved without changes in a patient’s lipid profile or liver function tests.3 After the fat cells are disturbed, the triglycerides are scattered in the interstitial tissue and transported through the vascular lymphatic system to the liver. They are metabolised by endogenous lipases to glycerol and free unsaturated fats.

These unsaturated fats are transported to the liver where they are treated like other unsaturated fats. Unmetabolised triglycerides are combined with transporter proteins or lipoprotein complexes and end up as part of the lipoprotein pool.3 Cryolipolysis has been commercially available for the longest amount of time, with research consisting of in vitro and animal models, as well as randomised controlled trials in humans.4 The principle behind cryolipolysis is the idea that adipocytes are more susceptible to cooling than other skin cells. Application of cold temperatures triggers apoptosis which begins an inflammatory response and leads to the removal of the dead cells by macrophages.4 Ultrasound cavitation uses ultrasound energy through the skin to influence adipose tissue disruption as the subcutaneous tissue absorbs the energy.

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The ultrasonic waves create compression cycles that exert positive pressure and expansion cycles that exert negative pressure, which aims to prompt the mechanical disruption of fat cells. In addition to this, there is a thermal mechanism which destroys fat cells at temperatures above 58°C causing small coagulative areas of necrosis whilst surrounding tissues are unaffected.4 Ultrasound energy directed into the deeper fat layers can prompt cavities in the fat and decrease the overall thickness of the adipose layer without injury to the skin, vessels, nerves or connective tissue.3 Radiofrequency devices cause thermal injury using electrical energy. These devices have been traditionally used to tighten the skin and rhytides, as thermal damage results in contraction of collagen and remodelling, however they can also be used to selectively heat subcutaneous adipose tissue and induce lethal thermal damage whilst sparing the overlying and underlying tissues. Thermal exposures to 43-45°C over several minutes may result in a delayed adipocyte cell death.4 In comparison to the above-mentioned technologies, low level laser therapy is a unique treatment modality because it is not based on thermal tissue damage. The proposed mechanism of action is based on the concept of producing transient pores in the adipocytes, allowing lipids to leak out.

This unique method of action is not one that is frequently discussed in the aesthetics industry and knowledge of this technology has not penetrated well. Equally there is little knowledge of this type of equipment in the public domain; therefore this article will seek to highlight some of the benefits and mode of action of this technology.

Aesthetics Journal

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Low level light laser Reports of low level laser light therapy (LLLT) were first published in 1970 by Endre Mester in Hungary, who noted hair regrowth in mice exposed to a 694 nm ruby laser. He subsequently used a helium-neon 632.8 nm laser to stimulate wound healing in animal models and clinical studies.5 In more recent years this innovative technology has generated an exceptional level of interest across many medical disciplines because of its ability to modulate cellular metabolism to induce beneficial clinical effects.6 LLLT has been shown to alter gene expression,7 cellular proliferation,8 intracellular pH balance,9 mitochondrial membrane potential,10 generation of reactive oxygen species11 and calcium ion level,12 proton gradient13 and cellular oxygen consumption,14 as well as a reduction in cholesterol and triglyceride levels.6 Currently LLLT is used by osteopaths and chiropractors, although it is often regarded with skepticism by the medical profession in general.15 With more research on LLLT taking place, it is becoming an emerging technology in the field of non-surgical body contouring.

Mechanism of action The mechanism is based on the absorption of red and near infrared light. According to the first law of photochemistry the observable biological effect after LLLT can only occur in the presence of a photoacceptor molecule that is capable of absorbing the photonic energy emitted.16 No photothermal mechanisms are associated with these devices so no heating sensation occurs. Cytochrome c oxidase, the terminal respiratory chain enzyme, has been

This innovative technology has generated an exceptional level of interest across many medical disciplines because of its ability to modulate cellular metabolism to induce beneficial clinical effects

identified as a photoreceptor target of LLLT.17 Cytochrome c oxidase is responsible for establishing the electrochemical gradient required for adenosine triphosphate synthesis.18 This enzyme is a membrane protein that has been indicated to absorb photonic energy. After laser irradiation at 633 nm, the mitochondrial membrane potential and proton gradient increases, which causes changes in the mitochondria, increasing the rate at which cytochrome c oxidase transfers electrons from cytochrome c to dioxygen.18 Such modulation of cell metabolism has been suggested to be associated with an increase in lipid peroxidation, which is the oxidative degeneration of membrane-bound cholesterol, resulting in breakdown of the membrane structure and function.18 Furthermore, the upregulation of reactive oxygen species can directly impact the cellular redox state and affect gene expression via activation of specific cell signalling pathways.18 LLLT excites cytochrome c oxidase which upregulates ATP synthesis and upregulates bioenergetics, which initiates the secondary messenger system to send an amplifying signal that diffuses throughout the cell to influence cell activity.19 LLLT provokes a shift of the intracellular redox state to an oxidative state, and activates redox sensitive transcription factors such as nuclear factor kappa B and activator protein-1, upregulating the expression of genes.19 It is thought that these transcription factors can influence membrane proteins and may alter the permeability of adipocytes.18 It is unclear at this time whether the transitory pore induced by laser therapy is the direct result of upregulated gene expression via transcription factor activation, lipid peroxidation by increased superoxide dismutase production or an exocytosis-like event.1 Research Clinical studies indicating the effectiveness of LLLT have used red diodes emitting light at a wavelength of 635 nm applied for 40 minutes (20 minutes to front and back) three times weekly for two weeks18 or green diodes emitting light at 532 nm for 30 minutes (15 minutes to front and back) three times weekly for two weeks.20 The 635 nm diode LLLT red diode laser device obtained marketing clearance from the FDA in 2010. It was tested on reduction of waist, thigh, hip

Reproduced from Aesthetics | Volume 3/Issue 9 - August 2016

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Conclusion

There may be some interesting health benefits with this modality as we also see a reduction in cholesterol and triglyceride levels, which could have interesting cardiovascular benefits

and upper abdomen circumference and shown to give a reduction of 4.5 inches in combined body circumference when used once per week for 40 minutes.21 The green LLLT device at 532 nm received FDA clearance in 2013.

The 532 nm device was cleared using the same protocols. Three treatments were administered each week for two weeks and measurements of the waist, hip, and thigh circumference were taken.

There was a mean decrease in measurements of 3.9 inches after the two week period.20 In a randomised study the LLLT technology also had an interesting effect on the endocrine system. Body weight is regulated by endocrine and neural components controlling energy intake and expenditure. This regulatory process is responsible for preventing even small imbalances between energy and expenditure. Regulation is a complex interplay of hormonal and neural signals. Leptin is an adipose-derived hormone, which acts primarily in the hypothalamus to influence appetite, energy expenditure and neuroendocrine function. Leptin is coded by the Ob (Lep) gene. Under normal function leptin suppresses hunger, however when the adipocyte is enlarged then leptin is overproduced and the corresponding receptor becomes resistant.22 There have been studies suggesting that laser therapy can modulate gene expression of leptin and this is a potential mechanism for further clinical efficacy.22 There are few studies specifically looking at the association of LLLT and leptin, however in one study 22 patients aged 18-65 participated in a non-controlled, non-randomised study and received low level laser treatments (Zerona, Erchonia Medical Inc.) three times a week for two weeks. Fasting leptin panels (a type of blood tests) were performed pre procedure and at two weeks after the final procedure. Patients maintained normal eating and exercise habits throughout the study. There was a mean reduction in leptin of 50%.

The mean baseline leptin measurement of 29.49 was reduced to 14.60, a statistically significant change of p=<0.0001(1).

There may be some interesting health benefits with this modality as we also see a reduction in cholesterol and triglyceride levels,6 which could have interesting cardiovascular benefits.

Body contouring will doubtless continue to rise in popularity as treatment modalities improve in efficacy and more patients are interested in exploring non-surgical options. It is an interesting development to have a device that has effects on the endocrine metabolism and may have further reaching benefits above those of simply reducing the measurements of adipose tissue in a patient. Further work looking at the endocrine effects of LLLT would be welcomed.

Dr Sarah Tonks is an aesthetic doctor and previous maxillofacial surgery trainee with dual qualifications in both medicine and dentistry. Based at the Chelsea Private Clinic, she practises cosmetic injectables and hormonal-based therapies.

REFERENCES 1. Avci P, Nyame TT, Gupta GK, Sadasivam M, Hamblin MR., ‘Low-level laser therapy for fat layer reduction: a comprehensive review’, Lasers Surg Med [Internet]. NIH Public Access, (2013), 45(6), pp.349-57. <http://www.ncbi.nlm.nih.gov/pubmed/23749426< 2. 2012 Plastic Surgery Statistics. [cited 2016 Jun 28]; Available from: <www.plasticsurgery.org> 3. Mahmoud ELdesoky MT, Mohamed Abutaleb EEl, Mohamed Mousa GS., ‘Ultrasound cavitation versus cryolipolysis for non-invasive body contouring’, Australas J Dermatol [Internet]., 24 (2015) <http://www.ncbi.nlm.nih.gov/pubmed/26299702> 4. Krueger N, Mai S V, Luebberding S, Sadick NS., ‘Cryolipolysis for noninvasive body contouring: clinical efficacy and patient satisfaction’, Clin Cosmet Investig Dermatol [Internet]. Dove Press, 7 (2014), pp.201-5. <http://www.ncbi.nlm.nih.gov/pubmed/25061326> 5. Mester E, Spiry T, Szende B, Tota JG., ‘Effect of laser rays on wound healing’, Am J Surg [Internet]., 122(4) (1971), pp.532-5. <http://www.ncbi.nlm.nih.gov/pubmed/5098661> 6. Jackson RF, Roche GC, Wisler DK., ‘Reduction in Cholesterol and Triglyceride Serum Levels Following Low-Level Laser Irradiation: A Noncontrolled, Nonrandomized Pilot Study’, 27 (2010).

7. Byrnes KR, Wu X, Waynant RW, Ilev IK, Anders JJ., ‘Low power laser irradiation alters gene expression of olfactory ensheathing cells in vitro.’, Lasers Surg Med [Internet]., 37(2) (2005), pp.161-71. <http://www.ncbi.nlm.nih.gov/pubmed/16037971> 8. Snyder SK, Byrnes KR, Borke RC, Sanchez A, Anders JJ., ‘Quantitation of calcitonin gene-related peptide mRNA and neuronal cell death in facial motor nuclei following axotomy and 633 nm low power laser treatment’, Lasers Surg Med [Internet]., 31(3) (2002), pp.16-22. <http://www.ncbi.nlm. nih.gov/pubmed/12224097> 9. Giuliani A, Lorenzini L, Gallamini M, Massella A, Giardino L, Calzà L., ‘Low infra red laser light irradiation on cultured neural cells: effects on mitochondria and cell viability after oxidative stress’, BMC Complement Altern Med [Internet], (2009) <http://www.ncbi.nlm.nih.gov/ pubmed/19368718> 10. Moore P, Ridgway TD, Higbee RG, Howard EW, Lucroy MD., ‘Effect of wavelength on lowintensity laser irradiation-stimulated cell proliferation in vitro’, Lasers Surg Med [Internet]., 36(1) (2005), pp.8-12. <http://www.ncbi.nlm.nih.gov/pubmed/15662631> 11. Alexandratou E, Yova D, Handris P, Kletsas D, Loukas S., ‘Human fibroblast alterations induced by low power laser irradiation at the single cell level using confocal microscopy’, Photochem Photobiol Sci [Internet], 1(8) (2002), pp.547-52. <http://www.ncbi.nlm.nih.gov/pubmed/12659495> 12. Tong M, Liu Y-F, Zhao X-N, Yan C-Z, Hu Z-R, Zhang Z-X., ‘Effects of Different Wavelengths of Low Level Laser Irradiation on Murine Immunological Activity and Intracellular Ca2+ in Human Lymphocytes and Cultured Cortical Neurogliocytes’, Lasers Med Sci [Internet]. Springer-Verlag London Limited, 215(3) (2000), pp.201-6. <http://link.springer.com/10.1007/PL00011318> 13. GORDON SA, SURREY K., ‘Red and far-red action on oxidative phosphorylation’, Radiat Res [Internet], 12 (1960), pp.325-39. <http://www.ncbi.nlm.nih.gov/pubmed/13851234> 14. Vacca RA, Marra E, Passarella S, Petragallo VA, Greco M., ‘Increase in cytosolic and mitochondrial protein synthesis in rat hepatocytes irradiated in vitro by He-Ne laser’, J Photochem Photobiol B [Internet]., 34(2-3) (1996), pp.197-202. <http://www.ncbi.nlm.nih.gov/ pubmed/8810537> 15. Chung H, Dai T, Sharma SK, Huang Y-Y, Carroll JD, Hamblin MR., ‘The nuts and bolts of low-level laser (light) therapy’, Ann Biomed Eng [Internet]., 40(2) (2012), pp.516-33. <http://www.ncbi.nlm.nih. gov/pubmed/22045511> 16. Karu T., ‘Lectures on basic science of laser phototherapy’, Prima Book, (2007).

17. Tsukihara T, Aoyama H, Yamashita E, Tomizaki T, Yamaguchi H, Shinzawa-Itoh K, et al., ‘Structures of metal sites of oxidized bovine heart cytochrome c oxidase at 2.8 A.’, Science [Internet].

269(5227) (1995), pp.1069-74. <http://www.ncbi.nlm.nih.gov/pubmed/7652554> 18. Jackson RF, Dedo DD, Roche GC, Turok DI, Maloney RJ., ‘Low-level laser therapy as a noninvasive approach for body contouring: a randomized, controlled study’, Lasers Surg Med [Internet]., 41(10) (2009), pp.799-809. <http://www.ncbi.nlm.nih.gov/pubmed/20014253> 19. Zhang Q, Piston DW, Goodman RH., ‘Regulation of corepressor function by nuclear NADH’, Science [Internet], 295(5561) (2000, pp.1895-7. <http://www.ncbi.nlm.nih.gov/pubmed/11847309> 20. Suarez DP, Roche GC, Jackson RF., ‘A Double-Blind, Sham-Controlled Study Demonstrating the Effectiveness of Low-Level Laser Therapy Using a 532-nm Green Diode for Contouring the Waist, Hips, and Thighs’, Am J Cosmet Surg. SAGE Publications, 31(1) (2014), pp.34-41.

21. Thornfeld C, Thaxton Pa, Hornfeldt C., ‘A six week low-level laser therapy protocol is effective for reducing waist, hip, thigh, and upper abdomen circumference’, <http://www.jcadonline.com/asix-week-low-level-laser-therapy-protocol-is-effective-for-reducing-waist-hip-thigh-and-upperabdomen-circumference/> 22. Maloney R, Shanks S, Maloney J, Zimmerman E., ‘The application of low level laser therapy for the reduction of adipocyte derived hormone leptin: A non controlled, non randomised study’.

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Treating Scars Dr Salinda Johnson outlines the most common types of scars and details some of the effective treatments available Scarring occurs in a variety of forms with various differing characteristics. Scarring affects all skin types, regardless of ethnicity, and can appear anywhere on the face and body. Types of scarring include keloid, hypertrophic and atrophic. Each year in the developed world approximately 100 million patients acquire scars as a result of 55 million elective operations and 25 million operations after trauma,1 some of which can cause considerable problems such as psychological distress, restricted movement (especially larger scars that stretch over joints), itching or discomfort. Global figures are unknown but are likely to be much higher. People with abnormal skin scarring may face physical, aesthetic, psychological, and social consequences that may be associated with substantial emotional and financial costs.1

Scarring Atrophic scarring An atrophic scar can occur anywhere on the body, although most of my patients decide to have facial or more noticeable atrophic scars treated. The characteristics of atrophic scars are irregular with jagged edges and a pitted, sunken, chicken-pox-like appearance. They are generally caused by damage to the underlying tissue of the skin.2 This tissue damage is caused by a loss of muscle or fat and the lack of sufficient collagen production in the area resulting in a sunken, depressed structure. A few examples of causes include: severe acne, chicken-pox, surgery or accidents that cause trauma to these underlying structures.

These scars are of a permanent nature if left untreated.2 Atrophic scars can be treated in a number of ways, with one of the most common being fractional laser or selective waveband technology (SWT). Other medical options available include subcision, hyaluronic acid fillers to raise the scar, chemical peels, microneedling or medical micropigmentation.

Hypertrophic scarring Hypertrophic scars (Figure 1) are usually raised and darker in colour than the surrounding skin and, unlike a keloid scar, they remain within the boundaries of the wound and can continue to thicken for up to six months. A hypertrophic scar is inflexible and can restrict movement.3 Hypertrophic scarring occurs after thermal and/or traumatic injury concerning the reticular dermis. In my professional observations I have noticed that a hypertrophic scar can take up to approximately two years to improve in appearance/heal fully. If there is no improvement within a year, the scar could potentially be a keloid scar. Treatments include: micropigmentation, silicone sheeting gel, scar revision surgery, steroid injections and electrosurgical excision.3 Keloid scarring Keloids are benign, dermal, fibroproliferative tumours characterised by excess collagen at the site of previous skin injury.4 The treatment of keloid scars remains a challenging clinical dilemma for both patients and providers. Intralesional cryosurgery has emerged as a safe and effective new treatment by destroying the hypertrophic scar tissue with minimal damage to the skin surface.4 Keloid scars extend beyond the borders of the original wound because Before

After

of the excess collagen formation when the skin heals. This is in contrast to hypertrophic scars, which are limited to the original wound site. Keloids often develop as soon as three months after injury, but may take several years to appear following the initial traumatic insult.4 Keloid scars are well-demarcated, rubbery, mildly tender, bosselated tumours with a shiny surface, often marked by telangiectasias and sometimes ulcerations.

Lesions are pink to purple in colour and may display hyperpigmentation. The most common areas where keloids form are the anterior chest, shoulders, ear lobes, cheeks, and skin overlying joints. After development, keloid lesions continue to persist without spontaneous regression and have no malignant potential. Patients often complain of feeling pain, itching and hyperesthesia. These symptoms, along with the contractures from excessive scar formation, can be extremely uncomfortable for patients.5 A histological examination of a keloid reveals larger, thicker, and more disorganised collagen fibres than those seen in normal skin.4 They are palestaining, hypocellular type I and III collagen bundles that lack nodules. Blood vessels are scattered and dilated, contributing to the poor vascularisation in keloid scars. Special stains can detect the overproduction of fibronectin, an extracellular matrix protein, which influences the formation of keloid scars.3 Excessive scar formation is due to abnormal wound healing following any injury to the deep dermis. Common causes include surgical procedures, piercings, vaccinations, lacerations, and burn injuries. Normal wound healing depends on the fine balance between extracellular matrix deposition and degradation.5 Keloid scars endure a longer inflammatory period compared to other scars, during which immune cells and proinflammatory cytokines continue to stimulate fibroblasts.5 The likelihood of developing a keloid scar is multifactorial with a strong genetic component. There is potential for all individuals (except those with albino skin) to develop keloid scars; however, the greatest incidence is observed in patients of darker skin colour. Keloids are most common in the second to third decades of life, and susceptibility decreases with age following this.5 Treatments include: electrosurgery and steroid injections.

Treatment Figure 1: Raised hypertrophic scar before and four weeks after one session of steroid injections. I would recommend that the patient has potentially one more steroid injection, followed by one to two SWT/laser sessions and hyroquinone cream to correct the colour.

Electrosurgery and steroid injections At the London Cosmetic Clinic we use a device that aims to rapidly and selectively destroy tissue by the passage of an electric

Reproduced from Aesthetics | Volume 3/Issue 9 - August 2016

@aestheticsgroup Before

After

Aesthetics Journal

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current, which works to burn off the tissue in question. Small skin lesions can be treated without anaesthesia, however the procedure for multiple scars or larger areas may require topical or local anaesthesia, Figure 2: Keloid scars with nodules on the depending on the patient’s front and back of earlobe before and four pain threshold. The weeks after treatment with electrosurgery and steroid injections. device works by emitting low-power high frequency alternating current. Electrical pulses travel via a probe, directly to the affected area of the body. The amount of output power needed is adjustable, and the device is equipped with different tips, electrodes and forceps depending on the electrosurgical requirement. We would then follow the treatment with steroid injections.

This treatment has minimal pain and scarring; however, due to it initially leaving an abrasion wound, the correct aftercare (saline wash, an antibiotic ointment and the correct dressings) is recommended to all my patients to avoid potential infection. Inflammation and swelling in the treated area may occur, however this resolves itself within a few days. My advice when it comes to using equipment is to be sure that physicians have been fully trained and are comfortable with using it.

Injury burns to both patient and staff can occur through carelessness during a procedure. Approximately 50-100% of keloids respond to the injection of a corticosteroid as it suppresses inflammation and mitosis while increasing vasoconstriction in the scar.6 Injections are given every two to six weeks until improvement is seen. This may cause subsequent side effects such as a network telangiectasia due to the thinning of the scar tissue or due to trauma to the area. These do subside as the scar tissue thickens, however I usually recommend a laser/SWT session to my patients to reduce or permanently remove telangiectasia.6 Pigment change can also occur in the treated area. This is temporary and usually returns back to normal once the injections are reduced or stopped. If hyperpigmentation occurs, I usually prescribe a 4% hydroquinone-based product to lighten the area and to treat postinflammatory hyperpigmentation.6

regard to the adjacent healthy skin. In order to obtain a good colour match, close examination of the scar and the surrounding skin is required. This treatment is also referred to as a scar camouflage.

If the scar is still pink-red or pink the tissue may not have healed sufficiently and it is not suitable to proceed with re-pigmentation. In this case patients will be advised on additional treatments with our skincare specialist such as laser/SWT treatment. We can reduce the redness of a flat scar with a laser system and then perform medical micropigmentation on the area. The patient could require up to four sessions. Types of scars you can treat on the face and body with micropigmentation: • Scar tissue resulting from plastic surgery; post-facelift scars are very popular to conceal • Scars from broken glass • Burn scars • Hypertrophic scars Most scar re-pigment procedures will require multiple sessions, due to the area being damaged tissue. Every patient will be advised upon consultation, as it is completely dependent on the area, however it generally takes between two to four sessions. Patients must be aware that maintenance is required every 12 to 18 months and so they must be motivated to pursue the relevant sessions as per recommendations by the specialist. During and after the procedure the area will display redness and perhaps capillary breakage that resembles the original trauma. Areas with substantial hyperpigmentation may not be suitable for medical micropigmentation as needle intrusion can worsen the condition. In these cases, I would rather prescribe a 4% hydroquinone cream to reduce the colour.

The thickness of the scar will influence the final colour outcome and pigment retention. Some scars can either reject pigment, in which case additional sessions will be required, or they may retain pigment creating dark patches in which case I would prescribe a 0.1% tretinoin cream and chemical exfoliator to exfoliate the area. Correct and diligent aftercare is given to all our patients to avoid potential infection from occurring. Redness, inflammation and scabbing is a natural part of the healing process which usually subsides within four to seven days. The scar will not appear camouflaged immediately after the initial procedure, in most cases results are seen after two weeks.

Medical micropigmentation In my clinic I use the medical micropigmentation method to treat scarring. This procedure is done by depositing micro amounts of coloured pigments into the skin leaving a trace of pigments, in order to re-colour an achromia or reconstruct a structure. The aim of re-pigmenting a scar is to diminish the visibility of the scar with

Fractional laser resurfacing Fractional laser resurfacing is a popular treatment utilised for the treatment of atrophic scarring, surgical scarring and striae. At the London Cosmetic Clinic we use a fractionated non-ablative laser that delivers a large number of very small spots per square centimetre of the skin. These columns of energy create a heat reaction in the dermis, which works on the principle of injury and repair leading to reversible necrosis resulting in collagenases, angiogenesis and structural changes within the dermis and scar tissue.7,8,9 Treatments are performed at six-week intervals and a course of three treatments is recommended. A topical anaesthetic such as EMLA or LMX 4 is applied prior to the application of the laser to reduce any discomfort.

There is little to no downtime associated with this procedure, the patient will usually feel a mild sunburn sensation and there will be mild to moderate erythema present, depending on the sensitivity of the patient.

Before

Before

After

After

Figure 3: Self-harm scars on the outer arm before and after micropigmentation treatment

Figure 4: Self-harm scars on the inner arm before and after micropigmentation treatment

SWT For any residual redness such as post-acne inflammation, postsurgical scarring, or pre-medical micropigmentation procedures, the laser treatment aims to diminish the redness of a flat scar. This can be

Reproduced from Aesthetics | Volume 3/Issue 9 - August 2016

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performed as soon as three weeks after surgery for optimal results, providing sutures have dissolved/been removed. SWT will treat the very light salmon-coloured scars using the sub millisecond pulse.10 Practitioners should be trained thoroughly on the administration of SWT and take care to ensure that the appropriate energy levels are delivered safely with the most suitable pulse duration used.

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medical consultation should always be undertaken to ensure all concerns are managed successfully. Pre and post information should be supplied to all patients prior to the selected treatment, as well as scheduled follow-up appointments to ensure the correct result has been achieved.

Surgery Surgery can improve the appearance of scars, change the shape of the scar and release a tight scar that is close to a joint in order to improve movement. Scar revision is a process of removing scar tissue.

After the excision the new wound is usually closed in order to heal by primary intention, instead of secondary intention. Deeper cuts need a multi-layered closure to heal optimally, otherwise depressed or dented scars can result. Surgical excision of hypertrophic or keloid scars is often associated with other methods such as pressotherapy or silicone gel sheeting. Be aware that performing surgery on a scar will leave a new scar and I have found that may take up to two years to heal. There is also an increased risk of further keloid and hypertrophic scarring following surgery. After surgery the recurrence rate for keloid scarring is approximately 50-80%.10 Conclusion Above all, it is my aim to make patients feel as comfortable and relaxed as possible, and to make them aware of their options and the realistic outcome of any treatment. At my clinic, we pride ourselves on patient care and experience, ensuring our patients’ visit and treatment is as informative, comfortable and professional as possible. A thorough

Dr Salinda Johnson regularly trains doctors, nurses and other medical practitioners on a range of medical aesthetic procedures with an emphasis on best practice and optimum treatment results. She began her aesthetic career in 2000, having completed a specialist fellowship programme in cosmetic dermatology. Dr Johnson continues to hone her techniques and expertise in the field, incorporating up-to-date procedures and best practice as they develop.

REFERENCES 1. Sund B., ‘New developments in wound care’, PJB Publications, (2000), pp.1-255.

2. UK Health Centre, ‘Atrophic Scars’, (2016) <http://www.healthcentre.org.uk/cosmetic-treatments/scarsatrophic.html> 3. Gauglitz GG, Korting HC, Pavicic T, et al., ‘Hypertrophic scarring and keloids: pathomechanisms and current and emerging treatment strategies’, Mol Med., 17 (2011), pp.113-125.

4. Har-Shai Y, Mettanes I, Zilberstein Y, et al., ‘Keloid Histopathology after intralesional cryosurgery treatment’, J Eur Acad Dermatol Venereol, 25(2011), pp.1027-1036.

5. Thomas DW, Hopkinson I, Harding KG, Shepherd JP, Int J Oral Maxillofac Surg., 23 (1994), pp.232-6.

6. Jacob CI et al. “Acne scarring: A classification system and review of treatment options.” J Am Acad Dermatol 2001;45:109-17 7. Beasley K, Dai JM, Brown P, et al. Ablative fractional versus nonablative fractional lasers-where are we and how do we compare differing products? Current Dermatology Reports. 2013;2:135–143.

8. Harithy Ra, Pon K. Scar treatment with lasers: a review and update. Current Dermatology Reports.

2012;1:69–75.

9. Bogle MA, Yadav G, Arndt KA, Dover JS. Wrinkles and acne scars: ablative and nonablative facial resurfacing. In: Raulin C, Karsai S, editors. Laser and IPL Technology in Dermatology and Aesthetic Medicine. Berlin Heidelberg: Springer; 2011. pp. 289–297.

10. Selective Waveband Technology (Denmark: Ellipse, 2016) <http://www.ellipse.com/en/Clinical/ Selective-Waveband-Technology> 11. Leventhal D, Furr M, Reiter D, ‘Treatment of keloids and hypertrophic scars: a meta-analysis and review of the literature’, Arch Facial Plast Surg. 8(6) (2006), pp.362-8.

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A summary of the latest clinical studies Title: Tightening effects of high-intensity focused ultrasound on body skin and subdermal tissue: a pilot study Authors: Choi SY, No YA, Kim SY, Kim BJ, Kim MN Published: Journal of the European Academy of Dermatology and Venereology, June 2016 Keywords: HIFU, skin tightening, Asian skin Abstracts: This pilot study assessed the efficacy and safety of High-intensity focused ultrasound (HIFU) for body tightening in Asian females. Six Asian female adults were enrolled in this pilot study. All subjects were treated with HIFU to the both cheek, upper arm, lower abdomen, thigh and calf using the following probes: 7 MHz, 1.5 mm focal depth; 2 MHz, 3.0 mm focal depth; 2 MHz, 4.5 mm focal depth; 2 MHz, 6.0 mm focal depth and 2 MHz, 9.0 mm focal depth. Three blinded independent dermatologists assessed results using the Investigator Global Aesthetic Improvement Scale (GAIS) using paired pre- and post-treatment (week 4) standardised photographs. Also, we evaluated skin elasticity at all treated sites using a cutometer. Participants used the subject GAIS to assess their clinical improvement after treatment and rated their pain using a visual analogue scale (VAS) immediately, one and four weeks after treatment. The three blinded-evaluators judged all treated sites as showing clinical improvement 4 weeks post treatment. Skin elasticity measured via cutometer was significantly improved 4 weeks after treatment at all treated sites (P < 0.05). All patients scored themselves subjectively as more than ‘improved’ on the GAIS. Immediately after treatment the mean VAS score was 5.17 ± 2.48, but no pain was reported at weeks 1 and 4.

effects on feminine tissues and appears to increase local blood flow, resulting in increased vaginal tightness and moisture. Improved appearance and friction resulted in improved confidence and reduced performance anxiety.

Title: Transcutaneous temperature controlled radiofrequency for orgasmic dysfunction Authors: Alinsod RM Published: Lasers in Surgery and Medicine, May 2016 Keywords: Radiofrequency, orgasm, sexual rejuvenation Abstract: To evaluate the safety, tolerability, and clinical efficacy of transcutaneous temperature controlled radiofrequency (TTCRF) on vulvovaginal tissue for orgasmic dysfunction. Subjects included 25 sexually active women, ages 21-65, with self-reported difficulty in achieving orgasms during sex (anorgasmic or slow-to-orgasm). Each patient received three sessions at intervals of about 1 month. Treatment was performed using a slim S-shaped probe with a stamp-sized metal radiofrequency emitter on one surface of the tip (25 minutes total time on average). External treatments covered the labia majora and minora, lower mons pubis, perineal body, clitoral hood, and clitoris. Full-length treatment of the vagina with concentration on the anterior wall was performed. Tissue temperature during therapy was elevated to and maintained between 40°C and 45°C. No anesthesia was required. After treatment, patients immediately resumed normal activities, including sex. Twenty-three of 25 patients reported an average reduction in time to orgasm of 50%. Patients also noted significant vaginal tightening effects, increased vaginal moisture, and improved vulvar and clitoral sensitivity. All anorgasmic patients reported the ability to achieve orgasms. Two patients had minimal response. TTCRF is an effective non-hormonal, non-surgical option for women having difficulty achieving orgasm. Treatment also has visible tightening

Title: Evaluation of anti-acne property of purified bee venom serum in humans Authors: Han SM, Pak SC, Nicholls YM, Macfarlane N Published: Journal of Cosmetic Dermatology, May 2016 Keywords: P.acnes, acne vulgaris, bee venom, lesion Abstract: Acne vulgaris is a chronic dermatologic disease with four factors involved in the development of lesions. Treatments need to address as many of these underlying factors as possible in order to reduce acne lesions. As such, purified bee venom (PBV) serum is an attractive therapeutic option for acne, but little data exist on the efficacy of this treatment strategy. In this prospective, non-comparative study, 30 subjects having mild-to-moderate acne vulgaris were enrolled and treated with PBV serum twice daily for a period of 6 weeks. Clinical evaluation of lesions by expert visual grading and image analysis were made at weeks 0 (baseline), 3, and 6.

The average visual acne grade of all volunteers significantly improved with the PBV serum treatment at weeks 3 (P < 0.05) and 6 (P < 0.001) when compared with the baseline grade at week 0. In addition, there was a mean percent improvement of 8.6% and 52.3% in acne grade observed after 3 and 6 weeks of PBV serum use, with 20% and 77% of the subjects showing improvement, respectively, when compared with baseline. Moreover, the subjects showed improvement in open comedones, closed comedones, papules, pustules, and nodules after 3 and 6 weeks of PBV serum use. Six weeks of treatment with PBV serum was found to be effective in the treatment of mild-to-moderate acne vulgaris, with no incidence of serious side effects or irritation.

Title: Efficacy and Safety of a Hyaluronic Acid Filler to Correct Aesthetically Detracting or Deficient Features of the Asian Nose Authors: Liew S, Scamp T, de Maio M, Halstead M et al.

Published: Aesthetic Surgery Journal, July 2016 Keywords: Hyaluronic acid, nose, non-surgical Abstract: To evaluate the safety, efficacy, and longevity of a hyaluronic acid filler in the correction of aesthetically detracting or deficient features of the Asian nose, twenty-nine carefully screened Asian patients had their noses corrected with the study filler (Juvéderm VOLUMA with lidocaine injectable gel). Individualised treatment goals were reflected, utilising a standardised injection procedure, and were followed for more than 12 months. A clinically meaningful correction (≥1 grade improvement on the Assessment of Aesthetic Improvement Scale) was achieved in 27 (93.1%) patients at the first follow-up visit. This was maintained in 28 (96.6%) patients at the final visit, based on the independent assessments of a central non-injecting physician and the patients. At this final visit, 23 (79.3%) patients were satisfied or very satisfied with the study filler and 25 (86.2%) would recommend it to others. In this small series of patients, there were no serious adverse events (AEs), with all treatmentrelated AEs being mild to moderate, transient injection site reactions, unrelated to the study filler.

Reproduced from Aesthetics | Volume 3/Issue 9 - August 2016

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discussions with the practitioner to resolve the concern directly or seek legal advice.

What to do when under investigation Aesthetic insurance and claims manager Naomi Di-Scala explains why aesthetic practitioners may find themselves under investigation and what to do in this situation Having spent years training in your profession, there is nothing more worrying than receiving a letter from your governing body advising you that your practice is being questioned because your ‘fitness to practise’ is under scrutiny.

A practitioner who is ‘fit to practise’ is someone who has demonstrated that they have the knowledge, skills and character to carry out their professional duties safely and effectively and pose no risk to the general public.1 The large majority of practitioners will be conscious of the requirements to comply with this and will endeavour to ensure they are always compliant with the guidelines set out by their governing body. But what should you do if, for whatever circumstances, you find yourself under investigation?

What happens first and why?

Generally speaking, the governing body, such as the General Medical Council (GMC) and Nursing and Midwifery Council (NMC), would usually receive a complaint from a third party that has concerns over your practice. This does not necessarily have to be a patient you have treated, it could be a colleague you work with, a supplier you obtain your stock from or even a trainer. It is rare that a peer puts in a complaint but it does happen if they have concerns over how you are conducting your practice. Investigations can occur for a number of reasons and some examples of allegations that could be brought against you are highlighted below (please note that this list is not exhaustive):2 • Repeated complaints over the outcome of a particular treatment, suggesting that

there may be a training requirement • Failure to meet the minimum training requirements for your particular profession • Failure to comply with a fitness to practise investigation or the blocking of an investigation • Evidence of fraudulent activity • Exploitation of vulnerable patient(s) • Health problems that are detrimental to your ability to work • Sexual misconduct • Violence, aggressive or threatening behaviour • Substance or alcohol abuse It should be noted, however, that the governing bodies do have a certain level of understanding where one-off incidents or mistakes are made. Ultimately, everybody is human and mistakes do happen. If a case arises as a result of a one-off mistake, although there may still be an investigation completed as a matter of course, dependent on its severity, sanctions being imposed are not definite.

What is the process for a fitness to practise investigation?

The governing body will initially receive the complaint or notice from a third party, and the matter will be investigated to determine whether or not the matter falls within their remit. If, for example, the matter refers to an ongoing general dispute between you and a patient, such as bad customer service or appointment times being cancelled, then the third party will be advised that no action can be taken by the governing body and the complainant should either try to enter into

In some cases, it is clear from the outset that there is no need for the insurer to investigate because the complaint is about matters that cannot raise an issue of impaired fitness to practise. Therefore these cases are closed without taking any further action.

Examples of cases closed without any investigation are: • Minor motoring offences not involving drugs or alcohol • A delay of less than six months in providing a medical report • A minor non-clinical matter (issue with service) • A complaint about the cost of private medical treatment If the case is one that falls within the scope of the governing body’s investigation process, a case manager will be allocated to advise you throughout the process. The case manager will usually make contact with you initially via letter and also via telephone communication.

They will advise you of the complaint that has been received and, depending on the nature of it, a timeframe for the process they intend to follow and what the next steps will be.

You will be provided with details of the complaint that the governing body has received, which will give an opportunity to provide a full response along with any evidence you may have to support your case and insurers’ advice. Supporting information will include documents such as: medical files, notes, consent forms and summary of treatment. The more compliant you are and the more evidence you have, the easier it will be to explain your actions. It is also important to be honest. Even if a genuine mistake has been made, if you advise your insurer about this, they will be able to communicate with you the best process forward with the governing body – solicitors will recommend honesty from the start to avoid completing a case at a later stage. If you are resistant to the investigation it will give the governing body more grounds for concern and they could potentially believe that you are trying to withhold information as you have done something wrong.

Following your response to the governing body, the case will then be reviewed by a committee who will decide whether your response to the allegations is sufficient for them to be assured that you are competent

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within your practice. The committee is made up of a panel of medical and lay performance assessors for the purposes of carrying out performance assessments in accordance with Schedule 1, and for the purposes of carrying out health assessments in accordance with Schedule 2.3 The decision that they then make will be sent to the complainant and the decision will also be issued to you.

If there is no further action, then the matter will be closed.

What should I do if I receive notification of a fitness to practise hearing?

It is very daunting to receive such notification, no matter how experienced you are. The first step would be not to hide away from it but to deal with it straight away. Initially a standard letter would be generated to advise you that a complaint had been raised and there is likely to be a request for your employment history for a period of time, along with your acknowledgement of the case. It’s important to note that non-compliance could have more serious implications or sanctions being imposed immediately.

The next step would be to notify your insurer of the investigation. Most medical malpractice policies on the market will have additional extensions of cover to provide you with indemnity in these situations. Providing that practitioners notify insurers before responding to enquiries, then initial advice should be provided by the insurer. Then, if the matter turns into a full investigation, a solicitor will be appointed by the insurer to work with you to build a supporting case.

Usually the defence costs associated with the appointment of a solicitor on your behalf would be covered by the policy. All insurance claims have the potential to increase excess/ premium, but this would be subject to insurance claims history and the underwriters’ criteria. The solicitor will then liaise with you to create a case to be heard in the court.

The time between the practitioner receiving the notification of the hearing, to the hearing itself, is varied and depends on how quickly the case is assessed. It is recommended that you check your policy coverage for regulatory investigations to ensure that you are adequately covered in the event a case is raised against you.

What sanctions can be imposed?

Following a full investigation, the committee will make recommendations in writing as to whether any further action should be taken.

The nature of the sanction being imposed will be dependent on the severity of the

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allegations and case and whether any fault has been found with the practitioner. In some scenarios the practitioner may be suspended from practising whilst more information is obtained in order to make the correct decision. If the investigating committee deems that the practitioner’s practice is impaired then they could impose the following:4 • Clinical supervision – whereby the practitioner’s work is only carried out under the supervision of a peer who has been approved by the responsible officer (likely to be the medical director of the organisation supporting you with your appraisal and revalidation).5 The supervisor then takes on the responsibility of the practitioner’s work and provides feedback to them and the governing body in order to carry out a review of their performance.

• Conditions being imposed on the registration of a practitioner – e.g. they can only perform certain treatments or their practice is subject to supervision.

• Personal development plans – where it is decided that the practitioner requires additional training and learning to become more competent, a personal development plan could be put in place. This will list the learning requirements for the practitioner and practical solutions in order for them to improve and demonstrate their learning.

Objectives will be set and feedback and reflective reports would then need to be submitted.

• Suspension from duties – this is typically imposed at the investigation stage if there is concern that patient safety is at risk.

• Striking off the register – this is the most serious outcome of an investigation whereby the committee deem that the practitioner is not adequately competent to perform their work without causing a risk to the general public and patient safety. The Medical Practitioners Tribunal Service, the disciplinary arm of the GMC, are the ones who decide on if a doctor should be removed from practising.

What to do if you disagree with the decision If you do not agree that the correct decision has been reached by the investigating committee, and then the court via the hearing, you are able to appeal. You will have 28 days to do so. Depending on your jurisdiction, this will determine where this should be appealed. Usually for England, Wales or Northern Ireland this appeal would go to the High Court and for Scottish cases

this would be presented to the Court of Session. A written notification of the hearing outcome will include details of the appeal process. If you received and signed for a notification at the hearing, the 28 days run from the date of the tribunal’s decision. If this did not happen, the 28 days will run from the day on which, as set out in the Medical Act 1983, notification was deemed to have been served on you, by post or email (if you provided the GMC with an email address to be used in relation to fitness to practise matters).

The GMC has the power to appeal if it considers that the hearing outcome is not sufficient for the protection of the public (which is the GMC’s overarching objective).

Solicitors will give you advice on recovering costs relating to the appeal.

Conclusion As a medical practitioner there is a certain occupational responsibility towards the general public and patients, which requires a good level of education and practical ability. Therefore it is important to ensure that you are always up-to-date with training and continued professional development.

However, no matter how compliant you are, there could come a time where a case is brought against you, as consumers become ever more aware of their rights and have more access to redress if they are unsatisfied or have concerns over a practitioner’s abilities. Therefore, make sure you are familiar with the process and your insurance policy, as they could help you considerably if this situation arise.

Naomi Di-Scala is cosmetic manager at aesthetics insurance company Hamilton Fraser and supports cosmetic practitioners through the claims process.

Di-Scala was previously claims team leader for five years, managing claims and dealing with complaints on medical malpractice, salon and surgery, landlords, commercial and household policies.

REFERENCES 1. GMC, The meaning of fitness to practise, gmc-uk.org, (2014) <http://www.gmc-uk.org/the_meaning_of_fitness_to_practise. pdf_25416562.pdf> 2. GMC, GMC Thresholds, gmc-uk.org, (2015);p.3 <http://www.gmcuk.org/Guidance_GMC_Thresholds.pdf_48163325.pdf> 3. GMC, The General Medical Council and its Committees, and the Branch Councils, gmc-uk.org, (2016) <http://www.gmc-uk.org/ about/legislation/medical_act.asp#s1> 4. GMC, The GMC’s fitness to practise procedures, gmc-uk.org, (2016); item 30, <http://www.gmc-uk.org/DC4541_The_GMC_s_ Fitness_to_Practise_procedures.pdf_25416512.pdf> 5. GMC, What is a Responsible Officer?, gmc-uk.org, (2016), <http:// www.gmc-uk.org/doctors/revalidation/faq_revalidation.asp>

Reproduced from Aesthetics | Volume 3/Issue 9 - August 2016

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The Business of Skin Skincare company brand education manager Sharon Cass outlines how practitioners can offer bespoke skincare advice to patients The skincare market and the aesthetics industry are increasingly saturated with both product offerings and service providers, particularly within the antiageing sector. This expands consumer choice but can make it harder for the voice of individual brands to be heard. Robust retail and treatment sales are essential for a financially successful clinical business, but more importantly, we need patients to follow the skincare advice we give them to support our procedures and ensure good results. So how can we reinforce our expertise and recommendations when patients are bombarded with so much information from TV, magazines, bloggers and even our competitors?

Follow the trends A surprising answer perhaps is that retail trends can provide a useful reference when deciding how to communicate with patients and can actually help us to stay relevant to them in this fast moving market.

This doesn’t mean changing what you do or dumbing down your approach, but rather, by modifying the language you use, how you frame advice and how you prioritise recommendations, you will be more accessible and better able to motivate patients to commit to the programme that is right for them. For instance, when we discuss reducing photodamage, hyperpigmentation or rosacea, it can sometimes be hard for patients to fully comprehend the changes they will see so we need to discuss benefits more than ingredients or procedures. By outlining the visible changes or benefits they could see in simpler terms (smoother skin, softer texture, brighter, plumper, evened-out skin tone and so on) we are using similar visual language to retailers that will be far more accessible and motivating for patients.

You need to be the expert that your patient is seeking and help them to navigate their way through the white noise of information and you will be better placed to do that if you understand the dialogue and influences your patients are exposed to elsewhere.

There is a lot we can learn from the retail environment and the ways they successfully motivate their customers to follow their advice.

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High street retailing has become an intensely personal environment with brands presenting themselves as understanding the concerns and needs of their customers and interacting with them to find tailored solutions both online and in store. Space NK, for instance, offers personalised recommendations through their consultants who check previous purchases against your results and then recommend further products based on your concerns or preferences. It is not just premium outlets that offer this level of service; mass-market retailers are also increasing the personal approach and capturing more of this advanced market. The Body Shop has a skincare-online service, where their expert will ‘hand pick the ideal skincare regime for you’.

Liz Earle also offers one-to-one guidance and has cleansing bars in its retail areas where its teams can show you how to get the best result for your particular skin condition.

There are many trends that a clinical environment should be well placed to compete successfully in and with a fresh focus we can make our products and services more relevant to today’s discerning and well-educated consumer. If we fail to communicate effectively we leave our patients open to the influences of retail media messages and brand marketing.

A growing market In 2015, UK consumers bought more than £4 billion worth of beauty and personal care products, making us larger than the French market for the first time with skincare sales growing by 4%.¹ According to Euromonitor, UK customers are some of the heaviest spenders on beauty and personal care products globally and are open to new products and ingredients that will enhance their routines.² The size of this market is growing and indicates that our potential customers are open to learning more about ‘at-home’ products that can improve their appearance. This creates a fantastic opportunity for clinical practices to capture some of this market but also to offer something different; a professional service offering evidence-based products and treatments that are effective, thereby helping our patients to avoid buying products that don’t work or are not suitable for their needs.

High street retailing has become an intensely personal environment with brands presenting themselves as understanding the concerns and needs of their customers

Reproduced from Aesthetics | Volume 3/Issue 9 - August 2016

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Dove campaign Dove campaigns include many initiatives that listen to their consumers and act upon them. As far back as 2006, 75% of their surveyed clients wanted to know how much media images were doctored,⁶ so they created their video ‘Evolution’ to show how unrealistic these images are for ordinary women to achieve. There are many other campaigns their ‘Real Beauty’ mantra encompasses and it is still an integral part of their marketing strategy. The success of this product franchise shows the approach of listening and approaching consumers differently is very powerful.

What are the key retail trends?

A key trend that clinics should be well placed to meet is the increased demand for bespoke, personalised products and services. According to worldwide consulting and research firm Kline, a rise in the expression of individualism has increased demand for custom-made products and services that feed into our desire to be unique.³ In the retail market this is translating into products that are blended and customised according to the customer’s unique profile, sometimes determined by DNA testing. This type of testing can identify specific genetic markers such as collagen degradation, inflammatory pathways, glycation and susceptibility to pigmentation to predict future ageing trends. DNA tests are carried out in-store and sent to the laboratory where they prepare a personalised report for the customer, mapping recommendations and bespoke skin formulas to the results of the test. In our clinical market this can be more about how we devise treatment protocols and homecare recommendations that are unique to each individual patient. We should already be treating each patient as an individual and tailoring our recommendations to their specific needs but this is an area we can really focus on, especially when it comes to retail recommendations.

It may not be obvious to a patient that your advice is unique to them so promote this as a particular benefit of visiting you.

Communicate with your patients that following their consultation they will receive a bespoke set of recommendations that will form a plan to address their individual needs. We need to listen to our patients’ concerns and goals and devise both treatments and homecare plans that are solution specific and targeted. Don’t just think of short-term goals; plan a treatment journey that is ongoing, regularly reviewed and includes skin priming and initial treatment, as well as maintenance programmes. This will motivate your patients to undertake more regular visits and allow you to review their success and adjust your advice as necessary. Make sure you also follow up on key retail homecare purchases and not just treatments. A call a few days later to see how the patient is getting on and if they are finding their new homecare regime effective reassures the patient that we genuinely care about their results and were not just trying to hard sell to them.

Be aware that some luxury market retailers already use this approach with great effect, regularly reviewing their customers’ purchases and gaining feedback on how the customer has found their product before making further recommendations. If we do not follow such diligent reviews with our patients then we are missing an opportunity to establish a deeper, long-term relationship with them and establish ourselves as the expert they rely on. It has never been more important to avoid a ‘one size fits all’ approach to product recommendations and treatments.

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Tools Diagnostic tools can really help with tailoring services for patients as they can demonstrate to the patient what is really happening under the surface and create a bespoke strategy. Questionnaires about lifestyle, and imaging systems and devices that diagnose oil secretion, hydration or photo damage, as well as DNA tests that determine future ageing, all help you to understand your patient more closely and produce relevant recommendations. Retailers are increasingly developing their own diagnostic systems such as apps that help consumers select products, and computer systems that diagnose skin more accurately, so this is an area the clinical environment can and should compete with effectively, as we can add our professional expertise to the diagnostic process.

A new age The next area that deserves our attention is the change in the way consumers now view the ageing process. New language such as ‘pro-age’ or ‘age-well’ now seems to be less of a trend and more of a change in consciousness; consumers are tired of fighting ageing, fighting the inevitable, and instead prefer to have the best appearance they can for their age. We can see this evidenced within several current media campaigns, outlined below. I predict we will see more of this as it feeds into our idea that we are beautiful in our own way; it is empowering and is the antidote to the unobtainable beauty standards and airbrushed images that have largely been presented thus far.⁴ The Dove

We should already be treating each patient as an individual ‘Real Beauty’ campaign shows positive, diverse images of women and actively promotes positive body image; their ‘Wrinkled or Wonderful’ adverts have shown inspiring images of ageing women who look fabulous despite having wrinkles.⁴ In 2014, Olay launched their ‘Best Beautiful’ campaign aimed at empowering women and invited them to ‘join in the conversation’ and share their ‘beautiful moments’.⁵ This campaign promoted the statement that beauty is an obtainable goal. L’Oreal has enlisted positive age ambassadors such as Helen Mirren with the tag line ‘it took years to look this good’ which have resonated well with an ageing population who see their advanced years in a more positive light.

This doesn’t make our industry irrelevant, quite the opposite, as it is hard to wear your age with pride if you haven’t aged that well.

I do think though that we ignore this change in dialogue at our peril. The language of ageing is changing and our patients will be increasingly looking for procedures and great skincare to help them be the best possible version of themselves rather than opting for procedures that alter or distort their natural features. Language such as refresh, brighten, enhance, soften and volumise are already evident in our market as much as the retail environment.

They communicate products and procedures that will help us look less tired, feel fresher and younger and seem more accessible and appealing to our patients who don’t want to look vastly different

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and actually fear the distortion of features they see in some high profile people in the media.

Seasonal skincare Another key trend that we should consider is seasonality and what products and services our patients are motivated to buy at specific times of the year. This doesn’t mean you need to deck your business with kitsch Christmas gifts if that is not your market, but you can highlight the products and services that will benefit your patients more and aim to correct seasonal changes in their skin. The Mintel report on seasonality indicated that seasonal product launches have increased from 9.8% in 2011 to 11% in 2014 with a strong consumer demand for skincare seasonal changes. Jane Henderson, global president of beauty and personal care at Mintel, stated, “Beauty manufacturers have started to go beyond taking simple seasonal approaches to public holidays or gifting occasions and instead are taking on the elements within their product innovation.”⁷ I think for clinical businesses this is the correct approach; we need to be mindful of pushing short term offers onto our patients, however it is absolutely appropriate to highlight services and products that could be beneficial and help solve seasonal problems. Be creative and focus yourself and your team on what people might need at specific times of year. Post-holiday packages to remedy pigmentation for instance; emollient/calming products to reduce sensitivity in colder weather; the correct suncare and SPF offering to ensure adequate protection in the summer, or lighter homecare products for clients who experience more acne breakouts in the summer time. Bringing this trend together with the first trend mentioned for bespoke solutions,

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why not offer patients quarterly assessments to create treatment and product programmes that help them navigate how their skin changes with each season for a truly customised approach? Whatever we are offering to patients in terms of treatments and products it is important in all our interactions to keep in mind that patients have more influences and information than they receive in clinic. By thinking like a consumer as well as a clinician we can offer advice and information that is more accessible and relevant. We can also start to see the retail environment as a source of information and even inspiration to keep up-to-date with what consumers want, helping in-clinic marketing drives to achieve maximum success.

Sharon Cass is a lecturer and public speaker specialising in medical aesthetic techniques, both here in the UK and internationally. Cass has more than 25 years’ experience in the professional skincare industry. Following a successful period as national clinic manager for a wellknown cosmetic clinic group, Cass now heads up the education team for Skinbrands.

REFERENCES 1. The Beauty Advisor, UK beauty market tops £4bn for the first time, The Beauty Magazine, (2016), <http://www.beauty-magazine.co.uk/uk-beauty-market-tops-4bn-for-the-first-time-> 2. Euromonitor International, Beauty and Personal Care in the United Kingdom, Euromonitor, (2015), <http://www.euromonitor.com/beauty-and-personal-care-in-the-united-kingdom/report> 3. Klineblogs, Top Trends of Cosmetics and Toiletries, Klinegroup, (2016), <http://www.klinegroup.com/ blogs/index.php/2016/01/28/top-trends-of-cosmetics-and-toiletries/> 4. Dove, Dove Real Beauty Sketches, Dove (2016) http://www.dove.com/uk/stories/campaigns.html 5. Clickz.com, Olay campaign positions #BestBeautiful as a rallying cry among women; Lisa Lacy, (2014) http://www.clickz.com/olay-campaigns-positions-bestbeautiful-as-rallying-cry-among-women/33720 6. Dove, Dove Stories, Dove (20160 http://www.dove.com/uk/stories/campaigns/evolution 7. Mintel, Beauty and Personal Care Announces Seasonality As A Key Beauty Trend, (2015) pp,3-4 <http://www.mintel.com/press-centre/beauty-and-personal-care/mintel-announces-seasonality-as-akey-beauty-trend/>

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

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from using your training, research and innovation for their own benefit.

Trade marking allows you to put the ® symbol next to your brand, which shows that it’s yours and warns others against using it.5 The TM symbol is used when you have applied for the trade mark but it isn’t registered yet. Although you can continue to use it if you wish to.

Trade Marking in Aesthetics Dracula Therapy trade mark owner Dr Daniel Sister and marketing director Jemma Patton discuss how and why aesthetic practitioners might consider trade marking a treatment, protocol or product for the aesthetics industry What is a trade mark?

A trade mark is a type of intellectual property protection that helps safeguard your brand. In aesthetics this usually means a product or a specific treatment protocol. A trade mark is different from a patent, which gives an inventor the right to stop others from making, selling or using their invention unless they are given permission.1 A trade mark is also different from copyright, which protects work that is recorded, either in words or sound, such as literary works and music.2 A trade mark – and note in the UK it is trade mark, in the USA it is trademark – allows its ‘owner’ to protect their brand and enables them to take legal action against anyone who uses their brand without permission. It allows exclusive access to the use of the trade mark in the areas you have it registered, or to sell and/or license it for others to use, which can be useful for developing a business.3 In the aesthetics industry, anyone who has created a treatment, protocol, a product, or a piece of equipment (a new piece of equipment would also need a patent) can, in theory, register it for a trade mark. However, it must be distinctive. This means you must be able to prove that it is sufficiently different from any other goods or services. For example, misspelling ‘Coka-Cola’ and trying to trade mark it would not be allowed, as it is too similar to the original. You’ll need to be detailed here – do your research and ensure you can explain how and why your product differs from others in the market.

The appearance of the trade mark must be unique, and it can include words, sounds, logos, colours or any combination of these.

It cannot contain offensive words, it cannot describe the goods or service, cannot be misleading, or be too common or distinctive.4 Why register a trade mark?

Having a registered trade mark could make your brand more valuable and give it added credibility and gravitas. You’ll protect your right to exploit, sell and license your own product. You’ll prevent competitors

What are the boundaries of a trade mark?

A trade mark lasts for 10 years and can be renewed in its final six months. Trade marks are territorial, so only offer protection in the countries they are registered in.9 A UK trade mark covers the UK, whereas a Community Trade Mark (CTM) protects throughout the EU, (whether a CTM continues to offer protection in the UK may be up for debate due to the recent result of the European Union referendum). It is also possible to apply for an international trade mark. You can either file applications in multiple countries, or file a ‘Madrid System agreement’,10 which allows you to extend protection of your trade mark via a single application. However, this can be costly, and only applies to the countries signed up to the Madrid System. It’s best to decide from the outset how much protection you want so that you know which trade marks to apply for.

How to register a trade mark Your first step should be to check to see if it is already registered.

Sometimes, even when we believe we are totally innovative and new, the reality is that someone else may have got there first. Look online for what you want to register by visiting the Intellectual Property Office website, which allows you to do a comprehensive search.6 Once you’re sure it is not already registered, in our experience it makes sense to use the services of a trade mark registration company, such as RevoMark, Trade Mark Direct or Trade Mark Eagle, to name but a few. It is possible to complete the process yourself, but in reality the cost is minimal compared to the amount of work involved, and using a specialist company helps you to avoid potential pitfalls along the way, such as paperwork errors, which cause delays. Many even offer a money back guarantee if for some reason registration proves impossible. Once you’ve submitted an application the registry will check it. It usually takes around three weeks for this to happen. Once it passes the checks it will be published in the trade marks journal, an online journal on the Intellectual Property website which allows for third parties to object to the mark. If no objections are filed within two months (for UK application) or three months (for CTM applications) then your certificate will be issued. In total the process generally takes five to six months. Trade marks are split into ‘classes’, of which there are 45. These classes represent different goods/services that you wish to use the trademark for. Our trade mark for ‘Dracula Therapy’ is within class 44 which includes ‘medical services, hygienic and beauty care for human beings and dentistry services’.7 Do I need to register a trade mark if I already have a company name?

Many people don’t understand why they need to register a trade mark if they already have a company name registered with Companies House. However, they are not the same thing. A company name simply establishes a business as a legal entity, it does nothing to protect the name of your brand. The same goes for domain names; having a website address does not give you any claim over the name of a brand.8 How do I protect my trade mark?

There’s little point in registering a trade mark if you are not prepared to protect it. Many registration companies also offer a ‘trade mark watch’

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service, but we chose to take on this role ourselves as we already have a comprehensive social media strategy and we find monitoring the brand name sits easily within this area. The process is fairly simple, but you do need to be constantly vigilant. We have Google Alerts set up to inform us of our trade marked name being used. By using Google Alerts, you receive an email any time Google finds new results on key words you choose. We also monitor social media networks for infringement. It’s best practice to attempt to resolve infringements amicably, but on occasion it is necessary to issue a legal letter. I would suggest hiring a lawyer in order to do this. This doesn’t have to be costly; a lawyer can draw up a template letter on which you can change the relevant details and re-issue. The letter should be issued on headed paper and contain your trade mark number and name – it’s not a legal requirement but best practice and looks professional.

Conclusion From our experience, registering the trade mark Dracula Therapy has absolutely been worthwhile. We’ve seen our brand grow and have been able to control and restrict its use in ways that benefit us.

PRP has many variables, so it’s given us the ability to distinguish our brand from others, to insist on specific training, protocols in treatment delivery and the contents of the kit being used. We would advise anyone considering registering a trade mark to do their research first. Be sure there is not a similar name already in use, be confident that your name is unique and be determined to follow up and monitor the use of your trade mark once registration is complete.

Aesthetics Dr Daniel Sister is a cosmetic, antiageing and hormone specialist. Since receiving his medical doctorate at the Paris Medical School, he has built a global reputation specialising in minimally invasive antiageing procedures.

Dr Sister appears regularly on television and radio and has written a number of books including Your Hormone Doctor, with Leah Hardy and Susie Rogers.

Jemma Patton works in digital communications within the beauty industry after a successful 20-year career as a journalist. She’s worked with Dr Daniel Sister and Dracula PRP Therapy since 2012, helping to develop the protocol as an internationally-recognised brand.

REFERENCES 1. GOV, Patenting you invention, gov.uk, (2016) <https://www.gov.uk/patent-your-invention> 2. The Copyright Licensing Agency, Protecting creativity, CLA, (2016) <http://www.cla.co.uk/copyright_ information/copyright_information> 3. GOV, Using someone else’s intellectual property, gov.uk, (2016) <https://www.gov.uk/usingsomebody-elses-intellectual-property/trade-marks> 4. GOV, Trade marks: protect your brand, gov.uk, (2016) <https://www.gov.uk/how-to-register-a-trademark/what-you-can-and-cant-register> 5. Intellectual Property Office, Trade mark search: by word or image, IPO, (2016) <https://www.ipo.gov. uk/tmtext.htm> 6. London IP, Trademark Classification, London IP, (2014) <http://www.londonip.co.uk/trademarks/ tm-classes/> 7. GOV UK, Trade marks: protect your brand, gov.uk, (2016) <https://www.gov.uk/how-to-register-atrade-mark> 8. The Law Donut, Choosing a business name FAQs, Law donut, (2016) <http://www.lawdonut.co.uk/ law/starting-up/choosing-a-business-name-faqs> 9. GOV, Renew your trade mark, gov.uk, (2016) <https://www.gov.uk/renew-your-trade-mark> 10. World Intellectual Property Organisation, Madrid – The International Trademark System, WIPO, (2016) <http://www.wipo.int/madrid/en/>

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begins to feel like they just cannot give any more.3 This is obviously not a good place to be in, emotionally, but that doesn’t mean there isn’t anything that you can do about it.

Work-related burnout Stress induced burnout in the workplace can be caused by any number of things, the most common of these being:

Avoiding Burnout Dr Kieren Bong explains what can cause stressrelated burnout, the signs to look out for and how to manage and prevent it Stress is everywhere. There are no maybes about our chances of experiencing stress – and its capacity to leave us in a state of mental overload or burnout – at some point in our lives.

No matter what our circumstances are, we must come to view stress not as a possibility, but as inevitability, a feeling bound to present itself no matter what our age or walk of life. Almost everything within our increasingly hectic, technological modern world holds the potential to induce some amount of stress. This is why approaching stress in the right way is essential. By managing stress accordingly, the potentially overwhelming and powerful forces it may exert over our minds can be reduced. It may seem counter-intuitive, but studies have shown that some amount of stress can prove beneficial. According to Daniela Kaufer, associate professor of integrative biology at the University of California, Berkley, “Some amounts of stress are good to push you just to the level of optimal alertness, behavioural and cognitive performance.”1 However, Kaufer is referring to an acute stress experienced within a short time span and, in the same way that a pint or two of beer could make you socially effervescent, and eight or nine pints would be more likely to have you stumbling around and loose-tongued, stress in excess can prove extremely unhelpful and disruptive. Long-term stress, also referred to as chronic stress, is detrimental to our overall health and wellbeing if not managed effectively. Longterm stress can contribute towards depression, anxiety and even coronary heart disease.2 Often a side effect of progress and improvement, and sometimes just an irksome symptom of a particular situation, plenty of research has been conducted within this field, and we are therefore left suitably availed to deal with its effects. Stress-induced ‘burnout’ can show itself in several different ways and none of them are particularly pleasant. Feeling constantly stressed, isolated and helpless, not to mention worn-out and exhausted, are all signs that you could be suffering from this unpleasant condition.3 When suffering from stress, every problem may seem exaggerated, unsurmountable and easier to just ignore. Things may start looking pretty bleak and finding the energy to even care about your duties might not seem that important to you anymore. Burnout affects us in more serious ways than ‘just’ our outlook; at times it can also threaten relationships and even your job. It isn’t all ‘doom and gloom’, however, there are steps that you can take to recover and even avoid burnout altogether.

What is stress-induced burnout?

To understand how to combat and avoid burnout we should first understand what it is and how it comes about. Burnout is brought on by constant, unrelenting stress, which brings about emotional and mental exhaustion – as well as more ‘physical’ exhaustions. As demands of everyday life, both at work and at home, begin to take their toll and you start to feel overwhelmed, your energy begins to wane along with your desire, motivation and interest in whatever it is that is causing the stress in the first place. Reduced empathy, productivity and motivation begin to make way for other more serious symptoms such as resentment, helplessness and cynicism, and there may even come a point where the sufferer

• Chaotic, high-pressure environment with little chance of relaxation • Unrealistic or demanding job performance expectations • Lack of recognition • Little to no control over your work, career or surroundings • Undemanding, monotonous work Burnout is not going to hit anybody overnight, it is a gradual and cumulative process, which unfortunately can make it harder to spot and prevent. If you have spotted any of the symptoms mentioned here then it isn’t too late to turn things around – it is never too late, in fact, and you always have options.

Tips to preventing burnout Instead of jumping out of bed to rush headlong into yet another challenging day, take a little time out each morning to get into a nice relaxing rhythm. Spend fifteen or twenty minutes just relaxing – you could try meditation or light stretching exercises, which can be extremely helpful. Meditation has been practised in many parts of the world (such as India) for thousands of years because people believe that it reduces stress and calms the mind. Some people believe that during meditation, the body ignites the ‘relaxation response’, which gives the body deep rest that is deeper than that obtained from sleep.4 When we are under stress, our muscles tense up. Several areas of the body are prone to tension resulting from stress such as shoulders, necks and back. Light stretching, on the other hand, can help relieve stress through relaxation of muscles. Eating healthily and nutritiously can also be a great mood enhancer, as is drinking plenty of water. Avoid or limit caffeine intake because caffeine can cause you to feel ‘wound up’, which can make stressful situations seem more intense. It is advisable to moderate your intake of alcohol and make mealtimes calm and relaxed.

Some people skip meals when they are stressed, but skipping meals can make stress-related symptoms worse. The better we treat ourselves, the better we begin to

Reproduced from Aesthetics | Volume 3/Issue 9 - August 2016

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feel not just about ourselves but also the world at large. Combined with exercise this can be a great way to really fill yourself with positive energy. Exercise and other physical activities produce endorphins – chemicals in the brain that act as natural painkillers – and also improve quality of sleep, which in turn reduces stress.

This is also a great occasion to put limits on the time and energy that you devote to certain activities and requests. Learning to say ‘no’ is one way of creating boundaries and setting limits on how you give away your time, especially on things that you know are going to put increased pressure on you in one way or another.

At first, saying no can be difficult but you have to remember that by saying no you are freeing up your time and also giving yourself more opportunities to say ‘yes’ to the things that you want to do or that you place more importance on. Prioritising your life is the first step in taking back control and avoiding stress-related burnout at work and at home.

That said, you should also pick a day (preferably your day off, for obvious reasons) where you can completely switch off. This means no mobile phone use, no computer, no emails. In fact, anything even remotely work-connected should be switched off. Give yourself a ‘you day’ and do something that you truly enjoy. If you do this at least once a week you will, almost immediately, begin to feel the stress leave your shoulders like shedding a cloak. If you have already begun to feel the effects of stress, and you can feel yourself going down the burnout road, then you should take action right away. The longer you leave this debilitating condition the worse it will get. It is not irreversible, not by a long way, and with the right techniques and a little support you can bring yourself back into a bright and wonderful world –

Aesthetics

and the quicker you face it the easier it will be. One way of tackling demanding or unrealistic duties at work is to speak to your supervisor or manager. Every employer has a duty of care and they can help you if you approach them. Being proactive in this way will also give you a mental boost because you are taking an active, positive approach to the problem. If you find that you need to switch jobs at work, then so be it – your health is more important than any job title, after all. Of course, it may also be the case that an entire career change is what is needed. That can be a scary thought, for anybody, but if your job is making you ill then perhaps it is something worth considering?

Whichever way you choose to tackle things, asking for help and support is always a good idea. Talk to your partner, your friends and your boss. Even the act of talking about an issue can help and the people you speak to may be able to support you directly.

Dr Kieren Bong is trained in both medicine and surgery and is one of Teosyal’s international trainers, speakers and key opinion leaders. In addition to being a university lecturer in cosmetic dermatology, he has been featured in numerous national publications. Dr Bong is also the pioneer of the ‘Two-Point Eye Lift” technique for periorbital rejuvenation.

REFERENCES 1. Press Trust of India, Stress can improve your brain’s performance, Business Standard, (2013), <http://www.business-standard.com/article/beyond-business/stress-can-improve-your-brain-sperformance-113041700296_1.html> 2. James L. Januzzi Jr; Theodore A. Stern et al, The Influence of Anxiety and Depression on Outcomes of Patients with Coronary Artery Disease, JAMA Internal Medicine, (2000) <http://archinte. jamanetwork.com/article.aspx?articleid=485397> 3. Melinda Smith, Jeanne Segal, and Robert Segal, Preventing Burnout, HelpGuide (2016) http://www. helpguide.org/articles/stress/preventing-burnout.htm 4. Herbert Benson & William Proctor, The Rise and Fall of the Healing Mind, Relaxation Revolution: The Science and Genetics of Mind Body Healing, (2010);p.56, Scribner; New York

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Reproduced from Aesthetics | Volume 3/Issue 9 - August 2016

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PURIFIED1 • EFFECTIVE2,3,4 • CONVENIENT5 Botulinum toxin type A free from complexing proteins

Bocouture® (incobotulinumtoxinA) 50 units Prescribing Information M-BOC-UK-0007 Please refer to the Summary of Product Characteristics (SmPC) before prescribing. Presentation: 50 units of Botulinum toxin type A (150 kD), free from complexing proteins as a powder for solution for injection. Indications: Temporary improvement in the appearance of moderate to severe upper facial lines (glabellar frown lines, crow’s feet lines, horizontal forehead lines) in adults below 65 years when the severity of these lines has an important psychological impact for the patient. Dosage and administration: Unit doses recommended for Bocouture are not interchangeable with those for other preparations of Botulinum toxin. Reconstitute with 0.9% sodium chloride. Horizontal Forehead Lines: Intramuscular injection, 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: Intramuscular injection (50 units/1.25 ml). Total recommended standard dose is 20units. 0.1ml (4units) 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: Intramuscular injection (50units/1.25mL). 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. Not recommended for use in patients over 65 years or under 18 years. 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 aging or photodamage). In this case, patients may 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).

Frequency of adverse reactions by indication is defined as follows: very common (≥ 1/10); common (≥ 1/100, < 1/10); uncommon (≥ 1/1000, < 1/100); rare (≥ 1/10,000, < 1/1000); very rare (< 1/10,000). 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 post-injection. Bocouture® may only be used by physicians with suitable qualifications and proven experience in the application of Botulinum toxin. Legal Category: POM. List Price 50 U/vial £72.00 Product Licence Number: PL 29978/0002 Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer Landstraße 100,60318 Frankfurt/Main, Germany.

Date of Preparation: July 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® 50U Summary of Product Characteristics (SPC).

April 2016. Available from: https:/www.medicines.org.uk/emc/ medicine/23251 2. Carruthers A et al. Multicentre, Randomized, Phase III Study of a Single Dose of IncobotulinumtoxinA, Free from Complexing proteins, in the Treatment of Glabellar Frown Lines. Dermatol Surg. 2013:1-8 3. Prager W, et al. Comparison of Two Botulinum Toxin Type A Preparations for Treating Crow’s Feet: a Split-Face, DoubleBlind, Proof-of-Concept Study. Dermatol Surg. 2010 Dec; 36 Suppl 4:2155-60 4. 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 5. BOC-DOF-012 Bocouture® Convenient to Use, August 2015 BOCOUTURE® is a registered trademark of Merz Pharma GmbH & Co, KGaA. BOC/78/JUL/2016/LD

Date of preparation July 2016

PURIFIED1• EFFECTIVE2, 3,4 • CONVENIENT5

Botulinum toxin type A free from complexing proteins

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Aesthetics

“Great results arise from the science of facial assessment, subtle techniques and the art of leaving the imperfections” Dr Kate Goldie shares her journey into aesthetics and discusses her passion for education and training It is uncommon to see a skateboarder, skateboard park developer and a snowboarding championship organiser written on the resumé of an aesthetic practitioner, but Dr Kate Goldie says she took the long way around to figure out what she wanted to do.

“I was living and snowboarding in the Scottish Highlands when I became really interested in psychology,” she explains. After completing a year of a psychology degree, Dr Goldie decided she wanted focus on medicine instead, and was accepted to study at Edinburgh University. “What I loved about medicine was all the possibilities and the fact that there are so many potential fields of specialism.” After graduating in 2002, Dr Goldie practised as a forensic medical examiner in the north of Scotland, where she would be on call 24 hours a day for one week, and have a week off the next. “It was during these weeks off that I thought I might do a botulinum toxin course – everyone thought that the idea was ridiculous, especially in northern Scotland.” Dr Goldie attended a training course run by consultant plastic surgeon Mr Adrian Richards, and was immediately interested in the field of aesthetics, “I was deeply impressed with how effective the treatments were and how delighted people and transformed patients seemed to be. This is what persuaded me to join the industry.” Dr Goldie then contacted as many clinics as she could to perform her treatments in. “I did that for two years and just really went for it. I treated as many people as I could. I love technique and I love product knowledge and understanding the innovation behind new technologies, but my own personal interest is the face and what makes it unique; what makes that person’s face interesting.”

According to Dr Goldie, in her early days of practising aesthetics, there wasn’t much information around in terms of technique, and she felt as though she and other people in the industry were constantly ‘making things up’ as they went along. “I realised innovation is necessary in a new field of medicine but I wanted to do this collaboratively. So I tried to get together with other people and think about ideas – I like to work with other people and tell them my thoughts and see if they agree, it’s good to have more minds on the same problem.”

She decided that in order to accomplish this, she would set up her own training academy in Scotland, European Medical Aesthetics Training, also known as Medics Direct Training. “There were very few courses at that time, and none that I felt gave much support afterwards. It was just a completely different world. I thought it was possible to make a difference in terms of how people set up a practice, and how they went about it, and to give them some grounding.” She says that a main focus of her course was to provide clinical support and form groups of practitioners who could help one another in their practices. She explains, “I wanted the training I provided to always have ‘backup’, meaning you could always have someone to phone up and ask questions to and have on-going clinical and business support.”

Happy with her progress in Scotland, Dr Goldie decided to branch out into England, and eventually started lecturing internationally, which she says has been particularly fascinating. “I have been to around 32

countries and four continents and have seen a lot of different aesthetic practices and techniques. I have covered a lot of different cultures and that’s been very interesting because you see the different ways that people perceive the face, especially in Asia. But even within Europe you have different subtleties of how people work and how they learn.”

Now, between treating patients at her private practices on Harley Street and Henley-on-Thames in London, Dr Goldie is still running her successful training academy based in Harley Street and in Glasgow, and educating practitioners throughout the UK. Whilst educating and connecting with different practitioners through her training and lecturing, Dr Goldie has realised that it used to be a lot easier to get into the industry than it is now, “It was much more basic. It’s now more difficult because the industry has expanded and patients are demanding so much more and are better educated about it.”

Her advice to practitioners hoping to be successful in the industry is to, “Start simple and stay simple until you are completely comfortable with every parameter of the technique. Also, be a part of groups and associations, and courses. Good courses ideally have someone who can provide on-going clinical support, and forming groups is really useful to have other people to gauge your practice.” Looking back at her success, Dr Goldie says her passion and career in aesthetics was unexpected, but wouldn’t have it any other way, “I thought I might do aesthetics and move onto something else but the psychology of visual perception, the way we see the face and the way we go about making decisions about the face, is totally interesting and I think that’s why aesthetics is never done for me!”

What treatment do you enjoy giving the most?

Soft tissue fillers because the ability to fine sculpt facial form and transform and balance facial proportions requires such an interesting combination of skills.

What new device are you excited about at the moment?

I am extremely excited about a new cellulite treatment called Cellfina because I like things that do something very specific and approach the problem directly.

What advice would you give your younger self?

Understand not just the anatomy, but applied anatomy, as it’s so important in comprehending any part of aesthetics – it gives context for everything.

Do you have an industry pet hate?

People from different aesthetic medical backgrounds not working together – our strength is pooling all of our skills together as they bring different views, qualities, skills and ways of seeing things.

What’s your top tip for practitioners?

Remember that great results arise from the science of facial assessment, the skill of subtle techniques and the art of leaving the imperfections.

Reproduced from Aesthetics | Volume 3/Issue 9 - August 2016

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The Last Word Dr Paul Charlson argues that mole apps should never replace a full consultation or be used to change clinical diagnosis Melanoma is a deadly and increasingly common skin cancer.

In fact, in 2012, there were reports of more than 100,000 new cases of malignant melanoma.1 It is often curable if detected and removed in the early stages so an early diagnosis is extremely important.2 Increasing public awareness of this disease, prevention and diagnosis are key elements in reducing morbidity and mortality.3 Generally, publicity about melanomas is positive, but it can have negative effects. It can make some patients anxious resulting in frequent consultations. It can also result in patients being referred on the ‘two-week rule’ (the time within which a GP must refer a patient with a suspected melanoma to a specialist) by primary care clinicians even though they are very likely to be benign, whilst melanomas in less anxious patients may be referred routinely with lengthened waiting times.4 Mobile apps have the potential to increase the quality and efficiency of healthcare, allowing patients to have quick and easy access to advice and information. They are a relatively new way for patients to be able to monitor their skin changes at home, in a user-friendly way, without having to visit their GP or dermatologist.

Although I believe mole apps are a relatively good thing, it is important that both practitioners and patients understand their limitations. I also stress that they do not, by any means, replace a consultation, proper medical skin assessment and diagnosis, and should not be used to sway clinical judgement.

The purpose of melanoma apps NICE recommends that patients that have a low degree of suspicion should monitor pigmented lesions by photography with a review at eight weeks.5 However, one of the key problems with photographing lesions is ensuring that photos are consistent so that change can be monitored effectively.

Many mole apps aim to allow the user to take more accurate photographs by recognising the position of the lesion, so to take the same image every time. They can also map out malignant patterns and set reminders to take the photographs regularly. Some apps provide useful information about melanomas, and others allow you to assess melanoma risk through question and answer-based interactive functions.

There are some obvious advantages of having an accessible app that enables patients to do these things: 1. Raises much needed awareness of melanoma risks 2. Monitors skin changes or non-changes over time by photographing lesions 3. Allows practitioners to monitor moles and engage patients in the process 4. Empowers patients to take responsibility for their health 5. Allows patients to understand their probable risks of developing melanoma 6. Reassures the ‘worried well’ who are frequently visiting their GP or dermatologist for mole checks

Aesthetics

Concerns Of course, anything that is helping to create public awareness of the importance of detecting melanoma is a good thing. When it comes to melanoma apps however, there are a few concerns that both patients and practitioners need to be aware of.

The first thing to note is that mole apps are not necessarily put through rigorous assessment. According to Pro-Cal Powertrain Development Ltd, its app Mole Monitor is the only available mole app currently approved by the NHS,6 while SkinVision, by SkinVision VV, claims to be the only mole app that is CE certified.7 Although I have seen many apps that appear to be just as good as these two, I have also seen some that are poorly designed and are extremely unhelpful to patients, providing images of mole types that might be misleading or wrong. When it comes to taking standard photographs, this is not so much of a concern. It becomes a concern when the apps are providing medical information and advice to patients, such as what a melanoma looks like and the point at which they should seek medical attention. The sheer number of apps available is also worrying – I was able to download more than 10 in just a few minutes. How is an individual to know which app to use when there are so many to choose from? I personally would recommend one that has been approved, or otherwise been developed by a dermatologist, which is usually stated in the app bio, because there is no sure-fire way for patients to tell whether the apps are providing the correct information.

Another issue, and probably the biggest concern, is that patients using mole apps could mistake this as an alternative to professional assessment. Although mole apps can be useful in determining skin changes, if a patient does not notice a difference in a few weeks, it does not rule out the possibility of a skin cancer. As well as this, if patients do not provide accurate responses to the app’s questions assessing their risk of developing moles, they might be misled into thinking that they do not have a high risk, and hence might not be diligent at applying sunscreens or monitoring their moles at all.

Conclusion It is my belief that mole apps, if used correctly, can be a useful resource for patients to monitor and track the changes of their skin as most people do not know if their skin has changed or not. However, mobile apps do not replace a consultation. These apps and their photographs are an adjunct to clinical decision-making. It is our responsibility as healthcare professionals to educate and advise our patients about the limitations and to encourage those at high risk to get their skin checked by a professional as well as tracking their moles with an app.

Dr Paul Charlson is an aesthetic practitioner and GP with extended interest in dermatology. He is the president of the British College of Aesthetic Medicine, medical director of Skinqure Clinics and has worked in community dermatology clinics taking GP referrals since 2004.

REFERENCES 1. Cancer Research UK, Skin cancer incidence statistics, (2013), <http://www.cancerresearchuk.org/ health-professional/cancer-statistics/statistics-by-cancer-type/skin-cancer/incidence> 2. Godman, H, What Are the Prognosis and Survival Rates for Melanoma by Stage?, Healthline, Healthline, (2014)<http://www.healthline.com/health-slideshow/melanoma-prognosis-and-survival-rates> 3. Pacifico MD, Pearl RA, & Grover R, ‘The UK Government Two-Week Rule and its Impact on Melanoma Prognosis: An Evidence-Based Study,’ Ann R Coll Surg Engl, (2007).

4. Jones R, Rubin G, Hungin P, ‘Is the two week rule for cancer referrals working?’ BMJ. 323(2001).

5. NICE, Melanoma and pigmented lesions: Management (2011) http://cks.nice.org.uk/melanoma-and-pigmented-lesions#!scenario 6. iTunes, Mole Monitor – Skin Mole Mapping and Cancer Symptom Checker (2016) <https://itunes. apple.com/gb/app/mole-monitor-skin-mole-mapping/id796651877?mt=8> 7. Skinvision, Our algorithm and medical credentials, <https://www.skinvision.com>

Reproduced from Aesthetics | Volume 3/Issue 9 - August 2016

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SKINBOOSTERS ™

Radiant Skin, Radiant Patients Restylane® Skinboosters™ are clinically proven to deliver progressive, long-lasting improvements to the skin condition of your patients.

The visible improvements provide high levels of patient satisfaction and the progressive treatment approach provides the opportunity to guide your patients in a consultative partnership helping to deliver attentive, personalised care and long-lasting results.

Kelly’s Story

A Restylane Skinboosters patient shares her experience Forehead area

“Before trying Restylane Skinboosters, I had never done an injectable treatment of this type – but I had been told what the treatment could do and was very hopeful that I would see some of these results for myself!

My practitioner explained that the results would appear over time, and that I would continue to see improvement even after my third treatment. I couldn’t wait to get started.

The procedure itself was better than I expected. It wasn’t too painful; I felt just a few small pinpricks, and my practitioner was very gentle.

I loved that I could go back to my normal, everyday activities right after treatment.

I really started to notice a difference after my second treatment. My skin started to glow, and felt so much fresher. I could feel that the structure of my skin had improved as well, and my face felt softer. I also had fewer fine lines around my cheeks and mouth.

I am so pleased with the results of my Restylane Skinboosters treatment that I would recommend it to any of my friends. The results are subtle and natural-looking but everyone tells me I look refreshed and that my skin is radiant. I can see and feel the same effects myself, and I feel younger! The treatment has even made a difference to me on the inside - I feel happier, and I feel good about myself.

Crow’s feet Cheek area Smile lines

Peri-oral lines

Neck area

Hands

Décolletage

All thanks to Restylane Skinboosters!”

A versatile treatment suitable for a wide range of age groups and skin types

www.restylane.co.uk RES/041/0516 Date of preparation May 2016

The VYCROSS™ Collection is the latest generation of CE-marked Juvéderm ® HA dermal fillers, building on the strong heritage and benefits of the Juvéderm ® Ultra range, helping to create natural-looking results and high patient satisfaction.1-5

The VYCROSS™ Collection includes:

JUVÉDERM® VOLBELLA® with Lidocaine

JUVÉDERM® VOLUMA® with Lidocaine

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1. Raspaldo H. J Cosmet Laser Ther. 2008;10:134-42. 2. Eccleston D, Murphy DK. Clin Cosmet Investig Dermatol. 2012;5:167–172. 3. Callan P et al. A 24 hour study: Clin, Cosme and Investig Derm, 2013. 4. Muhn C et al. Clin Cosmet Investig Dermatol. 2012;5:147-58. 5. Jones D et al. Dermatol Surg. 2013;1–11.

UK/0721/2015

Date of Preparation: October 2015