Aesthetics february 2014 by Aesthetics & CCR

VOLUME 1/ISSUE 3 - FEBRUARY 2014

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Anatomy of the lower face - CPD Dr Raj Acquilla on the anatomical basis and aetiology of lower facial ageing. CPD accredited article

Non-surgical lower face lift

Botox and wellbeing

Experts discuss treatments, techniques and trends for lower face rejuvenation

Dr Ravi Jandhyala on how treatment with botulinum toxin type A can improve patient quality of life

Revalidation for doctors and nurses Dr Paul Myers and Emma Davies summarise the new rules

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Contents • February 2014 INSIDER 05 The Word Dr Mike Comins on developments in the aesthetics industry in 2014 06 News The latest product and industry news 12 On the Scene Dr Leah Totton’s highly anticipated clinic launch 14 News Special: Aesthetics Online Investigating new adjudications surrounding advertising in aesthetics

CLINICAL PRACTICE Lower face Anatomy Page 17

CLINICAL PRACTICE 17 CPD Clinical Article Dr Raj Acquilla on the anatomy of the lower face 22 SPECIAL FOCUS: Non-surgical lower face lift Leading clinicians explain their treatments and techniques 26 Techniques Dr Linda Eve on delivering Sculptra using cannulas 28 Clinical Study A study on use of radio frequency to treat primary axillary hyperhidrosis 34 Spotlight On The benefits of the new Regenlite Transform by Dr Donna Freeman 36 Clinical Focus Dr Elisabeth Dancey explores the treatment of labia majora hypotrophy with Desirial Plus 38 Clinical Study Dr Ravi Jandhyala investigates the relationship between botulinum toxin type A and wellbeing 42 Treatment Focus Lisa Littlehales on the use of BTL’s Vanquish for uniform fat loss 43 Abstracts The latest clinical studies 45 Aesthetics Conference and Exhibition Special Focus The latest news and reasons to attend ACE 2014

IN PRACTICE 49 Revalidation for doctors and nurses Dr Paul Myers and Emma Davies share advice on how to be prepared 52 Taxing Times Accountant Ben Korklin on getting ready for tax year end 54 Learning from spas Wendy Lewis suggests taking inspiration from spas for a better patient experience 56 Dealing with Negative Reviews Tingy Simoes explains how to handle unfavourable feedback online 58 In Profile We speak to BACN vice-chair Sharon Bennett 60 The Last Word Dr Sarah Tonks shares her views on the culture of secrecy in cosmetic interventions

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IN PRACTICE Revalidation Page 49

Clinical contributors Dr Mike Comins is president and fellow of BCAM. He is part of the cosmetic interventions group and is an accredited trainer for advanced Vaser liposuction. Dr Raj Acquilla is a cosmetic dermatologist with over 11 years experience in facial aesthetic medicine. He is a UK ambassador and masterclass trainer in botulinum toxin and dermal fillers. Dr Elisabeth Dancey has been practising cosmetic medicine since 1993. She introduced mesotherapy to the UK having studied at Liege, Belgium. She now owns Bijoux Medi Spa in central London. Dr Linda Eve is founder and medical director of the EvenLines Clinics. She won the National Aesthetics Award for the Best UK Small Clinic for 2013-2014. Dr Donna Freeman is director of clinical research and education at Chromogenex, focusing on the development of new devices and technologies and construction of technical articles. Dr Ravi Jandhyala has over nine years experience in aesthetics. He is a member of the Royal College of Surgeons of Glasgow and a leading voice on botulinum toxin. Lisa Littlehales is a registered nurse with 15 years experience in aesthetics. She is general manager of Harvey Nichol Knightsbridge and Beyond MediSpa Edinburgh, specialising in non-surgical treatments.

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Editors’ letter

The Word

Welcome to the February issue of Aesthetics. Despite dreary weather, Aesthetics this month is positively uplifting, with lower face smile rejuvenation the focus of our CPD-accredited feature: non-surgical lower face lift (p. 17), and our Leah Hardy round table discussion on lower face rejuvenation Editor techniques (p. 22). In his study, Dr Ravi Jandhyala adds to the growing body of evidence for the positive psychological affects of treatments with botulinum toxin on p. 38. Our contributors this month include Dr Linda Eve and Dr Elisabeth Dancey, who share their experiences of using Sculptra with cannulas (p. 26) and the new hyaluronic acid product Desirial (p. 36). Plus there is information about new devices, including a study on the effectiveness of radiofrequency as a treatment for hyperhidrosis, and how Regenlite’s new Transform device boosts growth factors for better skin health. We also offer vital advice on managing reputation attacks online and improving your patients’ in-clinic experience. On p. 60 Dr Sarah Tonks says it’s time for celebrities to admit the help the aesthetics industry gives them. What do you think? I’m also proud to bring you our guide to the Aesthetics Conference and Exhibition (ACE) in London, 8-9 March. In your supplement, you’ll find a complete programme with a comprehensive list of speakers and contributors. The exhibition is free to enter and registration is still open for the conference, which is fully CPD accredited with 59 points available. I very much hope to see you there.

This month I’m delighted to welcome four new committee members onto the board of the British College of Aesthetic Medicine (BCAM). Dr Beatriz Molina, Dr Ruth Harker, Dr Kathleen Long and Dr Paul Charleston join Dr Kam Singh and myself to continue BCAM’s vital work in providing not only a professional support network for aesthetic doctors, but also training and education. As a body, we hope that 2014 will be the year when we will see implementation of improved standards, education and regulation in aesthetic medicine. BCAM continues to work with the Department of Health, The British Standard Institute and now Health Education England to help ensure that this happens. As such, 2014 will also see the launch of BCAM approved courses, workshops and online learning platforms catering for all levels and competencies of aesthetic doctors. Aesthetic medicine is moving forward at a fast pace, and I am pleased to see revamped older products, such as collagen stimulating injections and thread lifts, making a well-deserved comeback. The use of volumising fillers is now more or less standard practice, as is the advanced use of botulinum toxin injections in the mid and lower facial muscles. Minor surgical body sculpting treatments are producing results unmatched previously. I am also very encouraged to find more and more cross referrals. Not just between colleagues, but also with groups such as personal trainers, nutritionists and psychologists/therapists. As medical professionals, it is crucial that we work together to provide the best care for our patients’ wellbeing, in all aspects of their health.

Dr Mike Comins (BCAM)

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 educational, clinical and business content. Dr Mike Comins is president and fellow of the British College

Amanda Cameron is a sales and marketing professional,

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

and was one of the first nurse injector trainers in the UK for dermal fillers. With over 20 years experience in the industry in both the UK and Europe, Amanda has extensive knowledge of medical aesthetics and business development.

Mr Adrian Richards is a plastic and cosmetic surgeon with

Dr Sarah Tonks is an aesthetic doctor and previous

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.

maxillofacial surgery trainee with dual qualifications in both medicine and dentistry, who fell in love with the results possible through minimally invasive methods. Now based at Beyond Medispa in Harvey Nichols, she practises cosmetic injectables and hormonal based therapies.

Sharon Bennett is currently vice chair of the British

Dr Nick Lowe is president of the BCDG and a consultant

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

dermatologist with over 30 years of experience and practises in London and California. Dr Lowe is clinical professor of dermatology at the UCLA School of Medicine in Los Angeles, as well as director of a clinical research company specialising in skin ageing.

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DISCLAIMER: The editor and the publishers do not necessarily agree with the views expressed by contributors and advertisers nor do they accept responsibility for any errors in the transmission of the subject matter in this publication. In all matters the editor’s decision is final. © Copyright 2013 Aesthetics. All rights reserved. Aesthetics Journal is published by Synaptiq Ltd, which is registered as a limited company in England; No 3766240

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Allergan’s Botox receives licence for treatment of crow’s feet lines

Allergan’s Botox has received national marketing authorisation for treatment of lateral canthal lines, commonly known as crow’s feet. The multi-specialty health care company announced in January that Botox has received the licence from the Medicines and Healthcare products Regulatory Agency (MHRA). The botulinum toxin type A treatment addresses moderate to severe lateral canthal lines resulting in temporary improvement. The marketing authorisation, specific to Allergan’s Botox, is based on the company’s successful global Phase III clinical trial programme in crow’s feet lines. President of Allergan Europe, Africa and Middle East, Paul Navarre said, “We are proud to deliver this important innovation to medical aesthetics practitioners in the UK, allowing them for the first time to treat the glabellar and crow’s feet areas either alone or simultaneously.” Dr Imran Lodhi, medical director of Allergan UK and Ireland, said, “We are delighted to be the first and only manufacturer licensed to treat crow’s feet lines with Botox either alone or in combination with glabellar (frown) lines.” “Through hands-on training and support, our goal is to give practitioners the confidence to deliver optimal treatment results for their patients, whilst maintaining natural expression and movement,” he said. “As the eye area is one of the most important treatment zones, we hope this new indication will enable healthcare professionals to treat it even more effectively.”

Study shows men more likely to receive treatments from untrained individuals Research conducted by Transform Cosmetic Surgery has found that men are twice as likely as women to have botulinum toxin or dermal fillers administered by somebody untrained. The study found that one in four male patients seeking non-surgical treatments received it from untrained friends, compared to one in 10 women. It also found that 17% of men would allow themselves to be administered botulinum toxin from an unqualified person, compared to 10% of women. 16% of men would allow somebody unqualified to administer dermal fillers, compared to 11% of women, and 19% of men would allow them to perform non-invasive body sculpting compared to 9% of women. 15% of men surveyed also admitted to having been treated by a third party when they were unaware of whether they had been appropriately trained to perform the procedure. Anne-Marie Gillett, non-surgical director at Transform Cosmetic Surgery, said, “Men are seemingly looking for a ‘quick fix’. This risk-taking and blasé attitude where their health is concerned, needs to be addressed, and quickly. We absolutely urge anyone thinking of undergoing non-surgical procedures to conduct thorough research so that they are armed with information that ensures they are making the right decisions when it comes to deciding who should administer their treatments and where.” 6

Aesthetics | February 2014

Call for Evidence issued for review into non-surgical procedures Health Education England (HEE) has issued a Call for Evidence to take forward a review of the qualifications required to perform non-surgical cosmetic procedures. Led by Charles Bruce, managing director for Health Education North West London (HENWL), the purpose of the review is to aid the development of a minimum standard for education and training within the field of non-surgical medical aesthetics. The review also looks at the qualifications required to be responsible prescribers. The project was established in September 2013 as a result of Sir Bruce Keogh’s ‘Review of the Regulation of Cosmetic Interventions’ report. The Call for Action aims to garner feedback from regulators, royal colleges and other stakeholders on what they believe should be the minimum standard required to perform these procedures. HEE are asking all interested parties to reply to the Call for Evidence, from professional associations, course providers to insurers, as well as medical aesthetic practitioners currently carrying out non-surgical procedures. The project has been gathering evidence since September of existing frameworks and standards applicable to all practitioners administering non-surgical procedures. Through this work the project has summarised common issues that exist between different groups practising within the field, from plastic surgeons, dermatologists, dentists, aesthetic nurses, other health care practitioners and beauty therapists. Factors include patient consent and health and safety. However, the challenge lies in establishing a minimum standard applicable to all. “The starting points of the various professionals delivering the treatments are very different,” said Jollie. “So whatever we come up with will take account of the fact that people have very different levels of experience and backgrounds.” These qualifications also need to be future-proofed, as HEE is keen to ensure any qualifications established need to encompass the rapid change in technology in the industry. Following the Call for Evidence, HEE will conduct workshops that will take place on February 24 and 28. These workshops will be followed by further events in March/April 2014 to discuss the outcome of the review. “It’s in the public interest to do whatever we can to make sure that the treatments are safe and that the people delivering those treatments have met the minimum standards,” said Jollie. Details of the call for evidence can be found at www.nwl.hee.nhs.uk and responses can be sent to cosmetics@nwl.hee. nhs.uk, no later than Sunday February 9 2014.

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Free Expert Clinic added to ACE 2014 programme The Aesthetics Conference and Exhibition (ACE) 2014 will be hosting a free Expert Clinic, new for this year. The clinic will provide delegates with the opportunity to meet with leading medical experts, who will answer questions and demonstrate how to deliver precise treatment techniques. Confirmed for the clinic so far are Dr Tapan Patel and Dr Raj Acquilla, who will be demonstrating periorbital beautification and a non-surgical lower face lift in the session. Also confirmed are Dr Sarah Tonks, Lorna Bowes, Dr Gabriela Mercik, Dr Leah Totton and Dr Martyn King. Dr Acquilla, cosmetic dermatologist at the Dr Raj Acquilla Clinic, said, “The Expert Clinics at ACE are about giving the delegates what they want to learn; expert tips and tricks in key anatomical regions, which will impact positively on patients. It is my pleasure to share the latest knowledge and techniques from around the world to help my colleagues optimise results in their practices.” To find out more about ACE and to book your place, visit www.ace2014. co.uk or call 01268 754 897.

Sinclair IS Pharma buys global rights to Perfectha dermal fillers Sinclair IS Pharma has bought global rights to Perfectha dermal fillers.The international speciality pharmaceutical company has acquired global rights to dermal gel brand Perfectha through the acquisition of Obvieline Laboratories SA. The Perfectha brand includes five gel products to treat different facial areas to reduce folds, lines and wrinkles. The company has also entered into agreements to acquire distribution rights from Obvieline’s parent company, Pharmavital SA. The total consideration of both acquisitions is €32.2 million (£26.7 million). The acquisition from Pharmavital is expected to close within six months. It is likely that the Perfectha range will be extended to include a pre-mixed lidocaine product towards the end of 2014. Global rights to Perfectha will see Sinclair IS Pharma establish a global facial aesthetics presence. Sinclair IS Pharma CEO Chris Spooner said, “The acquisition of Perfectha is a significant strategic step enabling us to create a global presence in facial aesthetics. We expect to benefit in the near term from accelerating growth and significant operating leverage.’’ As a result of the company’s expansion plans, Sinclair IS Pharma is currently advertising for an additional member to the team. Greg Parker, national sales manager at Sinclair IS Pharma said, “We are currently looking for an experienced product specialist to join our Aesthetic Account Manager team covering the North West.“This is an exciting opportunity to join a rapidly expanding and fast moving company, with its sights clearly set on developing an incredible aesthetic portfolio.” To find out more about this role contact enquiries@sinclairispharma.com

News in Brief Dr Askari Townshend appointed Sinclair Pharma medical consultant Dr Askari Townshend has been appointed new medical consultant for Sculptra, Sinclair IS Pharma, as previous medical consultant Dr David Evans retires. Dr Askari, medical director at Northampton sk:n clinic, said, “Sinclair IS Pharma share my passion for top quality and small group training, which is so important for aesthetic treatments.” Murad launch Rapid Collagen Murad has launched its first first topical product that contains pure collagen. Murad Rapid Collagen Infusion deploys the use of broken down collagen protein to hydrate and plump the skin with amino acids small enough to penetrate it. Developed by Dr Howard Murad and Jeff Murad the topical product targets wrinkles and fine lines. Dermadart launch Precision Skin Needling British brand Dermadart has launched a new microneedling device that uses an electromagnetic drive system to avoid potential risks of skin tearing. Precision Skin Needling has an electromagnetic linear drive allowing for a millisecond speed of operation and minimal pain. The skin rejuvenating treatment treats generalised and acne scars, wrinkles, stretch marks, and sun damage. Theradome Laser Helmet is FDA cleared Over-the-counter laser hair restoration treatment Theradome Laser Helmet LH80 PRO has acquired FDA clearance. The technology is clinically tested and is intended for use by patients suffering from thinning hair and androgenetic alopecia. The helmet uses laser light therapy, which the manufacturers claim will limit hair loss and double follicle size of existing hair. New map showing cellular response to UV Researchers have unveiled a new map showing the network of genetic interactions underlying the cellular response to UV radiation. Researchers at the University of California, San Diego School of Medicine, along with colleagues in the UK and The Netherlands, have established this resource to better understand how cells are damaged by UV radiation, and how they repair themselves. The findings can be found in the December 26 issue of Cell Reports. Over 1,000 registered for ACE 2014 Places are fast filling up for the Aesthetics Conference and Exhibition (ACE) 2014. With over 1,000 already registered to attend, the two-day conference and exhibition is already proving to be an industry event not to be missed. ACE will take place on March 8 and 9 at the Business Design Centre in London. www.ace2014.co.uk

Aesthetics | February 2014

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Question Time now free with ACE conference pass Entry to the Aesthetics Conference and Exhibition (ACE) Question Time evening is now free when purchasing a one or two-day conference pass. New for 2014, the Question Time evening session in March, sponsored by 3D-LipoLite, is facilitated by former BBC News Broadcaster Peter Sissons, and brings together a panel of leading industry professionals to discuss the latest topics influencing the industry. The latest member to join the panel is Mr Dalvi Humzah, consultant plastic, reconstructive and aesthetic surgeon based at the Plastic Dermatological Surgery. A former NHS consultant plastic surgeon, Mr Humzah currently maintains a plastic surgery private practice and is a key opinion leader for several aesthetic companies. Other panel members include Dr Andrew VallanceOwen, member of Sir Bruce Keogh’s Cosmetic Interventions Review team, and Apprentice winner Dr Leah Totton. To find out more about ACE and to book your place, visit the website at www.ace2014.co.uk or call 01268 754 897.

LPG launch new awardwinning Endermolift LPG Systems have launched the new Endermolift, a cellular stimulation solution for the effects of ageing. The technology was recently awarded the Innovation Award 2013 for Aesthetic Medicine at Face2Face Cannes, and the Anti-Aging & Beauty Trophy 2013 at AMEC, Paris. The manufacturers claim that Endermolift is the only technology to increase the natural synthesis of hyaluronic acid by 80%. The mechanical stimulation device stimulates fibroblasts and fat cells in a non-aggressive way, treating lines, puffiness and dark circles. Endermolift uses motorised pulsating flaps to carry out the anti-ageing treatment. LPG International Trainer Pernelle Hourcade said, “This technique has scientifically been proven to have a large impact on fibroblast function - production of collagen, elastin (+46%) and hyaluronic acid (+80%) – and to naturally rejuvenate skin from within. The results are the increase of the skin firmness (+23%), elasticity and hydration, as well as a clear improvement of glowing complexion, wrinkles and fine lines (21%).”

3D-Aesthetics set for an exciting 2014

Talk Aesthetics #dangersofsocialmedia

LiniaCosmeticSurgery / @LiniaCosSurg @Bea_John enjoyed your piece in this month’s @ aestheticsgroup. Really informative.

3D-Lipo has celebrated a successful start to 2014, following a year that saw them reach distribution in over 10 countries. Now, with the help of Dr Leah Totton, they are to launch their new duo cryolipolysis device, 3D-LipoMed, which is able to treat patients who want both body contouring and skin tightening. Dr Totton’s new clinic is the first in the UK to feature 3D-LipoMed. She explains she wanted to offer a medical-grade treatment that catered to her patient demographic. “Many will be professional women in their late 30s and 40s, for whom cellulite is a big problem,” said Dr Totton. “I tried various machines and 3D-LipoMed provides great results.” Managing director of 3D Aesthetics, Roydon Cowley, says, “Affordable technology with extensive clinical trial data, full CE certification and excellent clinical results provides a total solution for practitioners”. The company has also seen more than 20 clinics sign up for the new 3D-LipoLite programme, in which the treatment is combined with a diet and exercise plan. Says Cowley, “After changing body shapes for two years, we can now tackle obesity and change lives.”

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Bernadette John / @Bea_John @LeahFHardy Sites promoting voucher discounts do nothing to enhance the professional reputation of a clinician. #facingthefuture

sharonbennettskin @sharonbennettuk @aestheticsgroup Looking forward to editorial board meeting dinner tomo eve with @ aestheticsgroup @DrNickLowe Lots to discuss. Remember to follow us at Twitter @aestheticsgroup and include #talkaesthetics in your comments.

Practitioners & their patients feel the difference... “The favourable safety profile has lead to high patient satisfaction and subsequent recommendations from one patient to another, increasing our practice1” n

Not palpable2 ®

No Tyndall Effect1 ®

Comfortable on injection2 ®

BEL065/0813/LD Date of Preparation: December 2013

1. Kuhne, U et al. Five-year retrospective review of safety, injected volumes, and longevity of the hyaluronic acid Belotero Basic for facial treatments in 317 patients. J Drugs Dermatol. 2012 Sep; 11(9):1032-5 2. Data on File: BEL-DOF2_001 Belotero Juvederm Study MRZ 90028_4007

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First swallowable weight loss balloon launched in UK Obalon, the first swallowable weight loss balloon has been launched in the UK. Obalon is distributed exclusively by Purple Surgical and is a non-surgical procedure, simply placed by swallowing a capsule the size of a large vitamin pill. The capsule, which has a dissolvable outer layer, is attached to a micro-catheter that inflates the balloon to the size of an apple. The balloon, as with gastric band treatments, works to decrease feelings of hunger, and sits at the top of the stomach. The treatment costs £2,000 and is intended for people whose body mass index is 27 or over. Obalon can only be administered by a physician who has received specialist Obalon training, and clinics are required to offer lifestyle and dietary advice along with the treatment. Obalon is currently offered in the UK at Spire Healthcare hospital locations, and at Parkside Hospital and Highgate Hospital in London. Spire clinics consultant Sally Norton said, “I’ve been monitoring Obalon’s progress over the last few years as I was very excited about the potential it could offer those patients who do not qualify for weight loss surgery but are struggling to lose weight and improve their health on their own. “It has minimal side effects, is quick and easy to place and is really well tolerated. It gives patients an initial weight-loss boost but also helps to change their eating behaviour that is needed for long-term weight loss,” she said.

£3.6 billion

2015

The field of cosmetic intervention in the UK is estimated to rise to the value of £3.6 billion by 2015. (WhatClinic.com)

MYA Cosmetic Surgery found that the average breast implant size requested reduced last year, from < 410cc in 2012 to 385cc in 2013 > (Make Yourself Amazing cosmetic surgery)

One in six beauty

clinics surveyed were happy to consider treating teenagers aged 16 and 17 with botulinum toxin. (The Mail on Sunday)

SPF 5-8 SPF 2-3 Darker skin has an inbuilt

Dermamelan repackaged to deter imitations Skin whitening solution Dermamelan by Mesoestetic has been repacked in order to make the solution harder to copy. Adam Birtwistle, managing director of Mesoestetic UK said, “Mesoestetic currently operates in a fragmented market with many other, less consolidated companies. One of the main challenges of the company is to fight against counterfeit products that offer cheaper alternatives to consumers. The financial crisis has worsened the problem. People are looking to save money by buying products or copies via unofficial channels. Dermamelan now features a seal to authenticate the product, along with a country code, agent code and sealed code. These codes are kept on customer order records so that members of the public buying the products may call for confirmation that it is genuine. “Counterfeit products are potentially very dangerous and put the consumer at risk,” said Birtwistle. “Mesoestetic has gone some way to deal with this with changes to some of the line’s packaging and traceability.” Aesthetics | February 2014

SPF of 5-8 compared to fair skin’s 2-3. (Dr Nick Lowe)

Children

as young as six are undergoing cosmetic surgery, often because of bullying. (American Society of Plastic Surgeons)

It’s predicted that there will be a big demand for plasma facials in 2014. Five UK clinics currently use plasma energy instead of laser. (WhatClinic.com)

The dermal ﬁller market is expected to grow in Western Europe by around 8% pa to 2017, with HA ﬁllers accounting for over 90% of procedures. (Millennium Research Group)

87% of people voted yes in a recent Guardian poll asking whether there should be a ban on cosmetic surgery for minors. (theguardian.com)

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Antioxidant Tiron found to protect skin from UVA rays

Events diary 8th - 9th March 2014 Aesthetics Conference and Exhibition ACE 2014, London www.ace2014.co.uk 3rd - 5th April 2014 Anti-Ageing Medicine World Congress AMWC 2014, Monaco www.euromedicom.com/amwc-2014 20th September 2014 British College of Aesthetic Medicine BCAM Conference 2014, RIBA, 66 Portland Place, London www.bcam.ac.uk 25th - 26th September 2014 The British Association of Aesthetic Plastic Surgeons - BAAPS Meeting 2014, London www.baaps.meetings.org.uk 3rd October 2014 British Association of Cosmetic Nurses BACN Meeting 2014, London www.cosmeticnurses.org

More men receiving treatment on veins More men between the ages of 40 and 50 are receiving treatments for veins according to statistics gathered from the Dr Newmans Clinic chain. The UK network of clinics has seen an overall rise in the number of male patients over the past 10 years, from 5% to 40%, with a doubling of patients from this age range. This rise has taken place predominantly in London, but is also evident in their clinics across the UK. The Dr Newmans Clinic chain specialise in the treatment of veins, using thermocoagulation as developed by Dr Newman. This involves the use of microwaves to destroy the thread veins without scarring, hyper or hypo pigmentation. Dr Peter Finigan, medical director at Dr Newmans Clinic, said, “Based on observations of our patients, it tends to be more common for men to develop chunky veins on their noses. So we are largely treating men’s faces and in particular their noses, though we have also seen an increase in treating thread veins on men’s legs.” The reason for the rise is thought to be down to a combination of factors, including; partners prompting men to have the treatment, comments by work colleagues, and men becoming more aware of their appearance. Dr Finigan added, “Thread veins can be caused by a myriad of factors. It’s a common misconception that they can only be caused by alcohol. 10

An antioxidant has been found to protect the skin from sun damage, helping to keep it looking younger for longer. The antioxidant, created by scientists at Newcastle University, provides complete protection from UVA rays, which make up 95% of UV radiation in sunlight. Laboratory tests demonstrated that Tiron provides 100% UVA protection. Dr Anne Oyewole, research associate of Dermatological Sciences at Newcastle University, said, “Tiron is an antioxidant and is able to mop up reactive oxygen species (ROS), which at high levels can damage DNA within our skin cells and destroy the supportive fibres within our skin, collagen and elastin, which are responsible for stretching our skin. Tiron is also able to reduce the level of free iron in our skin cells, which is released as a result of sun exposure.” Professor Mark Birch-Machin, professor of molecular dermatology at the university, has said that more tests are needed to ensure the product is not toxic, but the results of the study, published in the FASEB Journal, are “exciting and promising”. He adds that a commercial product could be available within five years. It has been suggested that the product will be administered via food or cosmetics. “Tiron is a synthetic compound and although further assessment of this compound is still required, it is most likely to be included in a cosmetic product or sunscreen which could be applied to the skin,” Dr Oyewole said. Medical professionals have said that results from the study should be treated with caution. Dr Indi Ghangrekar, health information officer at Cancer Research UK, said, “This research was done on cells in the lab, rather than on people, and only looked at UVA radiation, not UVB – both of which are linked to skin cancer. “We also don’t know if this man-made antioxidant might be toxic in humans, as the authors point out,” Dr Ghangrekar said. “So this research is a long way off telling us whether it could be useful in any way in skin cancer prevention.” Clinicians have also said that there is anti-ageing potential in antioxidants but thorough research is required to determine this. “Antioxidants, which reduce free radical damage and oxidative stress by protecting the mitochondria, can be highly effective in skin anti-ageing,” said cosmetic dermatologist Raj Acquilla. “Any new product must demonstrate efficacy in vivo through robust clinical study.”

Contribute Are you interested in submitting an article, study or letter to Aesthetics.? We are interested in helping you share your knowledge and expertise. Contact the editor leah@aestheticsjournal.com

Aesthetics | February 2014

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Dr Leah Clinic Launch, London The launch for Apprentice-winner Dr Leah Totton’s much anticipated first clinic took place on January 22 The clinic, designed by interior designer Rolfe Judd and based at 24 Chiswell Street, Moorgate, has four treatment rooms and nine qualified staff, ranging from doctors to nurse prescribers and aesthetic therapists. “We have a full clinical team that is quite doctor-heavy,” Dr Totton said. “But I was also keen to make it multidisciplinary. That’s key in this industry, and was important for us in terms of setting a standard.” The clinic offers a range of aesthetic treatments, including advanced facials, chemical peels, dermaroller therapy, microdermabrasion, enhancement treatments such as botulinum toxin injections, facial filler, cheek enhancement, lip augmentation and nose-reshaping. “I’m not just offering Botox,” Dr Totton said. “I want to cater for younger ladies too, with facials and non-invasive microdermabrasion.” The Dr Leah Clinic will also offer multi-platform fat loss technology 3D-LipoMed by 3D Aesthetics, which offers fat freezing, cavitation therapy, skin tightening and reduction of cellulite. Dr Totton’s clinic is the only one in the UK to own the medical-grade version of 3D-Lipo. The launch was attended by a host of medical professionals, including medical director of the clinic, Dr Martyn King. Karren Brady, esteemed judge of The Apprentice also attended. Karren Brady said, “Leah is a determined and remarkable young woman. She has worked incredibly hard and it has been a pleasure to see her build her business and brand. “This is a difficult business, which doesn’t always operate with integrity when it should,” she said. “And it’s a business that has been male dominated. The hard work starts now.” Dr Totton has confirmed she will not provide Botox treatments for those under 18. She said, “The key thing we want to champion is safety in this industry. We will not be administering anti-ageing botulinum toxin treatments for teenagers; it’s not good practice. Our clinic will provide a safe haven for men and women to undergo treatments.” Dr Beatriz Molina, director of conferences at BCAM, also attended the launch. She said,

“Leah approached us about becoming a member of BCAM. I came along to explain how the organisation could help her: she already has an interest in industry regulation, and it will aid her in terms of revalidation and appraisal. She has a lot of publicity surrounding her, so it will be good for her to do everything perfectly and be accredited by the body. Her involvement will also help BCAM and the industry as a whole; having somebody high profile involved will raise awareness to industry safety.” Dr Totton, who is part of the Aesthetics Conference and Exhibition (ACE) 2014 Question Time panel and is presenting a demonstration on a 3D-LipoMed treatment, explains the importance of conferences. “I think sometimes the aesthetics industry can be isolating,” she said. “Key things for professional development include understanding what’s new in the industry, having a clinical excellence board, and discussing new treatments with other aesthetic professionals. “Being part of conferences and having practical demonstrations is essential, as we all need to be continually learning and embracing other practices,” she said. For the immediate future, Dr Totton plans the launch of the Dr Leah skincare range. “I’m really looking forward to introducing that into the clinic, and hopefully the marketplace,” she said.

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Insider News Special Report

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Aesthetics Online In the post-Keogh era, two new adjudications from the Advertising Standards Authority indicate clinics must work harder than ever to ensure their websites follow the rules In December 2013, health minister Dr Dan Poulter announced that the government would be, “Outlining rigorous plans to clamp down on irresponsible cosmetics advertising.” This statement made clear that the government would uphold recommendations made in response to Sir Bruce Keogh’s ‘Review of the Regulation of Cosmetic Interventions’ report, regarding the advertisement of cosmetic interventions. It certainly appears that even before the response is published, in this post-Keogh era, clinics whose advertising is in breach of regulations can expect to face swift sanctions. And these could have implications for almost every non-surgical clinic in the UK. Last month, the Advertising Standards Authority (ASA) took action against two clinics whose websites mentioned Botox. As a prescription-only medicine, the advertising of Botox to the public is prohibited. The original complaints against HB Health of London and Dermaskin chain came directly from one source, The Independent Healthcare Advisory Service (IHAS). In both cases the websites made claims about Botox, and discussed its use for facial lines and wrinkles. HB Health listed Botox as a treatment on its home page, and this mention linked to another page which described Botox in more detail as a beauty treatment. Dermaskin’s website included claims such as “this revolutionary treatment … .is the most popular such treatment in the world” and “thousands of these treatments are performed every year with astonishing results”. Both clinics defended their wording, but the ASA said, “ It was felt that these went beyond factual references to Botox and constituted a direct promotion of a POM.” Both clinics changed their home pages, HB Health referring to ‘wrinkle softening treatment’ and Dermaskin to ‘anti-wrinkle treatment,’ but the ASA did not consider this adequate and demanded further changes. In its adjudications, the ASA said it was not acceptable to: • Promote Botox except as a possible treatment option after a consultation, 14

and to “ensure that references to Botox were only presented in the context of a potential outcome of a consultation with the clinic.” • Provide information on Botox which could be navigated to directly, without consumers also viewing information about the consultation process. • To suggest Botox be used off licence, so only treatment to the glabella lines could be referred to (and now crow’s feet) but not forehead lines or peri-oral lines. • To show any before or after photographs showing the potential outcome of treatment, as these “would be understood as an efficacy claim and therefore constituted a promotion for Botox.” In addition, the ASA said information on Botox can only be, “Presented in a balanced and factual way and for such factual references to reflect the content of the Summary of Product Characteristics (SPC) document.” This means that any claims, such as HB Health’s statement that “Botox dramatically softens facial lines and wrinkles leaving you looking younger,” are not permitted, but statements such as “Botox is the brand name for a form of Botulinum type A, which is produced by the bacteria clostridium Botulinum. Botox is an injection of minute doses into certain facial muscles …”, “Botox is injected using a disposable syringe with a very fine needle. A very small amount of the botox powder is diluted with saline …” and “Once you have been treated it usually takes two to five days before wrinkle softening treatment actually takes effect and sometimes even a little longer to notice the full effect” were all permitted as factual claims. The Committee of Advertising Practice write and maintain the UK Advertising Codes which are administered by the Advertising Standards Authority. Its guidelines state that “Other than referring to a consultation for lines and wrinkles, marketers should take care not to refer to Botox at all on the home page of their website or a place where casual browsers can come across information relating to Botox with ease. An advertiser may include a price list with a range of treatments available but the Aesthetics | February 2014

price list should not include product claims or actively encourage viewers to choose a product based on the price.” In 2012 the ASA ruled against a clinic whose website referred to Line Relaxing Treatment (Botox) and whose price list included ‘Line Relaxing Treatment’ saying, “Consumers would understand the reference to ‘Line Relaxing’ treatment in the price list was a reference to Botox and therefore promoted a POM.” There is clearly still a huge amount of confusion as to what is allowed when it comes to clinic websites. When HB Health told the ASA that, “References to Botox were extremely common within the beauty industry and that many websites for clinics contained similar content,” they were entirely accurate. The best source of help is probably the help note published by Committee of Advertising Practice (CAP) in October last year. For the first time this addressed non-surgical advertising. “We know that it’s important that we are able to reflect the changing market,” says ASA spokesperson Matt Wilson, “Particularly the huge growth in non-surgical procedures and the increasing use of digital marketing.” The note covers advice on areas such as before and after photos, endorsements, testimonials, prescription-only medicines and sales promotions. It sets the limits of advertising botulinum toxins, stating that clinics, “Should do so in a non-specific way without a reference to Botox,” specifying instead a description such as, ”A consultation for the treatment of lines and wrinkles.” This note should be required reading for anyone working in digital marketing in aesthetics, and for doctors themselves. Clearly, in the post Keogh era, simply doing what everyone else does, even if you aren’t making outrageous, unethical or even inaccurate claims, will not protect you from being reported to the ASA, having to face embarrassing publicity and needing to amend your website. For more help and advice on advertising cosmetic interventions visit www.cap.org. uk, and view the Help notes section in the Advice and Training tab.

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Clinical Practice CPD Clinical Article

Non-surgical lower face lift Dr Raj Acquilla MBChB MRCGP MBCAM Cosmetic dermatologist with over 11 years experience in facial aesthetic medicine. UK Ambassador, global key opinion leader and masterclass trainer in the cosmetic use of botulinum toxin & dermal fillers. Speaker of the Year 2012 at the UK Aesthetic Awards. Faculty lecturer at IMCAS, AMWC, FACE, ECAMS and AAAM. Clinic and Academy in Cheshire and London. www.the-masterclass.co.uk

ABSTRACT Lower face lift has historically been the preserve of the surgical specialty. However, owing to the increasing anatomical knowledge of facial ageing through cadaveric study and non-surgical lifting techniques we are now able to achieve excellent outcomes with injectables. The ongoing advancements in filler science, technology and development of sophisticated injection techniques also contribute to the success of the injection facelift.

INTRODUCTION In this paper I will explore the anatomical basis and aetiology of lower facial ageing. In particular we shall highlight the changes occurring in the facial skeleton, fat compartments, musculature and skin. Understanding the pathology allows us to generate a treatment protocol in keeping with the most effective sequence of treatments at the correct injection sites in order to generate tissue lift and support. In my experience, effective treatment of this area tends to produce impactful results associated with high levels of patient satisfaction.

LOWER FACIAL AGEING During ageing of the lower two thirds of the face we observe the following changes when considering the tissue layers from superficial to deep [1]: Figure 1

Figure 2

1. Skin – laxity, sagging and excess due to photo damage related loss of collagen and elastin 2. Fat – mid and lower facial lipoatrophy resulting in deflation and subsequent inferior migration of the fat compartments 3. Muscle – lower facial depressor Fig 1 and 2 display the ageing process hypertonicity and hypertrophy which of the lower two thirds of the face exacerbates soft tissue descent 4. Bone – facial skeletal resorption and remodelling which compromises soft tissue support in the anterior, lateral and vertical planes Overall there is gradual age related change in face shape from the aesthetic ideal oval or heart shape towards a square or inverted triangle described as the Erosion of Beauty by Carruthers et al in 2006 shown below [2]. Figure 3 [2]

Aesthetics | February 2014

ANATOMY - MUSCLES The elevators of the mid and lower face from medial to lateral [3] 1. Levator labii superioris alequae nasi – oral snarl 2. Levator labii superioris – vertical lift of upper lip 3. Zygomaticus minor – oral smile 4. Zygomaticus major – oral smile 5. Risorius – lateral lift of oral commissure during laughter 6. Buccinator – retraction of the oral commisure 7. Mentalis – lower lip elevator The depressors of the lower face from medial to lateral [4] 8. Depressor septi nasi – nasal tip descent 9. Depressor labii inferioris – lower lip depressor 10. Depressor anguli oris – oral commissure depressor 11. Platysma – powerful lower facial descent during grimace The modiolus [5] is an important fibromuscular junction [6] adjacent to the oral corner, which is the insertion point for the orbicularis oris and seven other lower facial muscles. Its vertical position can be influenced by strategic weakening of lower facial depressors with botulinum toxin. This has a strengthening effect on the reciprocal elevators of the mid face, generating a lifting effect. [7] Figure 4 [8 & 9]

VASCULAR SUPPLY The facial artery enters the face at the anterior border of the masseter muscle and travels in a superomedial direction towards the modiolus then upwards just lateral to the nasolabial fold to the alar fossa [9]. As it runs up the lateral border of the nasal bones it becomes the Angular artery before giving rise to the terminal branches

Figure 5 [8 & 9]

Clinical Practice CPD Clinical Article

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(supratrochlear, supraorbital and the intraorbital arteries). These branches share an anastamotic relationship with the ophthalmic artery, thus explaining the risk of visual acuity compromise following intravascular embolisation [10]. The proximal branches of the facial artery in the lower face from inferior to superior: 1. Marginal mandibular artery – running medially in the mandibular groove 2. Inferior labial artery – running medially in the lower lip 3. Superior labial artery – supplies the upper lip and nasal collumellar branch The branches have a midline anastomosis with collateral supply, which can reduce the risk of necrosis following vascular injury [5]. The external carotid artery runs lateral to the mandible and gives rise to the Transverse facial artery at the level of the tragus. This travels medially behind the zygomatic arch and supplies the mid face and buccal regions [11]. It is important to note that the corresponding venous structures lie lateral to the facial arteries, which must also be avoided to minimise bruising [12]. Figure 6 [8 & 9]

The sequence that we observe age related volume loss and dehiscence between facial fat compartments can be summarised as follows [14]:

Figure 7 [14]

1. Anterior herniation of the infraorbital fat leading to ‘eye bags’ and deterioration of the tear trough deformity 2. Atrophy of the lateral malar fat compartment without ptosis associated with reduced projection at the Ogee curve 3. Deflation of the lateral temporal cheek fat with mild descent 4. Deflation and descent of the medial malar fat compartment exacerbating the depth of the naso-labial fold 5. Antero-medial herniation of the buccal fat compartment (Figure 8) resulting in fat accumulation and sagging at the jawline Figure 8 [9]

NERVE SUPPLY

The motor supply to the muscles of facial expression comes from the facial (seventh cranial) nerve. It enters the face just below the tragus embedded within the body of the parotid gland where it emerges at its medial border and divides into five main branches from superior to inferior (temporal / zygomatic / buccal / mandibular / cervical) [3]. Disruption to these branches may result in a motor palsy therefore extreme care must be taken when injecting this area [13]. The sensory innervation to the face is supplied by the trigeminal (5th cranial) nerve through its three branches (opthalmic / maxillary / mandibular). The branches of relevance to the mid and lower face from superior to inferior are [3]: 1. Zygomaticotemporal nerve – lateral cheek and lower eyelid sensation 2. Infraorbital nerve – entering the malar region via the infraorbital foramen (1cm below the infraorbital rim in the mid pupillary line) medial cheek and lower eyelid, lateral nasal wall and upper lip sensation 3. Mental nerve – entering the chin/jaw via the mental foramen supplying sensation to the chin, jawline and lower lip Sensory branches allow patient feedback but injections around these nerves can be exquisitely painful and should be avoided unless performing a regional block with local anaesthetic [10].

FAT COMPARTMENTS In 2007, Rohrich and Pessa assessed 30 hemifacial dissections following injection of methylene blue dye into facial fat. The findings concluded that the subcutaneous fat is divided into discrete fat compartments separated by septi [14] or ‘retaining ligaments’ [15]. The sequence in which these compartments change in volume and position with age was found to be an important factor in assessing and treating facial deflation and subsequent descent [14]. We have since used this information to develop accurate treatment strategies, which lift and project specific fat compartments to achieve a desirable aesthetic effect [4]. 18

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It therefore confers that following a sequential technical strategy to restore volume and lift soft tissue in keeping with the order of these age related changes will produce more effective correction of this process [4]. Figure 9 [6]

FACIAL SKELETON During ageing there is a significant effect on bone density and remodelling. In the facial skeleton we can observe these changes in the transverse, vertical and anterior projection of the bony landmarks as follows: 1. Loss of the youthful convexity of the frontal skull 2. Temporal hollowing and narrowing of the bi-temporal width 3. Orbital remodelling, flattening and lateral extension of the orbital floor 4. Reduced projection of the zygomatic arch and maxilla 5. Increased diameter of the pyriform aperture resulting in nasal descent 6. Retrusion of the dentition due to maxillary and mandibular resorption 7. Loss of mandibular height, width and anterior projection These combined changes result in less effective soft tissue support, dehiscence, descent, deterioration and sagging at the jawline [9].

Aesthetics | February 2014

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TECHNICAL STRATEGY STEP 1 - BOTULINUM TOXIN

CASE STUDY

Given that a significant component of lower facial descent is Figure 10 [8&9] exacerbated by the hyperactivity and hypertrophy of lower facial depressors, we can effectively use botulinum toxin in specific doses to selectively weaken these depressors. This allows the antagonistic mid facial elevators to facilitate lift and equilibrium in the lower face. This technique was described by Dr Phillip Levy in 2007 as the Nefertiti lift where 130 patients were studied and reported high satisfaction levels for jawline tightening and lift [16]. Following injection of botulinum toxin into the mentalis (4-5U deep), depressor anguli oris (1-2U SC) and platysma (5 x 2U SC) in the pattern above, the patient should be reviewed at two weeks for HA filler.

STEP 2 – HYALURONIC ACID FILLER

Figure 11 [8 & 9]

We can volumise and lift lower facial soft tissue in keeping with the sequential changes in facial skeletal projection and fat compartment atrophy and migration during ageing as described above. The eight-point injection lift was described by Dr Mauricio De Maio in 2010 which I have modified below [4].

64-year old female before and after injection lower face lift using: • Botox – Mentalis 5U, (DAO 2U, Platysma 10U, Masseter 18U) each side • Juvederm Voluma® – 2cc each side divided into 0.1-0.2cc aliquots as above Before

After

Risks & Complications Botulinum toxin [11]

Hyaluronic acid [16]

Facial asymmetry Asymmetric smile Salivary incontinence Dysphasia Dysphagia Anterior neck weakness Ptosis

Bruising / swelling Lumps / nodules / granuloma Infection / abcess Allergy / hypersensitivity Vascular compromise Necrosis / tissue loss Bio-film and delayed reactions

Adverse events can be minimised by selecting the correct patient, product, dosage, placement and administration by the appropriate person in a suitable environment using an aseptic technique. Effective treatment planning and executing a robust protocol can help to reduce risks and complications.

CONCLUSIONS 1. Lateral malar fat compartment – to promote superolateral lift 2. Beautification point (intersection of upper alar / tragus line with lateral brow line) to optimise convexity and projection at oblique Ogee curve 3. Malar groove – to correct depression and promote anterior projection and vertical lift of the medial cheek 4. Alar fossa – supports the upper 1/3 of the nasolabial fold 5. Oral commissure – oral corner lift and marionette line correction 6. Menton – promote anterior / inferior chin projection to Steiners line 7. Pre-jowl sulcus – uniform chin / jowl transition and jawline continuity 8. Angle of mandible – superolateral lift and contouring of the jawline

Recent advancements through rigorous scientific study and development have culminated in a deeper and more cultivated understanding of the injection face lift. We now have the knowledge and tools to deliver exceptional products using the most sophisticated techniques. These non-surgical interventions have never been more effective in influencing muscle, fat compartments, retaining ligaments, surface tension and genuine tissue lift. Through ongoing refinement of the art and science of facial aesthetics, our results can only improve and surpass the expectations of our patients, raising the bar in our industry and promoting excellence as a pre-requisite standard.

REFERENCES 1. Hunter JS, J; Dahl, M. . Clinical Dermatology. 3rd ed. Massachusetts: Blackwell Science ltd; 2002 2. Carruthers et al, Derm Therapy, Vol. 19, 2006, 177-188 3. Drake RL et al. Gray’s Anatomy for Students. Churchill Livingstone; 2005. 4. Injectable Fillers in Aesthetic Medicine, Mauricio de Maio, Berthold Rzany, Springer, 2nd Edition 2014 5. Weinberg MJ et al. Facial Plast Surg 2009 ;25(5):324-8. 6. Mendelson, B. & Wong , CH.Aesthetic Plast Surg. 2012 Aug;36(4):753-60 7. Cohen AJ et al. Mid face facelift. Medscape, 2012. 8. Endoscopic Plastic Surgery, Bostwick, Eaves & Nahai, 1st Edition 9. Clemente Anatomy – A regional Atlas of the Human Body, 4th Edition 10. Draelos ZD, Editor. Cosmetic Dermatology: Products and Procedures, 1st edn, Chichester, West Sussex: Wiley-Blackwell; 2010.

11. Hartstein, ME. et al. Midfacial Rejuvenation. Springer, 2012 12. Coleman, SR et al; Aesthet Surg J. 2006 Jan-Feb;26(1S):S4-9. 13. Cohen J. Dermatol Surg 2008 ;34(Suppl 1):S92-9. 14. Rohrich; Pessa, JE (2007). “The fat compartments of the face: anatomy and clinical implications for cosmetic surgery”. Plastic and reconstructive surgery 119 (7): 2219–27; discussion 2228–31. 15. Furnas, DW (January 1989). “The retaining ligaments of the cheek.”. Plastic and reconstructive surgery 83 (1): 11–6. 16. Levy PM. “Nefertiti lift” J Cosmet Laser Ther. 2007 Dec;9(4):249-52.

FURTHER READING: Papageorgiou, KI et al Aesthet Sur J. 32(1) 46 –57 2012 Lowe NJ et al. Dermatol Surg 2005;31:1616-25

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The Low Down. Rejuvenating the Lower Face Practitioners discuss the importance of a cocktail approach to lower face ageing, sharing their tips and techniques

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Studies have shown that while younger women are mostly concerned about the look of their bodies, older women tend to be more dissatisfied with changes related to facial ageing, particularly in the lower face.[1] As discussed in the previous feature, multiple, interacting changes to the soft tissues and skeleton cause the visible signs of ageing in the lower face. Dr Nick Lowe says contributing factors including smoking, acne and genetic factors. “Smokers have been found to appear five to ten years older than non-smokers of the same age, with increased sagging and more lower facial lines. Previous inflamed acne on the lower face increases collagen and elastin damage and contributes to sagging around the chin and mouth. Orbicularis oris movements such as lip puckering and pursing create wrinkles. Familial thin lips create a higher risk of barcode lines as they have less resistance to the folding of skin around the lips, and an inherited small or posterior chin (micrognathia) will also add to sagging of the jawline. Cosmetic dentistry, if done well, can considerably improve perioral ageing.” As the causes of visible ageing in the lower face are complex, reversing age-related changes using non-surgical methods may require a ‘cocktail’ approach, involving topical treatments, toxins, dermal fillers and skin tightening. For patients whose primary problem is superficial damage, such as wrinkling from smoking or UV exposure, Dr Lowe suggests encouraging use of a cream with both UVA and UVB protection plus a minimally inflammatory retinol. “My favourite is Isotrex gel,” he says. “If there is relatively superficial sun damage I may also use the Fraxel laser at 1550 nanometres. This penetrates into the mid-dermis, producing tightening and stimulating of collagen. For deeper folds and wrinkles I may suggest Intracel. The insulated needles deliver radio frequency and resultant tightening to the collagen and elastin tissues. Both Fraxel and Intracel produce minimal inflammation which is very important.” For ageing around the mouth due to loss of volume, fillers are the treatment of choice. Says Dr Lowe, “In my opinion, only hyaluronic acid fillers are safe to use in the lips and perioral area. I prefer to use a product which includes a local anaesthetic. This means choosing from the Juvederm, Restylane or Emervel families. I use a very fine, 30G cannula for the vermillion border then use the needle to deposit a small amount of dermal filler into the body of the lip and massage it smooth. I like Volbella as it is soft and produces little swelling at the injection site. However it may not last as long as other fillers. “I use approximately 1cc in the lower lip and a third of this in the upper to maintain good proportions. For patients with thinner lips, I’ll consider refining the effect with a maximum of one further syringe four to six weeks later. A slower improvement is more discreet for the patient, is less likely to cause bruising and increases the persistence of the filler, probably due to less inflammation, swelling and oedema in the area.” If a patient presents with significant ‘barcode’ lines above the lip, look at the patient’s dynamic movements to see how the lines change with muscle activity. Says Dr Lowe, “If this is significant I may consider botulinum toxin as an additional treatment. I use a total of about four units of Botox, or 12 units of Dysport or five units of Xeomin, deposited in two to four tiny amounts spaced out along the upper lip, depending where the maximum muscle activity is.” Dr Rita Rakus, who also likes to use Volbella for lip enhancement, says that many patients are concerned about the risk of a ‘trout-pout’. “For these patients discussion of the role of Hyalase in dissolving hyaluronic acid fillers can allay their fears.“ she says. “It is part of sensible counselling that includes warning of possible bruising and swelling that may occur. It is important to remember that lip enhancement is never totally predictable. As they age, some patients develop a thin, compressed look to the lateral border of the lips, and ask for volumisation in that area. However, on injecting I sometimes discover that only the central portion of the lip will become fuller, with the edges Aesthetics | February 2014

Clinical Practice Special Focus

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EndyMed 3DEEP

remaining flat. In these cases I add more product to the centre of the lip at the top and bottom, and add a very small amount, around 0.5mls, to the area around the mouth, halfway between the centre of the border and the lateral edge, with more emphasis on the bottom lip, to lift the lip line. For patients with thin, ‘letterbox’ lips it can be difficult to get volume while the mouth is closed. For those patients it can be helpful to show them in a mirror how their lips look fuller when they are in motion.” For barcode lines, Dr Rakus says, “Fillers still achieve good results, but lasers such as Fraxel and Total FX can be highly effective in minimising fine lines and are often used in a combination treatment plan.” Ageing is often associated with a downturned, ‘sad’ mouth, which develops due to descent of surrounding tissue, habitual expressions and loss of volume. The use of botulinum toxin in the lower face, in particular to relax the depressor anguli oris muscles to create lift at the oral commissures is increasingly popular. However, Dr Mervyn Patterson warns that special care must be taken when treating the lower face. “If treatment of the depressor anguli oris is unequal on both sides the smile will be asymmetrical and difficult to correct. Slight diffusion laterally of toxin in the mentalis will affect the depressor labia inferioris which leads to a very unusual looking movement of the lower lip.” Aesthetic nurse Sharon Bennett says, “To avoid asymmetry, when targetting the perioral area and the depressor anguli oris it is important to avoid the orbicularis oris, which would affect the sphincter and closure of the mouth with reduction in ability to pucker, while injections given too medially will affect the depressor labii inferioris between the DAO and the mentalis. This will cause a flattening of the contour of the lower lip, an asymmetric smile and reduction in the ability to purse the lips. You can

I use the tower technique when injecting in the zygomatic arch, placing little towers of one of the thicker fillers, Dr Nick Lowe

Dr Ariel Haus using the Sublime skin tightening system

normally palpate the DAO by getting the patient to contract the muscle for example asking them to pronounce the letter ‘e’.” Dr Mervyn Patterson warns that, “Over zealous orbicularis oris injections impair the ability to pronounce ‘p’s and ’b’s. The correct procedure only lasts about 6 weeks.” Surgeon Adrian Richards adds that excessive relaxation of the depressor anguli oris muscle (DAO) may lead to the elevation of the corners of the mouth. This occurs because of the action of their antagonist levator anguli oris muscles, which elevate the corners of the lip. With less resistance to the levator muscle, the lips can curl up in an unnatural ‘joker smile’. This may be a particular risk with older patients because the philtrum area tends to lengthen with age, which lowers the central part of the upper lip. Says Richards, “The key is to be very conservative and very superficial. I would use 2 to 2.5 units of Botox, and inject just into the skin, allowing the toxin to diffuse into the muscle.” If a patient has a strong platysmal muscle pulling down the angle of the mouth giving jowls and marionette lines, Dr Lowe says, “I inject a maximum of ten units of Botox or equivalent into the muscle, divided equally between the right and left sides of the platysmal bands.” Lower facial ageing may also be caused by volume loss in the mid-face, so don’t ignore the use of lifting fillers injected into the lateral cheek and over the zygomatic bone to lift the lower face and mouth area. Dr Lowe says, “I use the tower technique when injecting in the zygomatic arch, placing little towers of one of the thicker fillers, injected vertically right on the periapical of the zygomatic arch with either SubQ or Voluma. Sculptra treatments can lift the mid-face but it is important to avoid the area around the mouth as it appears that the action of the muscles in this area concentrate Sculptra into small areas, which may result in nodules.” However, Dr Patterson says, “There is only so much lift one can be achieved with fillers, and lifting becomes more difficult with more aged faces without creating an over-inflated look to the cheek. Early intervention is best and patients should be informed when surgery is the best answer to their concerns.” For early signs of jowling, Dr Lowe says a more youthful jawline appearance can be achieved using a hyaluronic dermal filler injected into the indentation just below the chin and before the jowl. “Used in combination with a thicker filler to lift the cheek skin this can be extremely effective, In addition, Nefertiti injections of Botox along the jawline can be effective in cases where the platysmal bands are pulling Aesthetics | February 2014

Clinical Practice Special Focus

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downwards and Thermage can be used above the jawline and to the lateral and mid cheeks to tighten.” The growing desire of patients for non-surgical skin lifting has led to the development of more skin tightening treatments. One of the newest to the market is 3D-skintech used by Dr Martyn King, which uses tri-polar radio frequency for painless skin tightening. Dr Lowe says, “I would consider radio frequency lifting and tightening lateral to the marionette and nasolabial lines. I use Thermage or Intracel using both monopolar and bipolar frequencies.” Dr Rakus advises, “Combining volumising with radio frequency treatments such as Thermage or Pelleve, or ultrasound therapy such as Ulthera can be very effective in helping to rejuvenate the lower face and oral commissures.” Dr Lowe also recommends the Venus Freeze (a combined radio frequency magnetic resonance system) to tighten skin sagging in this area. “Studies conducted by US dermatologist Dr Neil Sadik and presented at the 5-continent Congress of Dermatology in Cannes in 2013 are very compelling. The treatment is painless but patients need at least five or six sessions a week or so apart to see long lasting results, plus a top up treatment three to six months later.” Dermatologist Dr Ariel Haus uses the Sublime skin tightening system on lower face folds, sagging jowls, neck and crepey skin. Sublime uses bipolar radio frequency and infrared light and requires three to five sessions spaced three to four weeks apart for best results. He says, “It is a comfortable treatment with zero downtime, making it a good choice for those who prefer a non-surgical option. It also gives a temporary instant lift, and I normally show patients half the face done before completing the treatment and they are very positive about the change.” Endymed 3DEEP is another pain-free option for skin tightening, with the energy delivered via multiple phase –

controlled skin electrodes. Surgeon Chris Inglefield describes it as “safe and effective.” For ‘pebbly’ or puckered chins, Adrian Richards recommends injecting either the central area or both lateral sides of the mentalis muscle with 2-2.5 units of Botox or equivalent. Dr Lowe adds, “Injections of Voluma or SubQ can do a lot to improve the appearance of a receding chin. When injected under the mentalis muscle, these fillers can last two years or more, as the anterior mandible does not move much.” For submental fat and fat around the jawline, the best treatment in future may be injectable fat dissolving injections. Ones currently in use include the deoxycholate-based treatments Lipodissolve or Aqualyx, while Kythera’s ATX-101 drug, after successful phase 3 trials, is expected to receive approval for use in the US this year. Dr Lowe says, “The lower face usually changes because the whole face is changing. It is extremely important to examine the patient carefully to assess the causes of ageing before treating the area, and a combination approach normally works best for global rejuvenation.” REFERENCES 1. Clin Interv Ageing. 2006 June; 1(2): 115–119

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Clinical Practice Techniques

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Using Sculptra with cannulas Dr Linda Eve describes the advantages for patients and clinicians of using cannulas to deliver Sculptra I have been using Sculptra for over seven years, and have carried out around 1,200 individual treatments. It is a unique, long-lasting collagen stimulator called poly L-lactic acid (PLLA), which stimulates the fibroblasts to create new collagen cells. It is the ideal treatment for patients who require general volume increase in the face such as in the temples, cheeks, lower face and chin areas. It is not advisable to use it in or above the lips nor across the forehead, eyelids or nose. Sculptra is suitable for patients who have suffered volume loss from as young as the mid-20s, to even the over 80s. It is particularly useful for giving soft volume and lift to patients with thin skin and volume loss where a surgical face-lift could leave them looking gaunt and dermal fillers might end up visible. Sculptra is mixed with sterile water and lidocaine 2% several days prior to treatment. Injections are placed in the sub dermal or supra-periosteum areas to stimulate the fibroblasts and injections must not be injected superficially in order to avoid the risk of nodules. While good results can be achieved with different techniques, my preference is to use a cannula rather than a needle when treating patients with Sculptra. I find that although the technique is more demanding, it has numerous advantages.

SAFETY With needles, there is little or no sensory feedback from the sharp tip, so it is easy to puncture a vessel or accidentally place product in areas such as the parotid gland. A cannula enters the subcutaneous plane quite easily, and, with sufficient experience, resistance to the blunt tip ensures you can feel exactly where it is. However, cannulas do need to be used gently otherwise it is still possible to enter a vessel if forced: I always advise aspirating before injecting. Unlike most dermal fillers, Sculptra is not viscous so reBefore

After

fluxing before injecting is easy and accidental intravascular deposition can be avoided.

PATIENT COMFORT The flexibility of the fine cannula makes the technique more challenging, but also makes the procedure far more comfortable for the patient. I begin all Sculptra treatments by numbing the needle entry point using a Coolsense for a few seconds. No topical anaesthetic cream is therefore required. I insert a flexible 27G x 37-40mm cannula through the entry point, which has been made with a 25G needle. The rest of the procedure is relatively painless due to the fast acting lidocaine mixed in with the Sculptra. I only need to make 11 to 13 entry points for a full face treatment compared to between 30 and 50 if using a 26G needle, because the long cannula allows me to cover a much wider area with each entry point. The cannula leaves minimal or no marks on the skin and dramatically reduces the discomfort of post-procedure massage. An additional advantage is that fewer than 10% of my patients experience minor bruising when I use cannulas.

REDUCED RISK OF NODULES In over 250 Sculptra treatments using cannulas, I have not had a single case where a patient has developed nodules. This is possibly mainly because with the cannula there is minimal risk of accidentally depositing droplets of Sculptra superficially into the dermis.

IMMEDIATE DRAMATIC FACIAL VOLUMISATION A full face treatment takes around 45 minutes and my patients can immediately return to non-strenuous activities, and they look as if they’ve had a temporary liquid facelift for a few days until the dilutant fluid has been absorbed. With such a low risk of bruising, my patients feel confident in having treatments even on the day of a special event.

TREATMENTS FOR A WIDE RANGE OF PATIENTS I use the cannula method very successfully even in difficult patients such 26

Aesthetics | February 2014

as those with extensive sun damage, thin dermis, leathered skin, or scarring from acne or chicken pox. For best results, a course of Sculptra treatments is normally required over a two to three month period using on average a total of two to seven vials. The number of vials used depends on patient age, presenting volume loss, and whether just the cheeks are being treated or the whole face. The gradual growth of collagen gives optimum results after about six to ten months following the last set of injections but early changes show at around two to three months. The effects of Sculptra last on average around two years when a smaller re-stimulation treatment is required to maintain the collagen lift. If no further treatments are given then the results achieved will be lost after about three years. A similar treatment using HA fillers could cost the patient around £4000 and only last approximately one year. A full face Sculptra treatment for the average 50-year-old costs around £2000, and a top up treatment costs around £1200 every two years. This affordability combined with the speed and painlessness of treatment creates enormous loyalty in patients. My Sculptra patients stay with me for years for their repeat treatments. It is not a treatment that patients ‘shop around’ for because once they see the results they always trust you. It is an amazing product that can be successfully used by itself or in combination with other dermal treatments to provide the most wonderful natural looking results. Dr Linda Eve MBBS is founder and Medical Director of the EvenLines Clinics based in Bournemouth and Spain since 2007. She won the National Aesthetics Award for the Best UK Small Clinic for 2013-2014 and the Dorset Venus Award 2013 for most successful female owned small business in Dorset. She regularly speaks at conferences and workshops on Sculptra treatments. Disclosure: Dr Eve is the UK’s key opinion leader for Sinclair IS Pharma, chairman of the UK Sculptra Advisory Board and member of the European Sculptra Expert Board. She recently launched the CanuSCULPT technique for treating patients with Sculptra and has been carrying out regular training courses in CanuSCULPT for Sinclair IS Pharma since early 2013.

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Clinical Practice Clinical Study

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Non-Invasive Short-Wave Guided Radiofrequency Device for Long-Term Sweat Reduction in Patients with Primary Axillary Hyperhidrosis: A Preliminary Study Prof. Igor Pinson, MD, PhD, Prof. Olga Olisova, MD, PhD, Prof. Irena Verkhogliad, MD, PhD. First Moscow State Medical University, Skin & Venereal Diseases Department, Moscow Russia. INTRODUCTION Radiofrequency (RF) electromagnetic energy applicator comprises a monopolar or bipolar electrode configuration and is applied in a stationary mode for deep skin heating, without being absorbed in the skin’s biological chromophores and without causing ablation of the epidermis and dermis. Since pathological and histological analysis in these indications revealed no irreversible damage to the upper skin layers or structures below the subcutaneous fat, RF technology may be an attractive non-invasive modality for sweat gland hyperthermia-induced thermolysis and thus compromising the sweat glands electro-chemical activity in primary axillary hyperhidrosis.

SWEAT GLAND NEURO-PHYSIOLOGY Hyperhidrosis is a disorder of excessive sweating by the eccrine sweat glands, due to overactive cholinergic innervation, beyond what is physiologically necessary for thermoregulation. Primary hyperhidrosis is a disorder in which there is excess sweating of the hands, feet, face, and the axilla. Found in greatest density in the axillae, palms, and soles of the foot, the eccrine glands produce sweat to help maintain body temperature in response to exercise or exposure to heat. Axillary hyperhidrosis is believed to arise from overstimulation of the eccrine glands by cholinergic nerve fibres of the sympathetic nervous system. Sweat glands are classified according to morphology and function as eccrine and apocrine sweat glands. Eccrine sweat glands are innervated by postganglionic sympathetic fibres of unmyelinated class C type via acetylcholine. When acetylcholine binds to muscarinic receptors on the sweat gland, intracellular Ca2++ concentrations increase. This results in an increase in the permeability of K+ and Cl- channels, which initiates the release of an isotonic precursor fluid from the secretory cells. Eccrine secretion is a clear fluid (pH 4.0-6.0) consisting of 99.0- 99.5% water and 0.5-1.0% solids, a mixture of inorgan28

ics salts, largely sodium chloride, and organic substances which include lactic acid and traces of urea. Eccrine glands are distributed throughout the skin in a common anatomic pattern of 3-6mm depth (Fig 1). The apocrine gland is relatively bigger than the eccrine. It is situated in the deep dermis or sub-cutaneous tissue at 6-8mm depth (Fig 1). The apocrine gland secretion is a thick, milky, odourless fluid rich in proteins, ammonia, lipids and carbohydrates. Their secretion, which fluoresces is a turbid fluid (pH 5.0-6.5) containing proteins, sugars, ferric iron, and ammonia.

TECHNOLOGY The SweatX system (Alma Lasers Ltd., Caesarea, Israel) is a high power, short-wave electromagnetic energy device operating at 40.68 MHz. It employs two types of RF-induced heating of biological tissue: (1) Unipolar Pro handpiece – single electrode characterised by high RF-energy penetration depth and (2) Coaxipolar Pro handpiece – coaxial electrodes optimised for shallow treatment. The dominant heating Figure 1. Anatomical view of the mechanism in both is rotational movement of water eccrine and apocrine glands. molecules in the alternating electromagnetic fields (dielectric heating). The handpiece is operated by dynamic phase control of the RF electromagnetic field intensity and depth of penetration to accommodate the different depths and physical size of the eccrine and apocrine sweat glands, and impedance matching network, which provides compensation of the reactance of the attached piece of the skin. Figure 2 depicts thermographs of the Unipolar Pro and Coaxipolar Pro handpieces with multi-level depths of tissue penetration: Unipolar-Pro: shallow (5-8mm), medium (10-12mm) and deep (15-18mm), and Coaxipolar Pro: shallow (1-2mm), medium (3-5mm) and deep (6-8mm), respectively.

MECHANISM OF ACTION When radiant RF electromagnetic energy is absorbed in tissue, it provokes oscillation of the dipole water molecules, which leads to frictional heating. Sweat gland water content is 99-99.5% whereas that of surrounding skin appendages (hair follicle, sebaceous gland) is significantly less. The rapidly oscillating electromagnetic RF field (40.68 MHz) emitted by the RF Unipolar Pro causes rapid roFigure 2. Unipolar-Pro (Upper) and Coaxipolar-Pro (Lower) tation of the dielectric water thermographs of dynamic phase control - shallow (left), molecules in the saturated medium, and deep (right). hyperactive sweat glands Aesthetics | February 2014

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Clinical Practice Clinical Study

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and consequently greater friction and heat production in the glands in comparison with that induced in lower water-content adjacent skin structures, such as hair follicles. The Coaxipolar handpiece greater power density targets the more superficial eccrine glands and traps the caloric reservoir of the Unipolar-Pro volumetric deep heating to increase glands thermolysis. Thus, the RF heating by the Unipolar Pro and Coaxipolar handpieces is to induce irreversible thermal damage to the hyperactive water-targeted and to both eccrine and apocrine glands which are significantly different in their physical size and anatomical depths.

CLINICAL STUDY Between December 2012 and March 2013, 20 patients (17 women and three men; age range 16-51 years old) diagnosed with primary axillary hyperhidrosis were randomly recruited to the study conducted at a major dermatology clinic in Moscow. Study objectives, protocol (number of treatments and intervals), benefits and possible risks were delegated to the patient by the clinic medical staff. Patient screening for the study was based on those routinely seeking dermatology services at the clinic. Each patient signed an informed consent. The following Inclusion/Exclusion criteria were applied. Inclusion criteria were: hyperhidrosis disease severity scale (HDSS) questionnaire between three and four (Fig. 3)

1 - My underarm sweating is never noticeable and never interferes with my daily activities 2 - My underarm sweating is tolerable but sometimes interferes with my daily activities 3 - My underarm sweating is barely tolerable and frequently interferes with my daily activities 4 - My underarm sweating is intolerable and always interferes with my daily activities Figure 3. Hyperhidrosis Disease Severity Scale (HDSS)

Figure 4(A)

Figure 4(B)

Figure 4. Positive axillary iodine-starch test (A); laser beam axillary skin temperature monitoring during SweatX treatment (B).

Each treatment comprised 2 treatment steps: Initially, the Unipolar-Pro was employed over the entire axilla area to increase the axilla temperature under 45°C to the therapeutic level by depositing 25kJ of dielectric RF energy at 70-80 watts. Immediately upon conclusion of the first step, the Coaxial Pro handpiece is applied to the same, now heated, axilla area. The purpose of the second step is to maintain the axilla deep tissue temperature at a therapeutic level of 48-50°C by depositing and maintaining thermal load primarily at the eccrine gland level (4-6mm in depth) by depositing 10kJ of dielectric RF energy at 50-60 Watts. Treatment time for each axilla was 8-10 minutes (~20 minutes for both axillae). Clinical endpoints were transient tissue erythema and skin tenderness, which lasted up to one hour. No pre-treatment local anesthesia or pain medications were used and downtime is minimal. Post treatment care was cleaning and drying both axillae. Each patient underwent four consecutive treatments spaced one week apart. Baseline photography of each patient’s axilla iodine-starch test was captured at baseline, one, three and six months after the last treatment. Adverse side effect log was recorded for each patient and after each treatment and during each follow-up visit.

RESULTS

All 20 patients completed the 1 study protocol. Expectedly, 2 during the treatment the axillae become erythemous 3 and tender which resolved up to three to four hours after 4 the treatment. No adverse side effects were noted or recorded between the study BL 1M FU 3M FU 6M FU treatments and the followFigure 5. Patients HDSS (1-4) at up visits. Before starting the baseline (BL), 1, 3 and 6 months (M) follow-up (FU) treatment protocol, eight patients (40%) reported sweating severity (HDSS) equal to HDSS 3, and 12 patients (60%) HDSS level 4. In the control group eight patients (80%) evaluated their sweating severity as HDSS 1 and two patients (20%) reported HDSS level 2. At the three month follow-up visit, patient improvement (by iodine-starch and HDSS) was almost unchanged (with one patient exception) in comparison with one month follow-up visit. At the 6 month follow-up, 11 patients (55%) were evaluated for sweat intensity of HDSS level 2, and nine patients (45%) reported sweat intensity of HDSS level 1 (Fig. 5). At six month follow-up visit, the control group patients showed no changes from baseline in their HDSS questionnaires. Figure 6 depicts the number of patients shifted from baseline HDSS (4 and 3) one month after the last treatment. From patient HDSS 4 group (n=8), five patients (63%) converted to HDSS 2 and three patients (37%) to HDSS 1. From patient HDSS 3 group (n=12), nine patients (75%) converted to HDSS 2 and 3 patients (25%) to HDSS 1. 15

In the iodine-starch test, a 10% povidone iodine antiseptic solution was applied to both axillae and allowed to dry for five minutes. Cornstarch powder was then spread on the area and any excess starch brushed away. After 15 minutes, the regions were photographed (Fig 4A). Exclusion criteria: iodine allergic reaction, active infection, pregnancy planning, pregnancy or lactation, prior surgery for axillary hyperhidrosis in the past 12 months, axillary injections of botulinum toxin A in the last 12 months, history of cancer, pacemaker or other electronic implant. At baseline eight patients had HDSS level 4, and 12 patients had HDSS level 3. Forty-eight hours prior to the iodine-starch test male patients were asked to shave both axillas and all patients to avoid any use of deodorants. All qualified patients exhibited positive iodine-starch test (Minor’s test) on both axillas. Each patient underwent four consecutive treatments spaced one week apart. Baseline photography of each patient’s axilla iodine – starch test and HDSS were captured at baseline, one, three and six months after the last treatment. During each treatment, room ambient conditions – temperature and relative humidity were monitored and recorded. Prior to the application of the RF handpieces, each axilla was coated with water-free aromatic oil for lubrication to ease handpiece engagement with the axilla area. Both handpieces were applied in overlapping strokes across the treatment area. Axillary skin temperature was monitored by laser thermometer (Fig 4B) to keep the epidermis below 45°C. 30

Aesthetics | February 2014

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Number of Patients

Figure 6. Patients HDSS 4 (white bar) and 3 (blue bar) at baseline and at one month (M) follow-up (FU).

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Baseline HDSS 4 & 3

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DISCUSSION This is the first study demonstrating the safety and long term efficacy (up to six months) of non-invasive short-wave guided dielectric radiofrequency technology for sweat reduction in patients with primary axillary hyperhidrosis. Interestingly, one month after the last treatment, all patients with HDSS 3 or 4 shifted to HDSS 1 or 2. This observation corresponded with an improvement in iodine-starch test results. Although a significant and similar improvement pattern was established one month after the last treatment in patients with HDSS 4 & 3 (Fig. 6), patients reported significant improvement in their daily sweat sensation already after their third and fourth treatment. The clinical results remained unchanged in most patients up to six months where patients demonstrated significant sweat reduction (Fig. 7). In the absence of histological evidence, it

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Figure 7. Right (upper) and left (lower) axillae before, one, three and six months after four treatments.

is speculated that the sustained high power RF dielectric heating of the highly saturated eccrine glands at different levels in the dermis and hypodermis may deactivate the gland electrophysiology function (i.e., thermal shock) and/or damage the hyperactive water-targeted secretory ducts of the eccrine glands by shutting down the electro-conductivity pathway of the glands and presumably deactivation or decay of pre-synaptic and post-synaptic excitation/activation of the gland cholanergic receptors. The current concept about axillary sweat glands differentiates between eccrine sweat glands producing abundant clear, non-odorous sweat and apocrine sweat glands excreting small amounts of turbid, odorous milky sweat. Since axillary hyperhidrosis is known to coexist with malodor, the SweatX technology may potentially be effective for the reduction in axillary osmidrosis (malodor). REFRENCES 1. Atkins JL, Butler PE. Hyperhidrosis: a review of current management. Plast Reconstr Surg. 2002;110:222-228. 2. Emilia del Pino M, Rosado RH, Azuela A, Graciela Guzman M. Effect of controlled volumetric tissue heating with radio frequency on cellulite and the subcutaneous tissue of the buttocks and thighs. J Drugs Dermatol. 2006;5:714-722.

Aesthetic Technology Limited Park View House, Worrall Street Congleton, Cheshire CW12 1DT t: 0845 689 1789 | e: info@dermaluxled.com w: www.dermaluxled.com Before and after images courtesy of; Rosacea – Blushers Clinic, Coventry; Psoriasis – Miss Zahida Butt, The Cosmetic Clinic, Kings Lynn; Acne – Dr Steve McGurk – Ilkley

Bocouture® 50 Abbreviated Prescribing Information Please refer to the Summary of Product Characteristics (SmPC). Presentation 50 LD50 units of Botulinum toxin type A (150 kD), free from complexing proteins as a powder for solution for injection. Indications Temporary improvement in the appearance of moderate to severe vertical lines between the eyebrows seen at frown (glabellar frown lines) in adults under 65 years of age when the severity of these lines has an important psychological impact for the patient. Dosage and administration Unit doses recommended for Bocouture are not interchangeable with those for other preparations of Botulinum toxin. Reconstitute with 0.9% sodium chloride. Intramuscular injection (50 units/1.25 ml). Standard dosing is 20 units; 0.1 ml (4 units): 2 injections in each corrugator muscle and 1x procerus muscle. May be increased to up to 30 units. Not recommended for use in patients over 65 years or under 18 years. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. Contraindications Hypersensitivity to Botulinum neurotoxin type A or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, Lambert-Eaton syndrome). Presence of infection or inflammation at the proposed injection site. Special warnings and precautions Should not be injected into a blood vessel. Not recommended for patients with a history of dysphagia and aspiration. Adrenaline and other medical aids for treating anaphylaxis should be available. Caution in patients receiving anticoagulant therapy or taking other substances in anticoagulant doses. Caution in patients suffering from amyotrophic lateral sclerosis or other diseases which result in peripheral neuromuscular dysfunction. Too frequent or too high dosing of Botulinum toxin type A may increase the risk of antibodies forming. Should not be used during pregnancy unless clearly necessary. Interactions Concomitant use with aminoglycosides or spectinomycin requires special care. Peripheral muscle relaxants should be used with caution. 4-aminoquinolines may reduce the effect. Undesirable effects Usually observed within the first week after treatment. Localised muscle weakness, blepharoptosis, localised pain, tenderness, itching, swelling and/or haematoma can occur in conjunction with the injection. Temporary vasovagal reactions associated with pre-injection anxiety, such as syncope, circulatory problems, nausea or tinnitus, may occur. Frequency defined as follows: very common (≥ 1/10); common (≥ 1/100, < 1/10); uncommon (≥ 1/1000, < 1/100); rare (≥ 1/10,000, < 1/1000); very rare (< 1/10,000). Infections and infestations; Uncommon: bronchitis, nasopharyngitis, influenza infection. Psychiatric disorders; Uncommon: depression, insomnia Nervous system disorders; Common: headache. Uncommon: facial paresis (brow ptosis), vasovagal syncope, paraesthesia, dizziness. Eye disorders; Uncommon: eyelid oedema, eyelid ptosis, blurred vision, eye disorder, blepharitis, eye pain. Ear and Labyrinth disorders; Uncommon: tinnitus. Gastrointestinal disorders; Uncommon: nausea, dry mouth. Skin and subcutaneous tissue disorders; Uncommon: pruritus, skin nodule, photosensitivity, dry skin. Musculoskeletal and connective tissue disorders; Common: muscle disorders (elevation of eyebrow), sensation of heaviness; Uncommon: muscle twitching, muscle cramps. General disorders and administration site conditions Uncommon: injection site reactions (bruising, pruritis), tenderness, Influenza like illness, fatigue (tiredness). General; In rare cases, localised allergic reactions; such as swelling, oedema, erythema, pruritus or rash, have been reported after treating vertical lines between the eyebrows (glabellar frown lines) and other indications. Overdose May result in pronounced neuromuscular paralysis distant from the injection site. Symptoms are not immediately apparent post-injection. Bocouture® may only be used by physicians with suitable qualifications and proven experience in the application of Botulinum toxin. Legal Category: POM. List Price 50 U/vial £72.00 Product Licence Number: PL 29978/0002 Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer Landstraße 100, 60318 Frankfurt/Main, Germany. Date of revision of text: FEB 2012. Full prescribing information and further information is available from Merz Pharma UK Ltd., 260 Centennial Park, Elstree Hill South, Elstree, Hertfordshire WD6 3SR. Tel: +44 (0) 333 200 4143 Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard Adverse events should also be reported to Merz Pharma UK Ltd at the address above or by email to medical.information@merz.com or on +44 (0) 333 200 4143. 1. Frevert J. Content in BoNT in Vistabel, Azzalure and Bocouture. Drugs in R&D 2010-10(2), 67-73 2. Prager, W et al. Onset, longevity, and patient satisfaction with incobotulinumtoxinA for the treatment of glabellar frown lines: a single-arm prospective clinical study. Clin. Interventions in Aging 2013; 8: 449-456. 3. Sattler, G et al. Noninferiority of IncobotulinumtoxinA, free from complexing proteins, compared with another botulinum toxin type A in the treatment of glabelllar frown lines. Dermatol Surg 2010; 36: 2146-2154. 4. Prager W, et al. Botulinum toxin type A treatment to the upper face: retrospective analysis of daily practice. Clin. Cosmetic Invest Dermatol 2012; 4: 53-58. 5. Data on File: BOC-DOF-11-001_01 Bocouture® is a registered trademark of Merz Pharma GmbH & Co, KGaA. 1131/BOC/NOV/2013/LD Date of preparation: November 2013

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Clinical Practice Spotlight On

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Regenlite Transform Dr Donna Freeman, Director of Clinical Research at Chromogenex, discusses the benefits of the new Regenlite Transform laser in treating dermatological conditions Following the N-Lite and Regenlite, Chromogenex has now launched Regenlite Transform the only laser proven to stimulate the skin’s immune system by triggering an increase in Transforming Growth Factor Beta (TGFβ). Previously dermatological conditions such as psoriasis and eczema have been treated using the vascular mode of pulsed dye lasers. However, studies conducted with Regenlite and published in the British Journal of Dermatology indicated that the effect on acne was primarily due to biostimulation, in particular in the upregulating of TGFβ, which is involved in producing collagen and in downregulating the inflammatory cascade. (1) It is also known to be intimately involved in the acquisition of an immune response in the skin, to reduce the skin’s reactivity to triggers such as bacteria and viruses. The study showed that as early as three hours after treatment with Regenlite there was a massive upregulation in TGFβ of between 500 and 1500%. In our studies some patients reported a reduction in the pain of inflammatory acne and relief from itching in eczema and psoriasis within hours of their first treatment. With the new Regenlite we have focused on the parameters that are most effective for biostimulation, making it a major advance in the treatment of inflammatory skin conditions such as acne, psoriasis, rosacea, eczema and for warts and verrucas. These new parameters use much lower doses of light than in the vascular mode, and even better targeted parameters than the previous biostimulation Before

After

Psoriasis, Before and three months after eight treatments.

Before

After

Rosacea, Before and after three treatments.

mode, making the treatments pain-free, very well tolerated, with no bruising or risk of hypopigmentation even in Fitzpatrick skin types V and VI. It is also the release of these molecules, in particular TGFβ, which produces the unique treatment results seen with this laser. TGFβ is known to be a potent

heat-damaged layer associated with ablative resurfacing techniques and initiates collagen stimulation without long-term impairment. The critical laser parameters engineered into the device to achieve bio-stimulation include pulse duration and temporal profile. The unique parameters ensure that erythrocytes remain intact, there is no endothelial cell Regenlite Transform introduces two unique modes necrosis and the of action, • Bio-stimulation, a multi-application mode formation of immature • Thermal for vascular treatments elastic fibres can be Delivering both double and triple pulse options, it uses low observed as soon fluency light to specifically target the microvasculature of as three days after the dermis and stimulate the tissue’s natural wound healing treatment(3). It uses response without any residual cell necrosis. Absorption of the a patented pulse yellow light into these blood vessels results in a mild thermal profile innovation effect and an inflammation that incites the release of cytokines of 100μs, which and growth factors and leads to the stimulation of new collagen. delivers consistent reproducible stimulus for neocollagenesis and a pivotal cutaneous immunological responses immunosuppressive cytokine. The action without tissue impairment. The pulse is of these is the promotion of inflammation generated by the ultra stable laser cavity, resolution within early acne lesions and which produces the fast rise pulse and pure prevention of microcomedone formation 585nm yellow light output. The absorption that occurs as a result of keratinocyte characteristics of oxyhemoglobin highlight hyperproliferation at the pilosebaceous unit. 585nm to be the perfect wavelength When the laser targets a small capillary; of light to combine maximum tissue 1) absorption in the oxyhemoglobin results penetration and maximum absorption. in heating of the capillary walls Wavelength stability is crucial to maximise 2) inflammatory mediators are released the absorption in oxyhaemoglobin and which stimulate fibroblast cells in the minimise unwanted purpura. Patients extracellular dermal matrix today are less likely to desire or tolerate 3) these fibroblasts produce new collagen. systemic treatments such as antibiotics or complicated and unpleasant ones as are Yellow laser light was originally used for traditional for psoriasis. I believe Regenlite the therapy of vascular lesions because Transform offers a more holistic treatment of their high absorption preference by that can improve patient safety, compliance oxyhaemoglobin. Following on from the and satisfaction. use of Argon (blue-green) laser light for REFERENCES the treatment of Port Wine Stains, attention 1. Seaton et al, British Journal of Dermatology focused on pulsed yellow dye lasers to 2006; 155: 748-755 replicate the highly selective damage to 2. Tan OT, Arch Dermatol 1986; 122(9): 1016-22 cutaneous micro-vessels but with minimal 3. Omi et al, Lasers in Surg Med 2003; 32: 46-49 injury to the overlying epidermis.(2) Dr Donna Freeman Careful consideration of the key parameters is director of clinical research and education of the laser can enable the focus of the at Chromogenex, treatment to not be the normal ectatic or with a focusing on dilated vessels of a vascular irregularity but clinical research, instead the smallest of the microvasculature development of within the dermis. Biochemical stimulation new devices and rather than thermolysis of these microtechnologies, construction of technical articles and documents. vessels mimics the effect of residual Aesthetics | February 2014

chromogenex

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The world’s first Super Fast Pulse 585nm laser for inflammatory skin conditions Introducing the world’s first Super Fast Pulse 585nm laser, a major advancement in the treatment of inflammatory skin conditions such as psoriasis, rosacea, eczema and acne as well as rejuvenation of the skin and other dermatological conditions. The Regenlite™ Transform is a new concept of therapeutic laser and the only laser proven to stimulate the skin’s immune system by triggering an increase in Transforming Growth Factor Beta (TGFβ) and engineered to deliver consistent results using patented pulse profile innovation.

Safe, fast and effective treatment for:

• • • • •

Psoriasis Rosacea Eczema Acne Rejuvenation

Enquire now visit www.regenlite.com

For further enquiries call 0800 037 or email sales@chromogenex.com

8003

UK: +44 (0)1554 755444 • USA: 1-855-438-4547 • South Africa: +27(0)11 079 4242 Australia: 1800 827 817 • Brazil: +55 (11) 4702 4451 • Hong Kong (852) 3965-3175

Chromogenex

@chromogenex

Made in the UK

chromogenex Leaders in Laser Technology

™

Clinical Practice Clinical Focus

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Desirial and Desirial Plus for intimate rejuvenation Dr Elisabeth Dancey explores the treatment of labia majora hypotrophy with Desirial Plus The menopause is characterised by decreasing ovarian and adrenal function, with alterations of growth hormone secretion. The skin and mucosa of the whole body are affected by the changes, due to the generalised nature of female sex hormone receptors. During the perimenopausal period, type 1 collagen decreases but type 3 increases. There is a global loss of 1% collagen type 1 per year, leading to a progressive hypotrophy and flattening of the dermoepidermal junction. The effects on the female genitalia can be summarised as the following. Labia majora hypotrophy – involution of the adipose and cutaneous component. Tissue loss is associated with function loss and the labia are unable to protect the vulva and vagina. Aesthetically the labia majora appears thin and wizened. (Fasola E, 2009) (Fasola et al 2010). (Macgregor JC 2008). The other is vulvo-vaginal atrophy. The stratum corneum is non-keratinised and there are no clearly demarcated layers as for the skin (Farage et al, 2011). There are no glands in the vaginal wall. Moisturisation and protection against disease is assured by the glands of the cervix, Skenes glands and Bartholins glands (however currently under dispute). Bacteria ferment secreted glycogen thus assuring a bacteriostatic acid environment. Desirial is a hyaluronic acid product created by Laboratoires Vivacy. It is a patented cross-linked interpenetrated network with added mannitol to aid longevity and reduce swelling. Mannitol acts specifically on hydroxyl radicals which destroy hyaluronic acid, thus prolonging the effect of the HA and minimising swelling and inflammation. (Back JF et al, 1979). Desirial Plus is created to reshape the labia majora and contains 21mg/g hyaluronic acid. It is presented in a 2ml syringe with 2 18 cannulae. Desirial Plus may be used by aesthetic doctors for this purpose. Desirial contains 19mg/g hyaluronic acid and is created as a biostimulant/ rehydrating agent in the medium to deep dermis. It restores volume, rehydrates the skin and the mucosa and stimulates fibroblast activity in the labia majora, vestibule and vagina. It is presented as 2 x 1ml syringes. Desirial should only be injected internally by a gynaecologist. Treatment with Desirial for vulvu-vaginal conditions Desirial should be used as part of a comprehensive treatment programme for the menopause together with other modalities such as hormones, diet, creams and lifestyle changes. The manufacturers insist that this treatment is carried out by a suitably trained gynaecologist. Desirial is a completely new treatment for an intimate area. It is essential that the treatment is offered in a discreet manner to avoid connotations of the sex trade. There may also be local taboos over discussing such a problem amongst menopausal women. However once these aspects have been overcome it is envisaged that the treatment will have its adherents and will, in the right hands and with the correct introduction, be successful.

Using Desirial Plus as an aesthetic practitioner • Treatment with Desirial Plus is similar to any treatment with HA using a cannula. The area should be shaved and cleaned with a bacteriocidal solution, avoiding chlorhexidine over the delicate mucosa. Local anaesthetic is essential as this area is very sensitive. • Mark the insertion area with a skin marker. Select the upper part of the labia majora above and lateral to the clitoris. Inject with local anaesthetic such as lidocaine 1%. • Make the pilot hole with the 19g needle provided in the pack. Aim the needle so that the track runs parallel to the skin, beneath the dermis. • Assemble the cannula onto the syringe. Using the pilot hole, gently insert the cannula so that it runs parallel to the skin, moving downwards towards the base of the labia (about 5cm). Once in the correct position, press the plunger and retract the syringe, depositing 2ml into the length of the labia. Remove the syringe and repeat the other side. • The main problem associated with this procedure is pain, which must be well explained to the patient. Local anaesthesia moderates this pain. Infection is a potential complication as for any HA treatment but pilot studies show this not to be the case with this treatment. • It is essential that the technique is perfected in order to avoid injection of the product into the Bag of Sappey. Inadvertent injection into this area will cause swelling, redness and pain similar to infection. Treatment with hyaluronidase into the lump will relieve the condition (1500 iu into the lesion). REFERENCES • Back JF et al. Increased thermal stability of proteins in the presence of sugars and polyols –Biochemistry – 1979 vol 18 No 23 p 5191 – 5196 • Chlebowski, RT, Hendrix SL, Langer RD, Stefanick ML, Gass M, Lane D, Rodabough RJ, Gilligan MA, Cyr MG, Thompson CA, Khandekar J, Petrovitch H, McTiernan A. Influence of oestrogen plus progestin on breast cancer and mammography in healthy post-menopausal women. The women’s health initiative randomized trial JAMA 2003 289; 3243-53. • Eva LJ, Maclean AB, Reid WM, Rolfe KJ, Perrett CW. Estrogen receptor expression in vulvar vestibulitis syndrome Am J Obstet Gynaecology 2003 Aug 189 (2) 458-61 • Farage MA, Maibach HI, Morphology and physiological changes of genital skin and mucosa. Curr Probl Dermatology 2011; 40: 9-19 • Fsaola E, Anglana F, Basile S, Bernabei G,CavalliniM. A case of labia majora augmentation with hyaluronic acid implant. Journal Plastic dermatology 2010 (6)3. • Levine KB, Williams RE, Hartmann KE. Vulvo-vaginal atrophy is strongly associated with female sexual dysfunction among sexually active women. Menopause, 2008, 15 (4pt 1) 661 -666. • Santoro, N and Komi J. Prevalance and impact of vaginal symptoms among postmenopausal women. Journal of Sexual medicine, 2009, 6 (8) 2133 – 2142.

Aesthetics | February 2014

Dr Elisabeth Dancey has been practising cosmetic medicine since 1993. She introduced mesotherapy to the UK having studied at Liege, Belgium and has pioneered several other treatments and products. She now owns and runs Bijoux Medi Spa in central London. She has trained and demonstrated the use of various hyaluronic acid fillers over the last 20 years and will be one of the trainers for Desirial.

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WonDERfUL SKin WonDERfUL yoU Restylane Skinboostersâ&#x201E;˘ are a groundbreaking deep skin hydration treatment that improve overall skin quality from within for a natural radiance that shows. Traditional skin care products applied on the skin surface can easily be washed away, while Restylane Skinboosters hold water deep in the dermal layer for lasting hydration and improvements to skin elasticity and smoothness. Discover Restylane Skinboosters and help patients discover the wonders of youthful, radiant skin. To find out more visit www.galderma-alliance.co.uk RES/022/1212n Date of Preparation July 2013

Galderma (UK) Ltd Meridien House, 69-71 Clarendon Road, Watford, Hertfordshire WD17 1DS Galderma Switchboard: 01923 208950 Email: info.uk@galderma.com

Clinical Practice Clinical Study

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Impact of Botulinum Toxin A on the Quality of Life of Subjects Following Treatment of Facial Lines

measure of QoL for comparison, each of the five cue scores was multiplied by the corresponding cue weight and the products of these calculations summed together.

RAVI JANDHYALA, MSc(LOND), MBBS(LOND), MRCS(GLASG), MFPM, LLM

The cue score (range 0–100) was derived from the length of the bar (in millimetres) drawn by the patient for that particular cue. The cue weight was derived from the proportion of weighting the patient had assigned, using the direct-weighting instrument, to that particular cue (range 0.00–1.00). At the follow-up visit, patients completed the SEIQoLDW procedure using both newly defined cues (subsequently labelled ‘new cues’) and the cues defined at their pre-treatment visit (subsequently labelled ‘old cues’). Cues are defined at each visit to ensure that the QoL scores derived are maximally relevant to the patient at that time. As a consequence, it is possible that a patient may define markedly different cues at the follow-up visit as compared to the initial visit. To account for this, the SEIQoL-DW protocol also recommends assessment of the patients using the old cues as defined at the initial visit.15

The Jandhyala Institute, Banbury, United Kingdom Demand for treatment of facial lines continues to rise, botulinum toxin (BoNT-A) is especially popular due to its efficacy and tolerability1, 2 BoNT-A is now used in a wide range of aesthetic applications in many areas of the face.3 As such, full quantification of the benefits of BoNT-A treatment is becoming increasingly important. A key area of interest is whether treatment actually improves a patient’s day-to-day life. Improvements in satisfaction, appearance, mood, and related outcomes have been well reported,4–13 but to date, data on whether these improvements translate to or correlate with changes in quality of life (QoL) are scarce. Dayan et al14 recently reported that onabotulinumtoxinA treatment of facial wrinkles significantly improved QoL and self-esteem as compared to both treatment with placebo and pretreatment baseline values using the Quality of Life Enjoyment and Satisfaction Questionnaire—Short Form and the Heatherton and Polivy State Self-Esteem measurement. In the present study, an investigation of QoL in patients treated with BoNT-A was undertaken by using patient rather than questionnaire-defined criteria to measure QoL, before and after treatment, using the Schedule for the Evaluation of Individual Quality of Life Direct-Weighting (SEIQoL-DW) tool.15 Furthermore, the hope was to establish whether there is any correlation between patient satisfaction and changes in QoL.

METHODS The study prospectively measured patient QoL data using the SEIQoL-DW tool15 immediately before and 28 days after treatment with BoNT-A (Bocouture® , Merz Pharmaceuticals GmbH, Frankfurt, Germany). Satisfaction with treatment was also assessed by patients using standardised photos taken during pre- and post-treatment assessments. All new patients aged 18 to 65 years 38

presenting at the Jandhyala Institute for incobotulinumtoxinA treatment for moderate-to-severe wrinkles of the glabella, forehead, or crow’s feet (as measured by Carruthers’ Scale16,17) were eligible for inclusion. Patients were excluded on the basis of previous treatment with, or contraindications to, BoNT-A treatment or a history of migraine. Patient history was taken and routine assessment carried out at the initial visit, and standardised photos were taken at both visits. Ethical review was deemed unnecessary according to the National Research Ethics Service (NRES) guidance document, and the study was considered a service evaluation.18

The SEIQoL-DW tool was administered according to protocol.15 At the first visit, The use of new cues gives a measure a standardised question was used to of QoL using the cues that the patient stimulate patients to independently feels are of greatest importance to them identify the five life areas (cues) of most currently, while the use of the old cues importance to them at that time. A list of facilitates direct comparison of QoL at potential areas was available for use as each visit. Marked differences in the cues a prompt for patients who had difficulty identified or the importance ascribed completing this task. Patients then to these cues may necessitate further quantified their present status in each of investigation and consideration in the their five identified cue areas by drawing interpretation of the results. However, a bar for each area against a 100mm scale, with a taller bar TABLE 1. Frequency of nomination as areas of importance indicating better current status Cue Area Visit 1 Visit 2 (the cue score). Finally, the Family 96.2% 90.6% patients weighted the five areas Work 62.3% 69.8% as to their relative importance Finance 52.8% 58.5% using the direct weighting Relationships 52.8% 45.3% instrument, effectively Health 50.9% 60.4% producing a five-segment Appearance 43.4% 43.4% pie chart, with each segment Social life 35.8% 13.2% indicating the importance of Living conditions 34.0% 20.8% the corresponding cue area Leisure activities 32.1% 13.2% (cue weight). Patients were also Marriage 13.2% 7.2% asked to assess their overall Pets 13.2% 7.5% Partner 11.3% 11.3% QoL using a visual analogue Divorce 3.8% 1.9% scale (VAS) of 0 to 100 (0 being Religion 3.8% 0.0% the worst possible, 100 the Education 1.9% 1.9% best possible). To produce the Friends 1.9% 1.9% final SEIQoL-DW index score, Mother 0.0% 1.9% which provides an overall Aesthetics | February 2014

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(7% lidocaine & 7% tetracaine)

CLEAN, SIMPLE AND FAST ACTING (7% lidocaine & 7% tetracaine)

THE FIRST AND ONLY SELF-OCCLUDING TOPICAL ANAESTHETIC Indications: For use in adults to produce local dermal anaesthesia on intact skin prior to dermatological procedures

Pliaglis Prescribing Information (UK & Ireland)

Presentation: 1 gram of cream contains 70mg lidocaine & 70mg tetracaine.Indications: For use in adults to produce local dermal anaesthesia on intact skin prior to dermatological procedures. Dosage and Administration: For procedures such as pulsed-dye laser therapy, Pliaglis should be applied at a thickness of 1mm for 30 minutes. For procedures such as laser-assisted tattoo removal, Pliaglis should be applied at a thickness of 1mm for 60 minutes. After the required time, the peel must be removed from the skin prior to the procedure. The maximum application area should not exceed 400 cm2. For facial procedures, Pliaglis should be applied by healthcare professionals only. Pliaglis should be applied with a flat surfaced tool, never with fingers. Pliaglis is for single patient use. Contraindications: Hypersensitivity to lidocaine, tetracaine, other anaesthetics of the amide or ester type, to para-aminobenzoic acid or any of the other excipients. Should not be used on mucous membranes or on broken or irritated skin.

Precautions and Warnings: Avoid contact with eyes. Treated area should not be occluded before removing Pliaglis from skin. Should not be applied for a longer time than recommended. Local anaesthetics, including tetracaine, have been associated with methemoglobinemia. It is not recommended to use Pliaglis before injection of live vaccines as lidocaine has been shown to inhibit viral & bacterial growth. Use with caution in patients with hepatic, renal or cardiac impairment, and in patients with increased sensitivity to systemic circulatory effects of lidocaine and tetracaine. Avoid trauma to skin whilst under effects of Pliaglis. Interactions: No interaction studies have been performed. Interactions following appropriate use are unlikely as only low concentrations of lidocaine and tetracaine are found in the plasma after topical administration of recommended doses. Patients taking drugs associated with drug-induced methemoglobinemia are at greater risk for developing methemoglobinemia. Undesirable Effects: In clinical trials, localised skin reactions at the application site were very common

but were generally mild and transient in nature. Reported adverse reactions include: Very common (≥1/10): erythema, skin discolouration; Common (≥1/100 to <1/10): skin oedema; Uncommon (≥1/1,000 to <1/100): pruritus, pain of skin, pain; Rare (≥1/10,000 to <1/1,000): paresthesia, eyelid oedema, pallor, skin burning sensation, swelling face, skin exfoliation, skin irritation; Not known (cannot be estimated from available data): urticaria. Rare allergic or anaphylactoid reactions associated with lidocaine and tetracaine or other ingredients in Pliaglis can occur. Prescribers should consult the SPC in relation to other side-effects. Packaging Quantities and Cost: UK-15g £22.95 (NHS), IRE-15g €27.00 MA Number: PL 10590/0059 (UK) & PA 590/26/1 (IRE). Legal Category: POM. Full Prescribing Information is Available From: Galderma (UK) Limited, Meridien House, 69-71 Clarendon Road, Watford, Herts, WD17 1DS. UK. Tel: +44 (0)1923 208950 Fax: +44 (0)1923 208998. Date of Revision: May 2013

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Galderma (UK) Ltd Date of preparation: August 2013

PLI/034/0813

Clinical Practice Clinical Study

aestheticsjournal.com

some variation is inevitable as patients’ priorities and concerns inevitably change over time, and a key strength of the SEIQoL-DW approach is its ability to take account of these changes. Patients also assessed their satisfaction with their appearance before and after treatment from the standardised digital photographs taken at each visit using a VAS ranging from 0 (not satisfied at all) to 10 (completely satisfied).

RESULTS 53 patients (aged 22–62 years [median age: 39.5 years]; 87% women) were enrolled in this study. All patients successfully completed the independent nomination of five important areas of their lives and allocated current status and relative importance to each. Family, work, finance, relationships, and health were the five most frequently identified cues at each assessment (Table 1). According to the cue weights ascribed (and considering only those cues identified by more than 10 patients), the five cues deemed to be most important were family, appearance, health, relationships, and finance at both visits (Table 2). QoL before and after treatment was significantly improved following incobotulinumtoxinA treatment according to the SEIQoL index scores generated using both the old (P =0.0006) and new cues (P =0.0235) (Table 3). Overall QoL as measured by VAS following identification and weighting of the SEIQoL cue areas was also found to significantly improve after treatment when assessed

after consideration of both the old (P <0.0001) and new cues (P <0.0001) at Visit 2 (Table 3). Satisfaction increased significantly following treatment (median satisfaction score post vs. pre-treatment: 9.2 vs. 4.3, P <0.0001), but evidence of any positive correlation between satisfaction score and QoL or SEIQoL score was minimal. Only QoL as defined by VAS following the use of the old cues at Visit 2 was found to significantly correlate to satisfaction score at the same visit (P =0.0404, all other correlations P >0.05). When considering the change in these scores, 100% of patients indicated that their satisfaction with their appearance had increased. However, not all patients indicated that their QoL had increased. Following elicitation of the new cues, 79 and 64% rated their QoL as improved according to their overall assessment and using SEIQoL, respectively. Using the old cues, these figures increased to 91 and 75%. No evidence of any correlation between the change in satisfaction score and the change in QoL (as measured by VAS or SEIQoL) was found (all P >0.05).

DISCUSSION The results of this study demonstrate that QoL is significantly improved following incobotulinumtoxinA treatment. Both overall QoL as assessed by VAS and SEIQoL scores were consistently higher following treatment, irrespective of whether the old or new cues had been considered during the SEIQoL process. While the recognised procedure is to elicit new cues

TABLE 2a. Mean weight ascribed to nominated areas at Visit 1 Cue

at the second visit, it is also to use the old cues to facilitate direct comparison15. It is reassuring to note that overall, the same cue areas were identified as being most important at Visit one and Visit two, suggesting that as a whole, the patient population was relatively stable in terms of non-treatment influences on their QoL. It is also interesting to note that while, perhaps surprisingly, ‘appearance’ was not one of the five most frequently selected cues in determining QoL, among those patients who did identify it as important, it could be considered a fundamental driver of QoL, as evidenced by its prominent weighting. Perhaps surprisingly, the present study found no consistent evidence of correlation between the level of patient satisfaction and their SEIQoL or overall QoL scores at either visit, despite all patients having an increase in satisfaction and the majority showing an improvement in QoL, particularly when assessed following use of the old cues at their follow-up visit. It is also of interest to note that when the change in satisfaction score following treatment was analysed against change in SEIQoL or overall QoL, there was no evidence of a correlation in the size of the change of the two measures. This may in part be explained by the fact that satisfaction with appearance is one of many factors that contribute to QoL and, as already alluded to, less than half of patients identified appearance as a major determinant of their QoL. As such, it is clear that while appearance is undoubtedly important to many patients

TABLE 2b. Mean weight ascribed to nominated areas at Visit 2

Number of patients who nomniated cue at visit 1

Mean weighting visit 1

Cue

Number of patients who nomniated cue at visit 2

Mean weighting visit 2

Family

33.9

Family

31.5

Appearance

21.5

Appearance

18.2 19.8

Health

19.8

Health

Relationships

18.5

Relationships

17.6

Finance

18.3

Finance

16.3

Work

13.9

Work

15.3

Living conditions

13.6

Living conditions

14.9

Social life

12.9

Social life

11.8

Leisure activities

11.7

Leisure activities

14.1

Marriage

22.2

Marriage

24.0

Pets

16.6

Pets

16.3

Partner

14.7

Partner

11.2

Friends

17.0

Friends

12.0

Religion

21.0

Religion

0.0

Divorce

20.0

Divorce

28.0

Education

11.0

Education

22.0

Mother

0.0

Mother

30.0

Aesthetics | February 2014

Clinical Practice Clinical Study

aestheticsjournal.com TABLE 3. Quality-of-life scores pre- and post-treatment Measure

Comparison

QoL (VAS) scores SEIQoL indicies

Visit 1 mean

vs. old cues vs. old cues vs. old cues vs. old cues

Visit 2 mean

P-Value

72.3

P<0.0001

58.7 63.7

receiving BoNT-A, the use of satisfaction scores alone may be an unreliable surrogate for QoL in day-to-day practice. These results, in combination with those of Dayan et al,1 suggest that serious consideration should be given to incorporating the measurement of QoL as an outcome measure following BoNT-A treatment. Further research is warranted in this area to further quantify the impact BoNT-A treatment has on patients beyond the observed changes in appearance.

70.6

P<0.0001

70.1

P=0.0006

67.9

P=0.0235

Dr Ravi Jandhyala is a member of the Royal College of Surgeons of Glasgow, and a founding member of the UKBTGA. He has over nine years experience in aesthetics and also consults for the pharmaceutical industry as a pharmaceutical physician. Mr Jandhyala owns the Enhance clinic in Banbury and is a leading voice on botulinum toxin.

REFERENCES DISCLOSURE 1. American Society for Aesthetic and Plastic Surgery 2010. http://www. The author has received research funding from Merz Pharma in relation surgery.org/sites/default/files/Stats2010_1.pdf. Accessed on Feb 14, 2013. to other studies. The study received support for medical writing and 2. Imhof M, Kühne U. A phase III study of incobotulinumtoxinA in the treatmedicinal products from Merz Pharmaceuticals. ment of glabellar frown lines. J Clin Aesthet Dermatol. 2011;4:28–34. 3. De Boulle K, Fagien S, Sommer B, et al. Treating glabellar lines with 16. Carruthers A, Carruthers J, Hardas B, et al. A validated grading scale botulinum toxin type A-hemagglutinin complex: a review of the science, for crow’s feet. Dermatol Surg. 2008;34(Suppl 2):S173–S178. the clinical data, and patient satisfaction. Clin Int Aging. 2010;5:101–118. 17. Carruthers A, Carruthers J, Hardas B, et al. A validated grading scale 4. Sommer B, Zschocke I, Bergfiled D, et al. Satisfaction of patients after for forehead lines. Dermatol Surg. 2008;34(Suppl 2):S155–S160. treatment with botulinum toxin for dynamic facial lines. Dermatol Surg. 18. Defining research. National Research Ethics Service. Ref: 0987 2003;29:456–460. December 2009. www.nres.nhs.uk/applications/is-yourproject-research/. 5. Stotland MA, Kowalski JW, Ray BB. Patient-reported benefit and satisAccessed on: February 14, 2013. faction with botulinum toxin type A treatment of moderate to severe gla19. Lipton RB, Varon SF, Grosberg B, et al. OnabotulinumtoxinA imbellar rhytides: results from a prospective open-label study. Plast Reconstr proves quality of life and reduces impact of chronic migraine. Neurology. Surg. 2007;120: 1386–1393. 2011;77:1465–1472. 6. Fagien S, Carruthers JD. A comprehensive review of patientreported satisfaction with botulinum toxin type A for aesthetic procedures. Plast Reconstr Surg. 2008;122:1915–1925. 7. Carruthers A, Carruthers J, Dessain AS. Preliminary results with the Facial Line Outcomes (FLO) Questionnaire in the treatment of multiple upper face rhytids with botulinum toxin type A. Results from a single-center, dose-comparison, pilot study. Poster presented at: the Academy Laser2005 Support Services meeting of the American Academy of Dermatology; July 20–24, 2005; Chicago, IL. Patient protective eyewear 8. Lewis MB, Bowler PJ. Botulinum toxin cosmetic therapy correlates with Laser safety eyewear a more positive mood. J Cosmet Dermatol.Disposable 2009;8:24–26. Laser, IPL and LED eyewear Laser Support Services 9. Wollmer J, Wollmer MA, de Boer C, et al.Mouthguards Facing depression with botuliLaser surgical instruments num toxin: a randomized controlled trial. Psychiatr Res. 2012;46:574–581. Patient protective eyewear Safety signage outcomes with botuli10. Fagien S, Cox SE, Finn JC, et al. Patient-reported Laser safety eyewear Safety interlocks num toxin type A treatment of glabellar rhytids:Laser, a double-blind, Laser Support Services Disposable IPL and LED eyewear Laser safety curtains Mouthguards randomized, placebo controlled study.Laser Dermatol Surg. 2007;33:S2–S9. Support Services has been supplying laser Laser surgical instruments 11. Carruthers A, Carruthers J. A single-center, dose-comparison studyto current productsPatient since 1990. Alleyewear supplies conform protective Safety signage Laser Services EC safety standards of botulinum neurotoxin type A in females with upper facial Support rhytids: Laser safety eyewear Safety interlocks Disposable Laser,JIPL and LED Laser eyewear Support Services Ltd. assessing patients’ perception of treatment outcomes. Drugs Dermatol. Laser Support Services Laser safety curtains School Drive - Ovenstone - Fife - KY10 2RR Mouthguards 2009;8:924–929. Laser Support Services has been supplying laser Tel: 01333-311938 Fax 01333-312703 Laser surgical instruments www.laser-support.co.uk — Email Enquiries@laser-support.co.uk products since 1990. All supplies conform to current 12. Carruthers J, Carruthers A, Monheit GD, et al. Multicenter, randomized, Safety signage Patient protective ECeyewear safety standards Patient protective eyewear Safety interlocks parallel-group study of onabotulinumtoxinA and hyaluronic acid dermal Laser Support Services Ltd. safety eyewear Laser safety eyewear Laser safety School Drive fillers (24-mg/ml smooth, cohesive gel) aloneLaser and in curtains combination for- Ovenstone lower - Fife - KY10 2RR Disposable Laser, IPL LED eyewear Tel: and 01333-311938 Laser Support Services has been supplying laserFax 01333-312703 Disposable Laser, IPL and LED eyewear facial rejuvenation: satisfaction and patient-reported outcomes. Dermatol www.laser-support.co.uk — Email Enquiries@laser-support.co.uk products Mouthguards since 1990. All supplies conform to current EC safety standards Mouthguards Surg. 2010;36:2135–2145. Laser surgical instruments Laser Support Services Ltd. 13. Beer KR, Boyd C, Patel RK, et al. Rapid onset of response and paLaser surgical instruments Safety signage School Drive - Ovenstone - Fife - KY10 2RR tient-reported outcomes after onabotulinumtoxinA moder- Fax 01333-312703 Safetytreatment interlocks Tel:of01333-311938 Safety signage www.laser-support.co.uk — Email Enquiries@laser-support.co.uk ate-to-severe glabellar lines. J Drugs Dermatol.Laser 2011;10:39–44. safety curtains Safety interlocks 14. Dayan SH, Arkins JP, Patel AB, et al. A double-blind, randomized, Laser Support Services has been supplying laser Laser Support Services has been supplying laser products 1990. supplies conform to current Laser safety survey curtains placebo-controlled health-outcomes of thesince effect of All botulinum safety standards products since 1990. All supplies conform to toxin type A injections on quality of Services life andECself-esteem. Dermatol laser Surg. Laser Support has been supplying Laser Support Services Ltd. current EC safety standards 2010;36:2088–2097. products since 1990. All supplies conformSchool to current Drive - Ovenstone - Fife - KY10 2RR 15. O’Boyle C, Browne J, Hickey A, et al. The Schedule for the Evaluation Tel: 01333-311938 Fax 01333-312703 EC safety standards www.laser-support.co.uk — Email Enquiries@laser-support.co.uk of Individual Quality of Life (SEIQoL): a direct weighting procedure for Laser Support Services Ltd. Laser SupportRoyal Services Ltd. quality of life domains (SEIQoLDW). Administration Manual. Ireland: School Drive - Ovenstone - Fife - KY10 2RR School Drive - Ovenstone - Fife - KY10 2RR College of Surgeons in Ireland; 1993.

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Tel: 01333-311938 Fax: 01333-312703 www.laser-support.co.uk — Email Enquiries@laser-support.co.uk

Clinical Practice Treatment Focus

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BTL Vanquish: Radio frequency fat loss Lisa Littlehales discusses the mechanisms and benefits of the new device from BTL Aesthetics for the abdomen and flanks Previously, when a patient had a large abdomen, the only option for them was liposuction or abdominoplasty, which can both cause pain and discomfort. Additionally, anaesthesia poses a risk on an obese patient, and the chance of scarring and seroma is high. As a result, many plastic surgeons do not want to perform liposuction on patients with a BMI over 28/29. Vanquish radio frequency, F.D.A. approved, offers an alternative form of fat loss for those who need debulking of the abdomen and flank areas. It is a contactless device that uses selective high radio frequency to generate heat only in subcutaneous adipose tissue. At Beyond Medispa, we have used it successfully in combination with cryolipolysis technology Zeltiq’s CoolSculpting, which can be used to shape after the endpoint is achieved. Previously patients were recommended to lose weight prior to undergoing CoolSculpting, which could then be used to shape and reduce pockets of fat. By using Vanquish, the patient can reach their endpoint much more quickly. The treatment programme for Vanquish is quick and effective, comprised of four half an hour sessions ideally spaced a week apart, with very little downtime. Patients typically see results at two weeks, and the endpoint is three months after their fourth treatment. The patient is then called back to clinic for reassessment, to either continue with the technology or move on to another nonsurgical fat reduction treatment. Clinical trials demonstrated that the system is safe without serious adverse events and produces consistent, statistically significant reduction in circumference of the abdomen. 20 patients from 18 to 70 years of age underwent the four weekly treatments; results showed the mean circumferential Figure A

Before

After

reduction for the abdomen was 4.8cm (measured 5cm above umbilicus), 5.4cm (measured over umbilicus) and 4.9cm (measured 5cm below umbilicus).1 The circumferential reduction was measured at baseline and after the fourth treatment. There were no significant changes in patients’ body weight during the therapy. Figure A shows a 29-year-old female patient who underwent five sessions of Vanquish, demonstrating uniform reduction of fat by equal diffusion of heat. Anecdotally, one patient has claimed that the treatment has improved her stretch marks, and others have claimed their skin tone has improved: this could be due to thermal injury in the area treated, which has stimulated fibroblasts to produce collagen and elastin, improving the quality of the skin. However, there are no studies to support these claims. Patients are weighed prior to the treatment, and photographs taken. This is essential, so patients’ consent must be obtained. They are placed on their back, and an applicator placed on them to protect the skin. The head of the machine is placed over the abdomen. The patient’s skin temperature needs to reach 40°C for successful treatment. They should not be left unattended throughout treatment; the clinician should regularly ask patients to score their comfort level between one and 10 and regularly measure the temperature of their skin to ensure it doesn’t exceed 42°C, as this could cause scarring. Abdominoplasty or appendix scars must be monitored, as the numbness associated with surgical incisions can impair the patient’s ability to feel heat. The selective high frequency (HF) generates heat in subcutaneous adipose tissue only, with no effect on the skin, and targets structures with high impedance, namely the adipose tissue. HF causes electron movement, resulting in movement of atoms and molecules in the adipose tissue. This generates friction, which is transformed into heat. The tissue temperature rises to 44-45°C, at which point apoptosis, the natural death of fat cells, Aesthetics | February 2014

occurs due to polar molecule oscillation. The fat cells are then macrophaged away by the liver. Unlike cryolipolysis, which triggers a slow metabolism of fat, radio frequency results in instant treatment. As metabolism is rapid, it is advised that for 24 hours before and after treatment, patients have a low-fat diet and do not drink alcohol, due to the heavy workload of the liver. Unlike liposuction, there is no scarring because the heat produced targets fat cells and bypasses the skin. The temperature therefore rises in the fatty tissue, but surrounding tissue stays protected from reaching high temperatures. The device also measures the hydration levels of the areas being treated. Patients need to be well hydrated before treatment, as water is essential to allow polar molecule oscillation to occur. In summary, Vanquish is a contactless device, which uses selective HF to target subcutaneous adipose tissue specifically, allowing for quick and safe treatment. We opted for it at Beyond Medispa because it can treat the largest area compared to other machines, and focuses on the abdomen and flanks, the most requested areas for fat loss treatment. Additionally, it has increased the range of patients we can treat, and complements our current sculpting device CoolSculpting and skin tightening devices, which we hope to invest in in the future.

REFERENCES 1. Stoilova I, et Lozanova P (2013) Selective High Frequency (HF) Device for Noninvasive Contactless Reduction in Size of Abdomen of the Body. Unpublished clinical study, conducted August – December 2013, available from BTL Aesthetics & CCF Media. Lisa Littlehales is a registered general nurse with 15 years experience working in the independent cosmetic surgery sector. She was previously National Training Manager and South East Regional Manager for The Harley Medical Group, and is now General Manager of Harvey Nichol Knightsbridge and Beyond MediSpa Edinburgh, specialising in non-surgical led treatments. She has no financial ties with any companies.

Clinical Practice Abstracts

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A summary of the latest clinical studies Title: Changes of eyebrow’s muscle activity with aging: Functional analysis revealed by electromyography Authors: Yun S, Son D, Yeo H, Kim S, Kim J, Han K, Lee S, Lee J Published: Plast Reconstr Surg. 2013 Dec 30 Keywords: Eyebrow movements, electromyography, frontalis muscle Abstract: This study evaluated the activity of frontalis muscle, corrugator supercilli muscle (CSM), and orbicularis oculi muscle (OOM) according to eyebrow movement and aging. Two random cohorts of women aged 20 to 30 years (young group, n=20, mean age: 24.8 years) and 50 to 70 years (old group, n=20, mean age: 55.8 years) were recruited prospectively. Surface electromyogram was used to evaluate motor unit action potential for each muscle in each of six eyebrow movements. In both age groups, CSM activity was the highest for all six movements. Frontalis muscle activity was highest with maximal frowning but not with maximal eye opening. OOM activity was significantly greater in the older age group than in the younger age group for the most actions. When motion proportion of each muscle is compared, the respective OOM and CSM indices were comparatively higher in the older age group than in the young group. Eyebrows are maintained by the dynamic balance of frontalis, CSM, and OOM, and various combinations of motor recruitment of these muscles determine the eyebrow position and shape. For youthful eyebrows, attenuation of the depressor muscle may restore the muscle balance in treatments for eyebrow rejuvenation. Title: Neutralizing antibodies to botulinum neurotoxin type A in aesthetic medicine: five case reports. Authors: Torres S, Hamilton M, Sanches E, Starovatova P, Gubanova E, Reshetnikova T. Published: Clin Cosmet Investig Dermatol. 2013 Dec 18 Keywords: Facial rejuvenation, botulinum neurotoxin Abstract: Botulinum neurotoxin injections are a valuable treatment modality for many therapeutic indications as well as in the aesthetic field for facial rejuvenation. As successful treatment requires repeated injections over a long period of time, secondary resistance to botulinum toxin preparations after repeated injections is an ongoing concern. We report five case studies in which neutralizing antibodies to botulinum toxin type A developed after injection for aesthetic use and resulted in secondary treatment failure. These results add to the growing number of reports in the literature for secondary treatment failure associated with high titers of neutralizing antibodies in the aesthetic field. Clinicians should be aware of this risk and implement injection protocols that minimize resistance development. Title: Midface and Perioral Volume Restoration: A Conversation Between the US and Italy Authors: Gilbert E, Calvisi L Published: J Drugs Dermatol. 2014 Jan 1

Keywords: Dermal fillers, midface, perioral, US and Italy Abstract: There are numerous dermal fillers available to injectors in the US and Europe for the correction of age-related volume loss in the midface and perioral regions. Product availability differs between these two aesthetic markets due to US Food and Drug Administration (FDA) regulatory requirements. The purpose of this study is to discuss differences in filler selection by two practitioners in the US and Europe based upon both stylistic approach and filler availability in each market. Seven patients were selected for discussion and divided into two groups: 1) those requiring midface volumization and 2) those undergoing perioral or lip volume replacement. Patients in the midface group were injected with Juvéderm Voluma® XC, Juvéderm® Volift® with lidocaine, Restylane- L®, Perlane-L® or Radiesse®. Patients in the perioral and/or lip group were injected with Juvéderm® Volbella™, with lidocaine, or Belotero Balance™. Patients were photographed before and immediately after injection to evaluate aesthetic outcomes. In each case, filler selection was based upon patient characteristics, anatomical considerations and inherent filler properties. In conclusion, volume restoration in the midface and perioral or lip region can be effectively achieved using a variety of dermal fillers. The dermal filler portfolio available in Europe is exponentially larger than that in the US. Title: Comparison of Validated Assessment Scales and 3D digital fringe projection method to assess lifetime development of wrinkles in men. Authors: Luebberding S, Krueger N, Kerscher M. Published: Skin Res Technol. 2014 Feb Keywords: Wrinkles, validated assessment scales, 3D digital fringe Abstract: The assessment of wrinkle severity is an important evaluation criterion to determine the efficacy of aesthetic treatments. Aim of the present study was to compare Validated Assessment Scales (VAS) and 3D fringe projection (PRIMOS(®) for the evaluation of facial wrinkles in men and to determine standard values for each level of the VAS. 150 male subjects (20 to 70 years) were selected following strict criteria. Wrinkle severity at periorbital, glabella and forehead lines was evaluated using the 3D fringe projection and 5-point photonumeric VAS. The results of both methods were matched by determining quantitative values for each level of the clinical rating scale. High average correlation with age was found for VAS, Wd, maxWd, lWd, Wv, aWa and pWa. With a Wd of 60 to 70μm crow’s feet and forehead lines are pronounced first, whereas glabella lines develop in subject’s mid-forties, by an Wd of 180μm. Wrinkle severity increases at all locations every 10 years of age by one level of the VAS. This increase corresponds to an increase of Wd about 100 μm at glabella and forehead lines, and about 50 μm at crow’s feet. The presented reference values for the Validated Assessment Scale are an important step towards an optimized assessment of skin aging and aesthetic dermatological treatments.

Aesthetics | February 2014

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ACE Special Focus

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With the programme growing constantly there are now even more reasons not to miss the defining medical aesthetics event of 2014. With just over a month to go, places are going fast so register FREE for your entry today.

Latest news on ACE 2014 Expert Clinic added to FREE Exhibition Programme As the latest addition to our huge programme of free Masterclasses, Business Track workshops and Live Demonstrations, we are delighted to be hosting an Expert Clinic for the duration of the event. Our Expert Clinic will provide you with the opportunity to meet with leading medical experts and witness them demonstrate how they deliver the perfect treatment technique and also answer your questions. Experts include Dr Tapan Patel and Dr Raj Acquilla, who will be demonstrating a periorbital beautification and non surgical lower face lift during this exciting session. Galderma and Allergan to host Masterclasses at ACE We can now confirm that Allergan and Galderma will join Sinclair IS Pharma, Skinceuticals and Zeltiq as part of our programme of Injectable Masterclasses. Access to Masterclasses is available to all healthcare professionals with a FREE exhibition pass or paid conference pass. Please provide your GMC, NMC or GDC number when booking. Watch this space for more details to be announced over the coming weeks! More exhibitors confirmed With numbers increasing on an almost daily basis, it is with great pleasure that we welcome Cosmetic Courses, Beehive Solutions, Blow Media, Cosmedic Pharmacy, Cross Medical and Lipo Angel to our list of Exhibitors. For more information about all of the exhibitors confirmed for The Aesthetics Conference and Exhibition, check out the Exhibitor Directory on the ACE 2014 website. 3D-lipolite sponsor ACE Question Time We are delighted to announce that the evening will be sponsored by 3D-lipolite, a new three-dimensional weight loss programme combining treatment with diet and exercise. For more information about all of our sponsors visit our website.

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Question Time is now FREE with Conference Bookings Evening Question Time hosted by Peter Sissons will now be free to all those purchasing a one day or two day Conference Pass. This exciting session will take place on Saturday March 8 offering Delegates the opportunity to observe and participate with a panel of leading industry figures discussing the latest topics affecting aesthetic medicine today. Confirmed panellists include Dr Andrew Vallance-Owen — member of Sir Bruce Keogh’s Cosmetic Interventions Review team, Dr Leah Totton — winner of The Apprentice, Dr Mike Comins, Dr Tracy Mountford, Sharon Bennett, Mr Dalvi Humzah and Dr Martyn King. The debate will take place following a drinks and canapés reception providing attendees with a chance to network with peers and colleagues, and share knowledge gained from the conference so far. 59 CPD Points now on offer With the event programme constantly increasing there are now up to 59 CPD points to choose from providing both conference and exhibition visitors with the opportunity to gain accredited education. For a full breakdown of CPD points available visit www.ace2014.co.uk/CPD ACE Event guide now available For more information about the conference programme, exhibition schedule, workshop agenda, speakers and our steering committee, check out the ACE Event Guide free with your issue of Aesthetics journal. You can also download the guide online, visit www.ace2014.co.uk Med fx registration and consumables partner It gives us great pleasure to welcome Medfx as our Consumables and Registration Partner. Med-fx is part of one of the UK’s largest specialist medical product distribution groups and supplies a wide range of aesthetics and skin rejuvenation products. Sponsored by:

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Aesthetics | February 2014

In Practice Revalidation

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Revalidation Special Dr Paul Myers summarises how aesthetic doctors can be prepared and meet the requirements for revalidation On December 3 2012 the GMC introduced revalidation, marking a turning point for every practising doctor in the UK. For the first time, a doctor who was registered with the GMC could only continue to practise medicine under strict conditions, to which a time limit now applied. These new regulations were introduced following incidents such as the Shipman and Bristol Royal Infirmary heart scandals, in order to monitor doctors more closely. They were also designed to reassure the public as it is claimed that revalidation will reduce risks to patients. The method requires every doctor to show that they are up-to-date, reflecting on their work, and practising according to Good Medical Practice Guidelines. Prior to this, a doctor practising with the UK registration could continue without supervision indefinitely and would only have their registration threatened if a complaint or problem came to the notice of the GMC. Now doctors have to be licensed as well as registered to provide clinical services in this country. The conditions of having a licence are dictated by the ‘Responsible Officer Regulations’. These state that doctors must have an annual appraisal, and must be assessed as to their fitness to practice once every five years in the revalidation process. No other country has such a rigorous method of controlling and assessing the medical competence of individual medical practitioners.

INDEPENDENT SECTOR DOCTORS AND RELICENSING The Medical Profession (Responsible Officer) Regulations 2010 came into force on January 1st 2011. From that date, designated organisations were required to nominate or appoint a responsible officer with statutory functions relating to the evaluation of the fitness to practice and monitoring of the conduct and performance of doctors with whom the body had a connection. The following year, on December 3 2012, all UK doctors were obliged to follow the relicensing regulations. Some of the new regulations can be particularly challenging for independent sector doctors: those practising within the NHS have had a system of regular appraisals and clinical governance for some years, which has become part of the culture of practising within the health service. However, independent sector doctors may practise in isolation, and perhaps don’t have the administrative backup that is necessary for successful revalidation. Aesthetic doctors also experience specific problems with appraisal and revalidation, particularly the difficulty in collecting supporting information, such as quality improvement data and feedback. HOW TO REVALIDATE AND KEEP YOUR LICENCE The GMC have told all doctors the date they want to receive their first revalidation recommendation from the responsible

KEY REQUIREMENTS FOR ALL UK REGISTERED AND LICENSED AESTHETIC DOCTORS You must make sure: • You are participating in an annual appraisal process, which has ‘Good Medical Practice’ as its focus • You are linked to a designated body • You know your route to revalidation • The GMC have been notified of the name of your designated body • You are collecting the appropriate information you need to be relicensed such as CPD evidence, colleague and patient feedback, quality improvement documentation, significant events and review of complaints and compliments

ISSUES OF WHICH YOU MAY NOT BE AWARE • If you cannot demonstrate that you are having an appraisal each year, there is a risk that the GMC will consider that you are not engaging with revalidation • If your GMC licence is removed it is an offence to practice medicine in the UK • There is a substantial difference between being licensed and being registered with the GMC • The GMC will bring forward your revalidation submission date if it thinks you are not engaging with revalidation • If you cannot find a responsible officer or suitable person to revalidate you, the only way you can keep your licence is through the GMC’s ‘Alternative Route’, which will involve a GMC written examination, and a clinical examination, as well as the annual appraisal obligation

Aesthetics | February 2014

officer (RO) of each designated body (DB). This is the ‘revalidation submission date’ or RSD. If you are not aware of your RSD, you should log in to the ‘GMC online’ section of the GMC website to see confirmation of your designated body, and crucially the designated body that you have told the GMC will provide your ‘route to revalidation’. Your DB is defined by your clinical practice and the organisation with which you are associated. Examples of DBs for aesthetic doctors could be a private hospital or clinic with which they are contracted, and which has DB, or the British College of Aesthetic Medicine (BCAM), which is a designated body in its own right, and provides a revalidation service. HOW DOCTORS CAN MEET THE GMC’S REQUIREMENTS FOR REVALIDATION IN THE FIRST CYCLE. The minimum requirements for doctors before they will be able to be revalidated are precisely defined by the GMC. Whichever organisation provides your annual appraisals and revalidates you, they all have to follow the regulations (found on the GMC website) and ensure that mandatory information has been provided. On the revalidation date the responsible officer of the DB will look at all five of the previous appraisals, and based on the ‘output statements’ and the appraiser’s summaries, will decide whether to recommend relicensing to the GMC. The responsible officer also examines the information held about the doctor within the designated body, for example complaints or problems that have been encountered in the previous five years. In the first few years of this process not all doctors will have five consecutive appraisals, so the responsible officers will base their conclusions on fewer appraisals. Dr Paul Myers is a full-time appraiser for doctors in the independent sector. He worked as an NHS GP for 25 years, and subsequently as a private GP with an interest in aesthetic medicine, and medical lasers. He is the director of Doctors Appraisal Consultancy. 49

COME AND SEE US AT STAND 60

In Practice Revalidation

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Revalidation Special Emma Davies explains the proposed system of revalidation for aesthetic nurses Since 1995, registered nurses have been required by The Nursing and Midwifery Council (NMC) as part of The Code (NMC, 2008) to keep knowledge and skills up to date, recognise and work within the limits of their competency and take part in appropriate learning and practice activities to maintain and develop competence and performance. Postregistration education and practice (Prep) is a set of NMC standards and guidance designed to ensure nurses provide a high standard of practice and care. Prep standards are legal requirements which must be met in order for registration to be maintained.

THERE ARE TWO KEY STANDARDS. 1.

A minimum of 450 hours practice in the previous three years. 2. Undertake and record continuing professional development (CPD) over the three years prior to renewal of registration. This must constitute a minimum of 35 hours of learning activity relevant to practice. At renewal of registration, nurses are required to sign a declaration that they have met the standards for Prep and may be required to submit evidence as part of NMC audit, (NMC, 2011). In September 2013, The NMC met to decide upon a model for revalidation, “To increase public confidence that nurses and midwives remain capable of safe and effective practice”. “The system of revalidation that we adopt must contribute to our core regulatory purpose, which is public protection. We aim to deliver a proportionate, riskbased and affordable system that will provide greater public confidence in the professionals regulated by the NMC. It is also important that revalidation raises standards of care and promotes a culture of continuous improvement amongst nurses and midwives.” (NMC, 2013) The main difference between Prep and the proposed system of revalidation appears to be an additional requirement to use feedback, from service users, employers and colleagues, to review the way an individual works and confirmation from, “Someone well placed to comment on their continuing fitness to practice”.

The NMC have consulted with a variety of stakeholders and now begin a six month public consultation to review and revise The Code (NMC, 2008), which sets out the standards of good nursing and midwifery practice, and how the proposed model of revalidation can be implemented in a variety of employment settings and scopes of practice. The new system is expected to launch in December, 2015. The consultation will run in two parts, the first will close on March 31, 2014. Nurses in aesthetic medicine work in a variety of ways; full time, part time, selfemployed, alone, or as part of a team. 78% of BACN members work alone, 41% are self-employed, 82% work part time with 47% continuing to work in the NHS 100% have undertaken some form of CPD (aesthetics specific) in the last 12 months, and 77% have undertaken more than three days in the last 12 months, far exceeding the NMC Standard. (BACN, 2013). We know there will be aesthetic nurses who do not access quality CPD activities and have had limited training, no supervision, mentoring or appraisal. Many of our members actively seek mentors and would welcome the opportunity to learn from their peers, but opportunities are very limited and there is currently no formal framework for mentoring, supervision or appraisal. Developing and maintaining skills in this constantly evolving field requires considerable investment in both time and money. Treatments have become increasingly invasive and complex and the lack of regulation and the disconnect from the regulators in place gives us great cause for concern. As an organisation, the BACN has made a positive start in identifying the problems and constructively ensuring they are addressed either by us, or by the appointed regulator. We have published ‘A Career and Competency Framework for Nurses in Aesthetic Medicine’, accredited by The RCN. The Framework recognises the evolving nature of aesthetic nursing and the need to provide clear guidance to help practitioners identify, evidence and develop competence. The practice of examination, supervision, assessment, appraisal and validation are key Aesthetics | February 2014

components. The document is designed as a practical and flexible tool, which can be useful in a number of ways. As a personal route map to benchmark current competency and identify personal training and learning needs, it provides suggestions for how competency may be evidenced and can be used with mentors, by educators, appraisers and employers. The main challenge and concern for nurses in aesthetic medicine is likely to be how they will access appropriate supervision, mentors and appraisal, if they are currently working alone. BCAM has been pro-active in organising Responsible Officers for appraisal and revalidation in line with GMC requirements. Currently, in nursing, there is no formal framework or accreditation/authority for appraisal. The BACN will be engaging with the NMC consultation in a constructive way and have been preparing to support members to manage any necessary change. REFERENCES • British Association of Cosmetic Nurses (2013) Membership Survey, available to members only. • British Association of Cosmetic Nurses (2013) An Integrated Career and Competency Framework for Nurses in Aesthetic Medicine, BACN. Contact, www.cosmeticnurses.org • Nursing and Midwifery Council (2008) The NMC Code of Professional Conduct: Standards for Conduct, Performance and Ethics, London: NMC • Nursing and Midwifery Council (2011) The Prep Handbook, London: NMC • Nursing and Midwifery Council (2014) Consultation on revalidation, available on-line http://www.nmc-uk.org/Nurses-and-midwives/ Revalidation/

Emma Davies is chair of The British Association of Cosmetic Nurses and has been practicing in aesthetic medicine since 1998. She was a committee member of the Royal College of Nursing Aesthetic Nurses Forum 2003-2010, and has contributed to a number of key publications. Her commitment to standards and work on behalf of aesthetic nursing as a specialist field of practice was recognised by Cosmetic News ‘‘Services to Industry Award’ and ‘Aesthetic Practitioner of the Year Award’, in 2012.

In Practice Finance

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Taxing Times? Accountant Ben Korklin provides key advice that will make the end of the tax year less stressful for aesthetic practitioners Whilst many aesthetic medical professionals and clinics will have an accountant or advisor to take care of their financial matters, it is vital that all industry individuals have a clear understanding of their finances in order to be able to effectively manage their business. As we approach the end of the tax year, I have set out some financial considerations that you should be aware of and how you can prepare accordingly.

Tax year end When thinking about your year-end, it is important to choose the right time for your business. Consider to what extent your business is seasonal: is there a time of year when it will be more convenient to close off your accounting records, ready for your accountants? From a tax viewpoint, the choice of a year-end early in the tax year for an unincorporated business often means that an increase in profits is more slowly reflected in an increased tax bill.

Company vehicles While the company car remains a valuable part of the remuneration package for many, tax and national insurance costs may mean that you need to consider whether your current arrangement represents the most tax-efficient option. The company car or van benefit is subject to a Class 1A national insurance charge of 13.8% payable by the employer. There is also a fuel benefit charge where fuel for private use is provided with the car. The rules also apply to employerprovided cars and vans. Now may be a good time to review your company car policy, and to determine whether it could be more beneficial to pay employees for business mileage in their own vehicles, at the statutory mileage rates.

Excluded business expenses You’ve heard the expression regarding what counts as ‘business expenses’: “Anything that relates to your business”. Whilst this is generally true, there are some expenses which, although genuine business expenses, are specifically excluded from tax relief, such as: • Business entertaining including the VAT (however input VAT on business entertaining of overseas customers is recoverable) • Charitable subscriptions and donations, except to small local charities • Political donations • Costs and fines for breaking the law • Loan capital repayments • The withdrawing of funds from the business by the director/ partner/principal 52

Recent changes April 2013 saw the introduction of a new cash basis for calculating taxable income for small, unincorporated businesses. One of the measures allows any unincorporated business to choose to use flat rate expenses for the following items of business expenditure: • Fixed allowances for business mileage • Expenses relating to business use of the home • Adjustment for private use of business premises

Avoid the penalties It is vital to be aware of all relevant tax dates to ensure you prepare and send off your accounts in good time. The HMRC website will detail the deadlines by which all payments and forms must be received by the relevant authorities. Or, in the case of reclaiming tax, the date by which your application must have been received. HMRC also recently unveiled a plethora of changes to its penalties and regulations, as well as proposed increases in its powers and capabilities. Another big change to the penalty regime is that the fines will no longer be cancelled if the taxpayer owes no money to HMRC, because there was no extra tax to pay or because it had been paid. The new penalties for filing tax returns late are as follows: • Day one - Individuals will be charged an initial penalty of £100, even if they have no tax to pay or have already paid all the tax owed • Over three months late - Individuals will be charged an automatic daily penalty of £10 per day, up to a maximum of £900 • Over six months late - Individuals will be charged further penalties, which are the greater of 5% of the tax due or £300 • Over 12 months late - Individuals will be charged yet more penalties, which are the greater of 5% of the tax due or £300. In serious cases people face a higher penalty of up to 100% of the tax due. Awareness of these key considerations allows you to more closely monitor the success of your business and plan ahead for future financial years. With knowledge of appropriate tax year ends, penalties you could be subject to and attention paid to recent changes, you will be better equipped to manage your finances accordingly. Ben Korklin qualified as a chartered certified accountant in 2008 which led to him starting his own firm in 2010, before joining Lawrence Grant as a partner in 2013. Ben’s client portfolio consists of UK companies and individuals, including sole traders, partnerships and limited companies, and he specifically provides specialist tax, business and accountancy knowledge to the beauty sector.

Aesthetics | February 2014

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In Practice Patient Experience

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WHAT AESTHETIC CLINICS CAN LEARN FROM SPAS Wendy Lewis suggests that clinic owners and managers should take inspiration from high-end spas to create a relaxing environment for patients

More often than not, as soon as you enter an upscale spa an immediate sense of calm immerses you. This comes from the aromatherapy candles infusing the air, the soft and flattering lighting, the handsomely upholstered seating, and the warm and friendly welcome when you check in for a selfindulgent treatment. These factors, and other pampering amenities, elevate the spa-goer’s experience, and according to the Global Spa and Wellness Summit, in 2013 we were loving it to the tune of $1.9 trillion US dollars worldwide. So what distinguishes the leading spas of the world? First and foremost, their goal is to guarantee the ultimate spa experience to all customers, and to deliver five-star service at all times. By contrast, think about the last aesthetics clinic you visited, including your own or the one where you work. What adjectives come to mind? Pampering, relaxing, indulgent, exclusive, and caring? Or is it more like rushed, rude, disorganised, sterile, and impersonal? Regrettably, I see more clinics where the latter applies far more than the former. Let’s look at what aesthetics clinics can learn to benefit from the world of highend spas. Below are some key spa trends that may serve as inspiration for taking your patients’ clinic experience to the next level.

STAY CALM & SPA ON The relaxation aspect of spas is what draws us in. It is a chance to unwind and block out the sensory overload of an overscheduled modern lifestyle. This resonates with busy mums, stressed out executives, frequent travellers, as well as pensioners and housewives alike. According to the new Spafinder Wellness 365™ 2014 Trends Report, “The physical benefits of spa and wellness activities have long been known to reduce stress and relax our bodies, but in 2014 and beyond there will be a sharp focus on interweaving mindfulness techniques into these practices to help us reach a whole new place of serenity and calm.” Spa-goers want to be taken care of and pampered. They crave a little, “me time”. But don’t confuse that with fluffy beauty treatments that don’t deliver visible improvements. Spa-goers want both an atmosphere of indulgent serenity plus a selection of the most advanced clinical procedures available, and your patients should be able to expect the same.

CUSTOMISED THERAPIES One of the cornerstones of the spa experience is not adapting a one-size fits all approach to clients. Customised solutions rate high with spa-goers and they are willing to pay a premium for the exclusivity of having a treatment 54

Aesthetics | February 2014

programme created by a specialist, just for them. Consider incorporating a skin care range that offers customised formulations that therapists can create right in the clinic, by adding antioxidants, peptides, retinol or other key ingredients to suit their patient’s skin’s individual needs. One example of a customised procedure that speaks to this trend is the Silkpeel Dermal Infusion System, with which the specialist can develop the best protocol for each patient. An alternative is to develop your own signature branded treatments that are exclusively yours, and that patients cannot get anywhere else. Maintaining detailed notes in patient charts can help therapists and practitioners stay on top of each patient’s progress and preferences. Imaging systems such as Visia® from Canfield also help facilitate this concept in clinics by tracking skin conditions, results, and educating the patient on his or her unique skin concerns.

TECHNOLOGY AND TREATMENT MERGE Spafinder Wellness 365, an online resource for spa facilities, also predicts that for 2014, the application of ‘Wired Wellness’, a combination of health and technology, has the potential to change the way we both look at and approach our overall wellbeing. Their definition of “Wired Wellness” is “any point where digital and wellbeing intersect – from digital devices that track our every move to straightforward online booking engines. These examples of digital connectivity that aid our access to wellness is something we’ve come not only to expect but also to demand.” This confirms that patients today want to have an efficient clinic experience, in line with other service businesses they frequent. Think boundarypushing technology like Apple. Accept credit and debit cards for payments by using one of the many apps or programmes on offer, and send patients their receipts in the same manner. Offer online bookings, cancellations, and service and product purchasing through your website or social media pages. Use a software program to confirm appointments by email or text. This has the dual advantage of both saving on staff time and reaching patients on their mobile devices, where they are likely to be at their most accessible and responsive. Technology takes some of the messy business, payment and scheduling details out of the experience so patients don’t have to sweat about the small stuff. They can just sit back and relax in the capable hands of your clinic staff. The total patient experience is paramount in a climate where favourable online reviews, ratings and personal recommendations are powerful influencers for getting patients through the door.

In Practice Patient Experience

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10 EASY WAYS TO UPGRADE THE CLINIC EXPERIENCE 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Brighten up entrance and waiting areas with good lighting and window coverings that allow natural light in Refresh fraying carpets, paint, floors, soiled furniture Spruce up restrooms with a large mirror, a supply of makeup remover, concealers, facial wipes and cleansers Add a self- service beverage cart with coffee system and waters Offer free Wi-Fi and charging stations in waiting area and rooms Manage waiting times to fall within 15-30 minutes maximum Give patients spa-style gowns, robes and slippers to change into Restrict mobile phone usage for staff in patient areas Enter patient birthdays into your database to send a Birthday Special Offer Implement a VIP Programme with unique benefits for your loyal patients who refer their friends and family

The patient experience begins with their first contact with your clinic, which may be online, by phone, or walking or driving past your street. Every little detail factors into the overall experience of each patient in your clinic. Consider every element of your clinic. Was the clinic hard to find? Is the décor cold and icy? Does the clinic staff’s attitude correlate to the décor? Does it take too many rings before the phone is

picked up? If you answered yes to any of the above, it’s time to take a closer look at what is going on under your roof. Running an efficient clinic and getting it right is not a simple task. It is not merely a matter of spending a fortune to build the most beautiful facility, and bringing in state-of-the-art treatments. It is not just about providing effective treatments at a fair price either. There is also the all-

important human factor. It’s about getting the right people on board who share the vision of the clinic manager or owner, and buy into a service culture that is so important today. It takes a cohesive team to make that happen. Ultimately, how your team interacts with each other as well as with your patients or clients can ensure that the experience of visiting your clinic is intimate, personal, unique and memorable, not unlike that of a high-end, luxurious spa. Think service, service, service to achieve this. Wendy Lewis is president of Wendy Lewis & Co Ltd, Global Aesthetics Consultancy, the author of 11 books on anti-ageing and cosmetic surgery, and founder/editor in chief of Beautyinthebag.com. She is an international presenter and lecturer and has written over 500 articles for medical journals and consumer publications.

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In Practice Public Relations

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Remove is obviously the ideal option, but hard to accomplish. Do consider that if you’re getting negative reviews regularly, you probably need to look within your practice to examine what might be causing these issues. Let’s say however that you know the feedback to be inherently inaccurate, false or defamatory, or even left by someone who is not a patient. Your first port of call should be to look at the website’s own terms and conditions in detail. Many of these sites state that reviews must only be left by genuine customers. Therefore, someone who was rejected at the consultation stage or is the partner or relative of the patient cannot, by explicit policy, be allowed to leave a review. Or, say, they are complaining about a procedure which you simply do not offer, therefore it can only be untrue. Additionally, certain forums ask that individual doctors/nurses/surgeons not be named. If any of these situations apply and the policy prohibits them, you can cite the terms and conditions, which automatically means that the website is obligated to remove the comment. This way, there is no need for contact with the person, whoever they may be.

Damage control:

Address is probably the most likely and appropriate avenue

Do you know how to react to negative online reviews? Publicist Tingy Simoes reveals the three essential rules of engagement that will help you protect your reputation online The vast proliferation of Yellow Pages-type directories and review sites, the number of which are growing almost daily, present today’s clinicians with a new and very open digital environment. Though this environment can offer valuable marketing opportunities, it can also on occasion leave clinics and clinicians vulnerable to attacks on their reputation. As a publicist with over 15 experience in the private medical sector, I have often had to deal with negative comments on behalf of my clients. I have also had to advise on steps to take after receiving unpleasant feedback, merited or not. In the big bad World Wide Web, it’s easy for reviewers to cloak themselves in anonymity. Thus a patient who smiled in your consulting rooms and gave you a hug may easily walk out the door and seek to shred your reputation via online forums, without you ever knowing who that person might be. Anonymity also protects competitors or even disgruntled employees (impersonators) who are out to maliciously hurt your practice’s reputation. Reviewers can of course be genuine patients wishing to air a bad experience, but sometimes they are extorters, e.g. those who threaten with, “Refund my money, or I will leave negative reviews about you online.” Whether the negative comments are deserved or not, there are various approaches that should be considered in regards to dealing with them. There are three levels of action for unfavourable online reviews:

> Remove < > Address < > Suppress < 56

to explore, if you don’t want to leave the review or comment unchallenged. But beware to keep your cool in this situation. It can be all too easy to take comments personally and react defensively but this is precisely what the reviewers are seeking to activate as a response. If the issue is negative comments on social media, try to take the dialogue offline as quickly as possible. Reply publicly if you can, explain that you’re sorry they’re having a difficult time and that your office would be glad to discuss their concerns with them. Offer a phone chat, a face-to-face visit, anything to get the conversation away from the prying eyes of everyone on Facebook, Twitter or on forums. Come across as polite, diplomatic and helpful, and whatever you do, do not engage in tit-for-tat! The patient will always appear more sympathetic to those reading. You are ethically obliged to keep quiet the medical details of a patient’s case so you cannot win in a public slanging match. If the review site in question offers you a right to reply, your response could be along the lines of, “I can’t tell who you are, but the information here doesn’t seem to fit with our procedures at the clinic…” and calmly point out the inaccuracies. Alternatively, if you think you know who the patient is, you could try to raise this with them directly, for example, “I have reason to believe you may have posted xyz. I can’t believe it was you really, but perhaps we can address any issues professionally” etc. As you well know, no two patients are alike and what works with one, may not with the other – so trust your instincts. Some of the biggest sources of complaints tend to be expectation failures and financials so always make sure to be entirely up front with your practice’s policies for aftercare, revisions or refunds from the very beginning. If the disgruntled patient wants a refund and you decide to offer it to them, make sure you work out a confidentiality clause. If, despite receiving compensation, they continue to publicly discuss details of the case, perhaps they waive their right to confidentiality as well. Always examine options with an experienced solicitor before handing out any cash.

Aesthetics | February 2014

In Practice Public Relations

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Suppress: At the American Society of Aesthetic Plastic Surgeons (ASAPS) annual conference last year I heard this statement in relation to online attacks: “The solution to pollution is dilution”. The key message here is to do your best to drown the reviews in positivity. Suppressing or diluting the impact of negative feedback requires you to be truly active. The era of sitting quietly behind a brass plaque in Harley Street, ignoring advertising, PR and social media marketing is well and truly over. Keenly encourage happy patients to leave positive reviews on all the most common sites. Make this part of your practice and have your team ask from the start whether patients are active online, and whether they’d be willing to review their experience. This may seem counterintuitive but it will help you maintain control of your image online and take ownership of what appears on those crucial first few Google pages. One or two negative comments will simply be lost in a sea of positive ones. However, if the negative feedback is the only feedback that pops up, you’re in trouble. If this is the case, work with your SEO and PR providers

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to standardise and optimise your site, and make sure you and your team regularly audit your online image. This can be done easily with free tools such as Google Alerts which notifies you of online coverage, or in a more sophisticated and targeted way via specialist agencies. Remember to also give the public a little bit of credit for being able to differentiate between genuine reviews and someone who seems unreasonable and disgruntled. Most people who take to the Internet to air their grievances do so because they don’t feel listened to. Perhaps they have been calling the practice and not receiving what they perceive to be help, or are being ignored. Try doing the opposite of this: overcommunicate. Tell them you’ve seen the feedback they left and you are committed to resolving the issues. Contact them regularly and keep them informed – many queries pop up post-procedure, so stay in touch. Turn lemons into lemonade by engaging and responding tactically. Always respond professionally; thank them and say you look forward to discussing the issues in person.

Whilst I do recommend seeking legal advice if comments are defamatory or outright libellous, I suggest you leave the threat of legal action as a last resort. As mentioned previously, the perception is that doctors and surgeons are ‘well-off’ and sympathy will always go to the seemingly defenceless patient. Having said all that, when all other avenues have been explored, you may be left with no other choice. Legal action is costly, so really question whether the online feedback is hurting your practice’s reputation or whether it is simply your ego. Ultimately, if something was done wrong, saying sorry works. It is known that patients don’t sue according to outcome, they sue according to their perception of caring. Show them that you do. Tingy Simoes is managing director of Wavelength Marketing Communications (www. wavelengthgroup.com) and author of ‘How to Cut it in the Media: A PR Manual for Aesthetic Plastic Surgeons and Professionals in Cosmetic Medicine’

In Practice In Profile

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“You must never stop learning in this industry” Sharon Bennett, founding member of the British Association of Cosmetic Nurses and UK lead on the BSI committee for aesthetic non-surgical medical standard, describes her journey to becoming a leading aesthetic nurse. Sharon began her career at Southampton University Hospital where, although she loved the work, she discovered that working in an NHS hospital wasn’t her long-term goal. “I loved the patients, the camaraderie and the educational element, but I didn’t take kindly to being ordered around,” Sharon says. In 1986, she applied for a position at the newly opened Harley Medical Group to find her independence. After two years, she decided to take her skills across the globe; travelling with her husband, she worked as a general nurse in a poor state hospital in the interior of Brazil. “It was an eye opener: the hospital didn’t even have disposable needles and syringes,” she says. “But it was so fulfilling.” Following this, she moved to Lisbon, Portugal, where she was asked by Harley Medical Group to open a clinic for them. She moved back to the UK in 1995, and managed a small cosmetic surgery clinic on Harley Street alongside plastic surgeon Peter Ashby. In 1996, she flew to Sweden with a colleague to clear the UK distribution for promising new product Restylane, which would later become the biggest dermal filler in the world. “Prior to this, we’d all been injecting collagen,” she says. “With Restylane, there was no need for an allergy test and we could inject into areas such as the body of the lip, not just the border.” Her role then expanded to include training, as she taught UK doctors and nurses how to inject the new filler. “This was the start of a new age of aesthetics,” she says. “It made so much more possible.” Sharon then spent two and a half years living in the South of France, commuting monthly to the London clinic before moving back to the UK permanently in 1999. She set up her own fixed base clinic with her business partner in 2007. “I’m quite headstrong and entrepreneurial, so I wanted to work for myself,” she says. Until recently, she also worked alongside dermatologists at Harrogate Hospital. She joined the Royal College of Nurses (RCN) aesthetics forum, and was co-opted on to their steering committee. “Aesthetic nurses work outside of the NHS with little support from the Nursing 58

and Midwifery Council, and this business can be terribly lonely,” she says. “So I joined RCN’s forum.” However, when the forum was dissolved shortly after, she was left feeling that there was a distinct lack of commitment to aesthetic nurses from any existing professional body. “We didn’t have any supporting association to turn to,” she says. “Everyone was scattered across the UK: how would anyone hear our voice?” In 2009, this concern led Sharon to form the British Association of Cosmetic Nurses (BACN), alongside fellow RCN steering committee members Emma Davies and Liz Bardolph. Through the BACN, she became involved in the British Standards Institute (BSI), the British representative for the European Committee for Standardization (CEN). In 2013, Sharon was asked to be the aesthetic non-surgical UK representative and assist in forming a standards document, which is currently pending approval by CEN. “I’ve thrown myself into standards because I’m passionate about making the industry safe and well-respected,” Sharon says. “The most important person is the patient but I also want aesthetics to be regarded as a specialty of nursing and medicine, rather than a beauty treatment associated with money and superficiality. My goal is that the BACN Competencies along with the CEN non-surgical standard will be adopted as the gold standard in non-surgical aesthetics in the UK.” Alongside her work to improve industry standards, Sharon is also focusing on her business, having just opened a new clinic in the centre of Harrogate and a second branch within Harrogate BMI Hospital. She is also looking for other opportunities to continue her own personal professional development and education. “There’s a dermatology course at Stirling University I would like to enrol on,” she says. “You must never stop learning in this industry. Every patient who comes in is different and brings with them new challenges.” And with this in mind, she’s set to stay in aesthetics for good. “Aesthetics fell into my lap, I didn’t plan to do it,” she says. “But now I could never go back to straightforward nursing.” Aesthetics | February 2014

Q&A What advice would you offer other nurses? Don’t try to be an expert at everything: if you can do one thing brilliantly, you will feel more confident. Additionally, don’t work in isolation: surround yourself with peers, a mentor, and a multi-disciplinary team. You will feel supported, and your patients will feel safe. What’s the best advice you’ve received? The suggestion to take my prescribing course; without it, you can’t move on in this business. My course at Leeds University was incredibly fulfilling: doing further courses in aesthetics or dermatology arm you with more knowledge. What’s been your biggest mistake? Occasionally making assumptions about patients: sometimes I have already decided what I want to do before they open their mouth. Take your time in consultation; listen to what they’re saying. What’s your favourite treatment? Dermal fillers: I’ve been doing them for so long, the syringe is practically my third hand. What’s your industry pet hate? My patients assuming that I’m a beauty therapist: sometimes they don’t realise how much academia and further education we do. What’s your favourite thing about the industry? The wonderfully supportive friends I’ve made: they’re my second family and are more important than any financial gain.

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In Practice The Last Word

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The Last Word Is it time for celebrities to come out of the closet? Stars’ secrecy around aesthetic treatments has negative effects on women and the industry, argues Dr Sarah Tonks. A quick flick through any glossy magazine demonstrates a confusing fetishisation of the female body in our culture. Attention grabbing headlines such as“21 Shocking Bodies That Will Make You Feel Normal!” (Now Magazine 24 December 2013) change to “Screw the diet!” (Now Magazine 31 December 2013) the very next week in the same magazine, demonstrating the ebb and flow of this fashionable tide in popular culture. From accepting and embracing the way you look, to single mindedly pursuing self-improvement, the pendulum swings back and forth. One thing that never changes is admiration for natural beauty. In almost every context, effortless and inherent beauty is praised whilst those who choose to enhance the way they look are ridiculed. There is some thing sad about her, it’s sad that she feels she needs it, she doesn’t have good priorities in life, she is vain and lacks character, she is desperate, she is wasting her money. In a society constantly reminding women that they don’t look good enough, it is ironic that those who pay more attention to the way they look are shamed and embarrassed for all to see. The reason for this is unclear. Improvement and enhancement of natural beauty provokes strong reactions; although she has always denied any surgery herself, Joan Collins once rather judgmentally said, “Plastic surgery is the plain woman’s revenge,” demonstrating the intense depth of feeling connected with the subject. It is no secret that women, especially celebrities, are under enormous pressure to look a certain way. We are all supposed to care about they way we look, whilst at the same time act modestly, like it isn’t a big deal. In today’s society, intrinsic beauty is in, enhanced beauty is out. The ideal is for cosmetic interventions to appear as if you didn’t need them in the first place, to look natural, whilst at the same time making you look “better” than the natural you. However, as we all know in the aesthetics industry, celebrities aren’t born with special celebrity genes. There is a reason Halle Berry looks better at 47 than she did at 37, and why Jennifer Anniston is growing more beautiful each year. So why don’t celebrities like to talk about the procedures they have had done? Although Simon Cowell once famously stated that to him botulinum toxin was, “No more unusual than toothpaste,” most celebrities are extremely coy about any beauty regime that may involve more than a facial. Cameron Diaz recently stated that she tried Botox but said it changed her face “in such a weird way,” and Jennifer Anniston apparently, “Tried Botox once but it was not good.” These stars have been reported as dabbling with injectables, but it is difficult to find an A-lister who is willing to admit their fresh looks may not be down to simple exercise, good 60

Aesthetics | February 2014

diet, and genetics. There is a very real fear amongst those in the public eye of being exposed as having aesthetic procedures, probably because they are aware that it may lead to ridicule and negative press. At the same time, we the public collaborate in the charade, buying magazines and enjoying the schadenfreude of the celebrity being “outed”. Perhaps because it invalidates their good looks and makes us feel good about ourselves. Embarrassment around the use of aesthetics forces patients to conduct their research and procedures clandestinely. Too often there are stories heralding a new death from complications of silicone buttock injections; a patient who has lost her breast as a result of post operative infection from a procedure carried out in unhygienic conditions; another who undergoes liposuction and dies as a result of perforation. When Angelina Jolie underwent a double mastectomy to reduce her risk of developing breast cancer after discovering she carried the faulty BRAC1 gene in 2013, she was lauded for raising awareness of the condition and the procedure. The media praised the actress for her decision to go public with the information. It was hoped that this action would promote understanding, diminish the fear of surgery and ultimately save lives by encouraging women to discuss the option with their doctors sooner. It could only be a positive thing if there were a similar A-list role model for cosmetic procedures. Someone who would be able to help diminish the stigma of the industry, and promote discussion and dialogue around the topic. It could only be beneficial to the self-esteem of girls and women to see that the unattainable expectations we all place on ourselves cannot be met without some assistance. For us as practitioners, this scenario would undoubtedly be good for business. Once fear and mystique are removed from the equation, celebrities have the potential to become examples of the results possible with good enhancement and rejuvenation. Patients would then become fully educated in the potential of specific treatments, and would be more likely to openly research their options rather than falling into the hands of rogue providers. An open dialogue such as this could also generate an uptick in the number of patients seeking out qualified practitioners. Now, we just have to find a suitable spokesperson. My vote is for Demi Moore, who at 51 has an enviable appearance due to a Hollywood-worthy regime of diet, exercise and the work of a very skilled aesthetic team. Dr Sarah Tonks is an aesthetic doctor and previous maxillofacial surgery trainee with dual qualifications in both medicine and dentistry.

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