Aesthetics February 2017

w om no 17 e.c er 20 nc st e gi CE fer Re A n r fo sco tic he st ae

VOLUME 4/ISSUE 3 - FEBRUARY 2017

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Marketing in Aesthetics CPD Julia Kendrick explains the regulations and guidelines for advertising and marketing

Using Chemical Peels

Impact of Winter on Skin

Avoiding Website Mistakes

Practitioners discuss how to safely treat hyperpigmentation with chemical peels

Sylvia Chrzanowska examines how to combat the effects of winter on skin

Adam Hampson outlines seven common aesthetic website mistakes and how to correct them

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

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CONTOUR & DEFINE

Contents • February 2017 06 News

The latest product and industry news

14 News Special: Transparency in Aesthetic Treatment

Aesthetics investigates why some patients do not speak openly about their aesthetic procedures

16 ACE Preview: Masterclasses

Discover how to make the most of the interactive Masterclass agenda

CLINICAL PRACTICE 19 Special Feature: Treating Hyperpigmentation

Practitioners discuss how to successfully treat hyperpigmentation with chemical peels

24 CPD: Maintaining Compliant Marketing in Aesthetics

Communications consultant Julia Kendrick assesses the regulations and guidelines for aesthetic marketing and advertising to the public

30 Palmoplantar Hyperhidrosis Dr David Jack outlines the treatment of overactive sweat glands in the

soles of the feet and palms of the hands

Clinical Contributors

34 Rosacea and IPL

Aesthetic nurse prescriber Sheila Maclean discusses how IPL can be used to treat rosacea

38 How Sleep Affects the Skin

Dr Rupert Critchley discusses how sleep deprivation can impact ageing

41 Dermal Filler Doses Dr Michael Aicken examines how much filler should be used in the

treatment of nasolabial and marionette lines

45 The Impact of Winter on the Skin

Aesthetic nurse prescriber Sylvia Chrzanowska examines how to combat the adverse effects of the winter season on the skin

49 Chemical Peeling Biochemist and clinical trial co-ordinator Peter Roberts details the

different chemical peel ingredients

55 Abstracts

A round-up and summary of useful clinical papers

IN PRACTICE 56 Avoiding Website Mistakes

Marketing consultant Adam Hampson examines seven common website mistakes and how to correct them

58 Selling Your Business

Aesthetic clinic managing director Ralph Montague describes the options available for selling an aesthetic clinic

61 Growth-focused Marketing Strategy

Marketing consultant Kayas Fayyaz explains how to create a marketing strategy to build brand authority

64 Waste Management Audits

Clinical waste advisor Rebecca Waters discusses how to simplify the waste audit process

67 In Profile: Dr Sean Lanigan

Consultant dermatologist Dr Sean Lanigan details his career in aesthetics and the importance of scientific research

69 The Last Word

Consultant trichologist Iain Sallis argues why aesthetic practitioners and trichologists should work together

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Special Feature Treating Hyperpigmentation Page 19

Julia Kendrick is an award-winning communications and PR consultant specialising in medical aesthetics. With more than 12 years’ experience, she aims to help brands, clinics and practitioners take a strategic approach to take control of their reputation.

Dr David Jack is an aesthetic practitioner based between his clinics in Harley Street in London and Scotland. David trained in the NHS until 2014 before leaving to establish his non-surgical aesthetic practice.

Sheila Maclean is an aesthetic nurse at the Pulse Light Clinic, which was initially founded in 2000. She has more than 20 years’ experience as a registered nurse in the NHS and private medicine, and specialises in the use of IPL for the treatment of rosacea.

Dr Rupert Critchley is the lead clinician and director of Viva Skin Clinics and clinical lead at The VIVA Academy Harley Street. He has completed an array of courses in advanced non-surgical aesthetics; attained MRCS part A and is also a fully qualified GP. Dr Michael Aicken graduated in 2006 from the University of Aberdeen with a degree in medicine and a bachelor of medical sciences. Dr Aicken established Visage Academy and has also been involved in the development of an aesthetic clinic management app.

Sylvia Chrzanowska is an aesthetic nurse prescriber who qualified as an RGN in 1999 and became a medical aesthetic nurse in 2004. Chrzanowska has been working at the forefront of advanced non-surgical treatments and is based at the Cosmetic Skin Clinic in Buckinghamshire.

Peter Roberts majored in microbiology and biochemistry in London and Sheffield. He is the founder and medical director of SkinMed, and has previously held roles with SmithKline Beecham and GlaxoSmithKline.

Less than two months to register for ACE 2017 on March 31 & April 1 www.aestheticsconference.com

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Editor’s letter It will come as no surprise to those of you experienced in event organising that it is a very challenging, time consuming, yet rewarding experience. As you know, ACE 2017 is not far away and we are currently Amanda Cameron finalising plans for each of the varied and Editor exciting agendas on offer. After the success of last year, we wanted to make the Premium Clinical Agenda just as interactive. For me, the planning and teamwork involved in offering aesthetic treatments is key, so be prepared to come with your ideas and questions for the experts. Delegates can choose to attend up to four sessions – The Ageing Female Face, The Male Face, The Basics of Facial Assessment and The Young Female Face – each specific to their learning requirements. In each session three practitioners will analyse and discuss with the audience their approaches to treatment, outlining the various options available and how to best utilise these for successful results. For just £109+VAT per session, with each session lasting three hours and offering three CPD points, the Premium Clinical Agenda really does offer value for money, and you are guaranteed

to go home with plenty of new tips and techniques to integrate into your clinic! With limited space available, make sure you book soon! Don’t forget, if you register for free you will have access to the Expert Clinic, Business Track, Masterclasses, Exhibition Floor and Networking Event, where you can learn a whole host of new skills to progress your treatment offerings and commercial success in 2017.

To find out more and to register visit www.aestheticsconference.com.

So, what articles do we have for you this month? As it is our dermatology issue, we have included some great pieces on treating hyperpigmentation (p.19), how sleep affects your skin (p.38), and an interesting article on rosacea – a condition that is often seen but sometimes not well comprehended. Find out more on p.34. Our CPD article this month is also a must read!

Julia Kendrick thoroughly explains the regulation and guidance surrounding the marketing and advertising of aesthetic treatments – a topic that is often misunderstood by practitioners, yet is of the utmost importance. Brush up on your knowledge on p.24.

Let us know what you thought of this issue by tweeting @aestheticsgroup or emailing editorial@aestheticsjournal.com.

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

Dr Raj Acquilla is a cosmetic dermatologist with more than 12

Sharon Bennett is chair of the British Association of

Dr Tapan Patel is the founder and medical director of VIVA

Dr Christopher Rowland Payne is a consultant

Mr Adrian Richards is a plastic and cosmetic surgeon with

Dr Sarah Tonks is a cosmetic doctor, holding dual

Dr Maria Gonzalez has worked in the field of dermatology

aesthetic surgeon and medical director at the Plastic and Dermatological Surgery. He previously practised as a consultant plastic surgeon in the NHS for 15 years, and is currently a member of the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS). Mr Humzah lectures nationally and internationally.

Cosmetic Nurses (BACN) and the UK lead on the BSI committee for aesthetic non-surgical medical standards. Bennett has been developing her practice in aesthetics for 25 years and won The Institute Hyalual Award for Aesthetic Nurse Practitioner of the Year in 2015. dermatologist and internationally recognised expert in cosmetic dermatology. As well as being a co-founder of the European Society for Cosmetic and Aesthetic Dermatology (ESCAD), he was also the founding editor of the Journal of Cosmetic Dermatology and has authored numerous scientific papers and studies. qualifications in medicine and dentistry. Based in Knightsbridge, London she practices a variety of aesthetic treatments.

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

years’ experience in facial aesthetic medicine. In 2015 he won the Aesthetics Award for Aesthetic Medical Practitioner of the Year and in 2012 he was named Speaker of the Year. Dr Acquilla is a UK ambassador, global KOL and masterclass trainer in the cosmetic use of botulinum toxin and dermal fillers. and PHI Clinic. He has more than 14 years of clinical experience and has been performing aesthetic treatments for ten years.

Dr Patel is passionate about standards in aesthetic medicine and still participates in active learning and gives presentations at conferences worldwide.

12 years of specialism in plastic surgery at both NHS and private clinics. He is a member of the British Association of Plastic and Reconstructive Surgeons (BAPRAS) and the British Association of Aesthetic Plastic Surgeons (BAAPS). He has won numerous awards and has written a best-selling textbook. for the past 22 years, dividing her time between academic work at Cardiff University and clinical work at the University Hospital of Wales. Dr Gonzalez’s areas of special interest include acne, dermatologic and laser surgery, pigmentary disorders and the treatment of skin cancers.

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Laviniah Karanja • Journalist T: 0207 148 1292 laviniah@aestheticsjournal.com ADVERTISING Hollie Dunwell • Business Development Manager T: 0203 096 1228 | M: 07557 359 257 hollie@aestheticsjournal.com CUSTOMER SUPPORT Sammy Carlin • Customer Support Executive T: 0203 096 1228 | support@aestheticsjournal.com Hayley Bartholomew • Sales Support Executive T: 0203 096 1228 | support@aestheticsjournal.com EVENTS Kirsty Shanks • Events Manager T: 0203 096 1228 | kirsty@synaptiqgroup.com DESIGN Peter Johnson • Senior Designer T: 0203 096 1228 | peter@aestheticsjournal.com

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ARTICLE PDFs AND REPRO

Material may not be reproduced in any form without the publisher’s written permission. For PDF file support please contact Sammy Carlin; support@aestheticsjournal.com © Copyright 2017 Aesthetics. All rights reserved. Aesthetics Journal is published by Aesthetics Media Ltd, which is registered as a limited company in England; No 9887184

DISCLAIMER: The editor and the publishers do not necessarily agree with the views expressed by contributors and advertisers nor do they accept responsibility for any errors in the transmission of the subject matter in this publication. In all matters the editor’s decision is final.

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Industry standards

Talk #Aesthetics

RCS urges surgeons to apply for new certification

Follow us on Twitter @aestheticsgroup #NewBook Dr Stefanie Williams @DrStefanieW Got a first draft of my #NewBook finished after a week of writing in the beautiful @grayshottspa in Surrey - the view out of my window!

#Training Harley Academy @HarleyAcademy Our Botox and fillers mentoring sessions are underway for 2017 #Botox #DermalFillers Dr Simon Ravichandran @Ravichand1Simon On my way to one of my favourite cities #Dublin for a jawline #Radiesse masterclass tomorrow #Offers Jemma Patton @JemmaAesthetics Shocked to see well known clinics offering discounts & limited offers on Botox. The rules are there for a reason! #GMC #pom #PatientSafety P&D Surgery @pdsurgery New Year Resolution...get my yearly update on life support #patientsafety

#Clinic Dr Razwan @Skyn_Doctor One of the busiest clinics of the year. Privileged to treat all those who attended Skyn Doctor today!

#Dermatology Dr Ariel Haus @Dr_Haus Yesterday I was delighted to tour the excellent facilities of the Skin Hospital in Sydney. This is the centre of excellence. #Dermatology

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The Royal College of Surgeons (RCS) has launched a new system of certification with the aim of making the cosmetic surgery sector safer for patients.

The online system aims to help patients to identify a surgeon with the appropriate training, experience and insurance to perform a specific procedure. In order to receive certification, surgeons will have to provide evidence of their training, professional skills, clinical skills, knowledge and experience. They will also have to attend an RCS-accredited professional behaviours masterclass.

“You only have to look through the adverts in lifestyle magazines to know cosmetic surgery is a booming industry in the UK,” said Mr Stephen Cannon, chair of the Cosmetic Surgery Interspecialty Committee (CSIC) and vice president of the Royal College of Surgeons. He added, “What many don’t know is that the law currently allows any doctor – surgeon or otherwise – to perform cosmetic surgery in the private sector.”

Mr Cannon continued, “We hope it will improve the reputation of a profession, which at times, comes under intense criticism in the media, sometimes with good reason.”

Multipurpose platform

Lynton Lasers launches new LUMINA model Aesthetic equipment manufacturer Lynton Lasers has launched a new model of the LUMINA laser and IPL platform.

The LUMINA combines five different technologies into one platform, providing treatments for hair and tattoo removal, antiageing, skin rejuvenation, pigmentation, acne, scarring, deep veins and skin resurfacing.

Other components of the new model include two IPL handpieces, a long pulsed Nd:YAG upgrade that aims to treat all skin types, including darker skin, and a laser upgrade for the removal of multi-coloured tattoos. Managing director of Lynton Lasers, Jon Exley, said, “The LUMINA has established itself as the device of choice for many aesthetic practices because of its unique flexibility to be upgraded with a variety of different technologies.

Therefore it presents clinic owners with an opportunity to invest in just one sole platform but with more than 24 different revenue streams readily available to their client base.”

Aesthetics | February 2017

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Volume restoration

SkinCeuticals releases Hyaluronic Acid Intensifier Cosmeceutical skincare company SkinCeuticals has added the Hyaluronic Acid (H.A.) Intensifier to its Correct portfolio. H.A. Intensifier is a topical serum that aims to restore skin volume by fortifying the skin’s firmness and plumping the skin for a more youthful appearance. H.A. Intensifier’s active ingredients include, proxylane, extracts of liquorice and purple rice, and a triple combination of HA to provide long-lasting hydration and improved skin texture. The company claims the new product, helps to reduce the appearance of fine lines and wrinkles and stimulates hyaluronic acid synthesis.

Leslie Harris, global general manager at SkinCeuticals, said, “We sought to deliver a product that could work either as a standalone topical solution, or as a complement to dermal filler treatments. We are thrilled to be able to offer H.A. Intensifier as an effective solution to volume loss.”

Microneedling

Bellus Medical releases new head for SkinPen Precision Aesthetic manufacturer Bellus Medical has launched a patented microneedle disposable head for the SkinPen Precision device. SkinPen Precision is a microneedling device that aims to improve the appearance of the skin and assist in reducing the signs of ageing and the appearance of acne scars. According to the company, the patented microneedle disposable head, which is powered by the hand-held base, is sealed to prevent fluid intake. The disposable head has a single-use lock-out feature that the company claims can remove any possibility of cross contamination. SkinPen Precision is distributed in the UK by aesthetics company, BioActive Aesthetics.

THE BUSINESS DESIGN CENTRE / LONDON / 31 MAR & 1 APR 2017

COUNTDOWN TO ACE 2017 BUSINESS TRACK The ACE 2017 Business Track , sponsored

by Enhance Insurance, will host 18 sessions dedicated to providing you with practical skills and advice that will support you in streamlining the commercial aspects of your clinic. Whether it’s advice on accounting, business growth, training, regulation, marketing, PR, digital strategies or opening a new clinic you need, the Business Track has it all! Whether you are new to aesthetics or an experienced practitioner, there are sessions that suit all learning requirements to help create or enhance your clinic. In addition, entry is free and you will gain 0.5 CPD points for every session you attend.

SPEAKER INSIGHT PR consultant Julia Kendrick will speak on building a brand at the Business Track. She says, “It’s so important practitioners attend aesthetic conferences – under one roof ACE has so many suppliers and services that they can use to bring their business to the next level, whether that’s new products and treatments or business services. They will get the chance to get one-on-one guidance, inspiration and build relationships with new contacts. In my opinion, attending is absolutely critical for business success.”

WHAT DELEGATES SAY

Rejuvenation

MAG launches bio-revitalisation product Aesthetic product supplier Medical Aesthetic Group (MAG) will distribute PRX-T33 to the UK. The PRX-T33 is a gel that is topically applied to the skin that aims to stimulate the dermal connective tissue to enhance the radiance and luminosity of the skin and reduce imperfections for up to six months. The treatment is formulated to address indications such as antiageing, scars, hyperpigmentation, stretch marks, atrophic scars and melasma. The components of the formula include 33% trichloroacetic acid, 5% kojic acid and 1% hydrogen peroxide (H202).

Aesthetics | February 2017

“The sessions were very informative and all speakers were willing to answer any questions!”

AESTHETIC DOCTOR, LONDON

“I achieved what I required from ACE; I updated my knowledge and had a good opportunity to talk to a range of suppliers!”

AESTHETIC NURSE, BIRMINGHAM

“The live demonstrations, the Masterclass sessions, the Exhibition and all of the programme content is good for professional development and ACE is the best conference to attend.”

AESTHETIC NURSE, GLOUCESTERSHIRE

HEADLINE SPONSOR

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Breast implants

Conference

New sponsors confirmed for ACE 2017

Two new sponsors have been confirmed for the Aesthetics Conference and Exhibition (ACE) 2017 taking place on March 31 and April 1. Aesthetic manufacturer Filorga will sponsor a Masterclass, while aesthetic supplier Med-fx will be the Registration and Consumables Partner. It will be the second year in a row that Med-fx, which supplies a range of aesthetic products including botulinum toxin, dermal fillers and other cosmeceutical products to the UK market, will work in partnership with ACE as the Registration and Consumables Partner. French manufacturer Filorga has had a successful year in the UK since initially launching at ACE 2016. Through its sponsorship of a Masterclass, Filorga will provide delegates with the opportunity to learn about the company’s products and treatment protocols in an hour-long session presented by a renowned key opinion leader. Rebecca Denham, national business development manager for Filorga, said, “Doctors looking for the latest products with clinically proven extended longevity and safety with natural results should attend the Masterclass to observe ease of use and injectable techniques.” Other confirmed Masterclass sponsors include Galderma, Merz, SkinCeuticals, Fusion GT, Lumenis, Intraline and Teoxane UK. For more information and to register for ACE 2017 visit www.aestheticsconference.com

Breast implants receive barcodes in a bid to increase patient safety Breast implants and other medical items are set to receive barcodes in response to a new initiative by the Department of Health. The initiative aims to improve patient safety and avoid future scandals like the Poly Implant Prothèse (PIP) breast implant scare of 2010, which involved faulty silicone implants. The new system is intended to record each medicine and implant given to patients by scanning the product packet and the patient’s identity wristband. The technology is intended to safeguard patients from harm in hospitals, reduce inefficiencies and improve patient experience.

Health Secretary Jeremy Hunt said, “This can actually save lives for the NHS; we have had a number of operations where the wrong implant is put into someone’s body and then that has to be changed at a later date. If we use modern barcode technology, we can deal with a lot of these problems.” According to the Department of Health, by using the barcodes on medical items, anything that might develop a fault in the future including a breast implant, can be traced.

With this new system, medical staff in England will be able to use the barcodes for stocktaking and to see if any batches of medicine are reaching their use-by dates. In addition, surgeons will be able to monitor whether one type of implant is outperforming another in terms of wear and tear. Consultant plastic surgeon, Mr Dalvi Humzah believes the new system will help improve data and insight of medicine distribution to patients. However, he added, “I am sceptical about the relevance of inputting barcodes on implants and the process that this will require, as the Breast and Cosmetic Implant Registry that opened in October 2016, which adheres to the World Health Organisation (WHO), is, in my opinion, adequate in capturing the details of breast implant procedures by both the NHS and private providers.”

Rejuvenation

AZTEC Services launches Tixel system in UK Aesthetic distribution company AZTEC Services has launched the Tixel system in the UK. Tixel, by Novoxel, is a thermal fractional skin rejuvenation system that has both an ablative and non-ablative mode.

Dr Harryono Judodihardjo of Cellite Clinic in Cardiff, the first person in the UK to offer this system, said he is so far very impressed with the results that he has achieved with the device. He said, “The Tixel system can deliver CO2 laser-like results but with many advantages. It is not a laser so no laser 8

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precautions are necessary. It produces less charring than a CO2 laser, meaning the recovery time is less, and, very importantly, it is significantly less painful, meaning most patients can tolerate the treatment without the use of any anaesthesia.”

Owner of AZTEC Services, Anthony Zacharek, said of the launch, “We are very pleased and excited to be the exclusive UK distributor for this exciting new technology. I have been in this market for many years and I believe this really is a unique product that has amazing potential.”

Aesthetics | February 2017

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Training

Mrs Sabrina Shah-Desai announces new course Consultant ophthalmic plastic reconstructive surgeon Mrs Sabrina Shah-Desai will hold a training course on managing dermal filler complications on March 4 in London. The new course, Anatomical Basis of Prevention and Management of Dermal Filler Complications, will be a hands-on fresh cadaver wet-lab that aims to promote safe aesthetic practice amongst medical professionals.

The wet-lab will cover basic, intermediate and advanced safe, reproducible filler injection techniques for the face, using different types of fillers. It will also include a practical session on injecting hyaluronidase, and delegates will be provided with a handout detailing recommended doses/dilutions and how to perform retrobulbar hyaluronidase injection for blindness. The course will also update delegates on current expert protocols for the management of vascular complications. Led by Mrs Shah-Desai, the course faculty will also include plastic reconstructive surgeon Dr Benoit Hendrickx and aesthetic nurse prescriber Jackie Partridge.

The full-day course will take place at King’s College London and the fee will include lunch, all refreshments, teaching materials that include hyaluronidase and fillers, and a certificate of attendance.

Insider News

Vital Statistics According to the International Society of Aesthetic Plastic Surgery (ISAPS), in 2015 non-surgical fat reduction was the fifth most popular non-surgical treatment, with 425,315 procedures reported (ISAPS, 2016)

75% of digital marketers say face-to-face events are the most effective marketing tool (Content Marketing Institute, 2015)

Rejuvenation

New antiageing neck treatment launches in the UK Cosmeceutical company INNOVATIVE SKINCARE has added antiageing neck treatment NECKPERFECT COMPLEX, to the iS Clinical range.

According to the company, NECKPERFECT COMPLEX helps to tighten, smooth and sculpt the fragile skin around the neck and throat, leaving the jawline and décolleté looking firmer and more defined.

A study by iS Clinical director, Dr Charlene DeHaven, which evaluated the efficacy of the new treatment in female subjects between the ages of 35 and 65 over a three-month period, indicated improvement in the appearance of the neck area including increased skin hydration, elasticity and improvement of neck profile and configuration.

“This multi-tasking product addresses several antiageing factors in a single formulation,” said Alana Marie Chalmers, director of Harpar Grace International, which is the distributing partner for iS Clinical. She added, “NECKPERFECT COMPLEX features botanical ingredients such as Prunus Amygdalus Dulcis (sweet almond seed extract) to help enhance suppleness and elasticity, while providing anti-inflammatory benefits, and calcium pantothenate (vitamin B5), which helps to encourage collagen production and improve cellular metabolism.”

Rosacea affects one in ten people in Europe (NHS, 2016)

Approximately 489,344 chemical peel procedures for facial rejuvenation were performed worldwide in 2015 (International Society of Aesthetic Plastic Surgery (ISAPS), 2016)

According to a report published by analytic company Mintel, one in five (19%) men feel that they are expected to remove hair from their torso (Mintel Men’s and Women’s Shaving and Hair Removal UK, 2014)

Aesthetics | February 2017

Almost half (47%) of small business owners handle marketing efforts on their own (Infusionsoft & LeadPages, 2016)

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Events diary

@aestheticsgroup

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

6th – 8th April 2017 15th Aesthetic & Anti-aging Medicine World Congress, Monte Carlo www.amwc2017.org

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

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

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

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Advanced Esthetics Solutions launches new laser Aesthetic distributor Advanced Esthetics Solutions has added the Bios Square Epil laser to its product offering.

The new device is a 270w long pulse alexandrite combined with a long and short pulse Nd:YAG laser with a ‘square spot’ head, built in smoke evacuator and a self replacement lamp system.

The device aims to provide treatments for vascular lesions, benign pigmented lesions, hair removal, non-ablative photorejuvenation, antiageing, warts and onychomycosis.

Medical director of London clinic BodyVie, Dr Andrew Weber, said that his clinic is the first in the UK to incorporate this device. He explained that he believes the device has, “Incredible versatility and is coupled with spot sizes ranging from 1mm to 30mm and the ability to fire up to three times per second.”

Douglas Sykes, managing director of Advanced Esthetics Solutions, added, “The ability to change the lamp in less than one minute without the need of a call out to an engineer is truly remarkable and its ability to carry out the treatments in fraction of the time introduces back the profit margins we enjoyed years ago; the Square Epil is truly the highest return on investment on any laser out there.”

Facial contouring

Microneedling

Medicos Rx trademarks the Hammock-Lift technique

Health officials investigate the risk of blood-borne viruses transmitted from microneedling

Aesthetic clinic Medicos Rx has trademarked the Hammock-Lift, a lower facial technique aimed at recontouring the jawline. The technique aims to address the changes in the mid-face including the descent of the facial skin and mid-face fat pads that result in the reduced appearance of the jowl and soft tissue disproportion. It also focuses on rejuvenating the lower face mandibular region by lifting and re-contouring the mid-face.

According to Medicos Rx, the Hammock-Lift is an advanced technique that requires specific anatomical knowledge and training to perform safely.

Director of Medicos Rx and consultant plastic surgeon Mr Dalvi Humzah, who pioneered the Hammock-Lift, will be demonstrating this treatment at the Dalvi Humzah Aesthetic Training Lower Face Injections sessions.

He said, “I am delighted to be able to teach this technique at our sessions. We will be using the anatomical landmarks and additional developments with specific injectable implants to achieve the best outcome.”

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Laser

3rd – 7th March 2017 American Academy of Dermatology Annual Meeting, Washington DC www.aad.org

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Public Health England (PHE) is investigating the potential risk of bloodborne viruses being transmitted through the use of microneedling.

If needlestick injuries to practitioners or cross-contamination to patients occurs, PHE says there is a risk of transmitting viruses including HIV, Hepatitis B and Hepatitis C. As part of the enquiry, PHE is working with environmental health officers and the device manufacturer to recommend design modifications, to reduce the risk of cross-contamination and needlestick injury, as well as supporting the development of improved training and infection control guidance for those providing the treatment.

Consultant plastic surgeon Mr Rajiv Grover, a former president of the British Association of Aesthetic Plastic Surgeons, said, “Just because something is non-surgical it does not mean it is non-medical. The use of needles does, at the very least, need some medical supervision. Firstly to avoid treating patients who have contraindications from dermatological conditions or potential scarring conditions.” He continued, “Secondly, complications can occur from needling – such as infections – and recognising and being able to treat these is essential. It is not good enough just to be able to handle a needle but essential to be able to handle the problems that may come from it too.”

Aesthetics | February 2017

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Skincare

Murad to introduce new retinol serum Skincare company Murad has added the Retinol Youth Renewal Serum to its product offering.

According to the company, the serum aims to minimise lines and wrinkles, and to produce a more radiant, youthful skin by incorporating Murad’s Retinol Tri-Active Technology, which it claims is a fast-acting retinoid. The formula also includes Swertia flower extract, which aims to regenerate skin cells and hyaluronic acid, to attract moisture deep into the skin’s surface to plump and create a smooth-filled appearance.

Roy Cowley, managing director of 3D-lipo Ltd

Private healthcare search engine WhatClinic.com has collated data indicating that enquiries for non-surgical facelift treatments increased by up to 91% in the last quarter of 2016.

The company’s insights are based on more than 584,000 visits to its medical aesthetics pages during 2016, with more than 63,525 online enquiries sent by UK patients to clinics on the site. The rapid increase in enquires during the last few months of 2016 could be an indicator of the treatments’ popularity in 2017, according to WhatClinic. Non-surgical facelift treatments are said to include everything from thread lifts to chemical peels, fillers and energy device procedures. Other trends predicted for 2017 according to the company include platelet rich plasma treatments, which saw an increase of enquiries by 28% in 2016 and deep chemical peels (25%).

Training

Dr Harry Singh announces new date for marketing masterclass Aesthetic practitioner Dr Harry Singh will hold a marketing masterclass on April 29 in London. The course aims to provide tips and strategies to boost and improve the services and performance of a facial aesthetic business.

According to Dr Singh, the masterclass will provide advice on handling telephone enquiries, arranging services into packages, planning marketing strategies aimed to increase profit and customer satisfaction, internet marketing, how to increase service use and how to remain updated on industry regulations.

The course also focuses on key performance indicators to assess the success of your business and areas for improvement. Aesthetic dentist Dr Lynda Allman, a previous attendee of the course, said, “The workshop really inspired me to focus on growing the facial aesthetics side of my practice. It offered lots of practical tips and strategies that I can implement straightaway and long term.” The marketing masterclass also offers CPD certificates and free postworkshop support.

What are your plans for future growth?

Due to the success of the UK market there is unprecedented demand on the export side of our business. This has meant taking on a dedicated team to expand our work on the support and development of this sector, which now accounts for more than 20% of our business and is expected to grow significantly.

What new developments are expected from 3D-lipo in 2017?

The company started with our 3D-lipo device for non-surgical body procedures and then last year developed and launched the 3D-skinmed non-surgical facial device, which has proven to be a popular addition. Nothing prepared us though for the success of our latest device, the 3D-Ultimate. As named, it is the ultimate platform for non-surgical face and body treatments with over seven technologies combined into one affordable platform. In November and December, we sold more than 35 machines pre-launch. We can’t wait to showcase this amazing device at the forthcoming trade shows!

This column is written and supported by duction Fat Re

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What are the major factors that have contributed towards the enormous success of the 3D-lipo brand?

There are several keys to our successful growth. Firstly, as a brand and as a device, 3D-lipo is fundamentally different.

When I designed our first device and created the branding I never wanted to follow a single technology route, as the market required change and I had no desire to go head-to-head with other equipment manufacturers. From the beginning I strove to develop a machine that contained several technologies that would enable clinics to target multiple indications and deliver the best patient outcomes for fat removal, skin tightening and the treatment of cellulite.

The results have always been the foundation of the company’s success. The sparkle of our national PR campaign was key. This has promoted our brand’s USP, which has ensured that our unique treatment is the most sought-after body treatment in the UK and offers a significant benefit directly to our client’s businesses. 3D-lipo is now benefiting more than 650 businesses in the UK!

No other system offers this advanced combination of technologies designed to target fat removal, cellulite and skin tightening without the need to exercise

Why choose 3D-lipo?

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Aesthetics | February 2017

• A complete approach to the problem • Prescriptive • Multi-functional • Inch loss • Contouring • Cellulite • Face and Body skin tightening • Highly profitable • No exercise required

Complete start up and support package available from under

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

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

Radio Frequency Skin Tightening Focus Fractional RF is the 3rd generation of RF technology. It utilises three or more pole/electrodes to deliver the RF energy under the skin. This energy is controlled and limited to the treatment area. Key advantages of this technology are high treatment efficacy, no pain as less energy is required, shorter treatment services and variable

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Insider News

News in Brief New marketing manager announced for Cambridge Stratum Aesthetic equipment provider Cambridge Stratum and its associated company Cosmex Clinic have appointed a new marketing manager, Vikki Baker.

Baker previously worked as a senior brand manager for Restylane at Galderma and has more than seven years’ experience working within the aesthetic and corrective market. Baker said, “I am looking forward to working with the team – I hope my wealth of knowledge and experience in the industry will help them grow.”

Resource launches to assist aesthetic businesses Aesthetic clinic managing director Ralph Montague has released a book titled, The Profitable Clinic – The Ultimate Guide To Making Money From Owning a Clinic, Spa or High End Beauty Salon. The book aims to provide practitioners with business advice to assist them in running a successful clinic. Montague said, “The book covers operational efficiencies and tactics to increase your profitability, which can be easily implemented into your clinic at any time.”

ACE Group creates incidencereporting platform The Aesthetic Complications Expert (ACE) Group is encouraging practitioners to join their newly launched website. The website aims to provide users with a standardised form for reporting a complication and a process for informing the Medicines and Healthcare Products Regulatory Agency, as well as the product manufacturers.

The group hopes that through increased incidence reporting, patient safety can be improved and any trends can be identified.

Image Skincare launches YANA collagen shots International skincare company Image Skincare has added YANA collagen shots to its product offering. According to the company, YANA is a liquid that should be taken daily, aiming to help the body rebuild and strengthen the skin by boosting the body’s natural collagen production to increase skin firmness, reduce wrinkle depth and restore hydration.

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Breast implants

Natrelle Inspira SoftTouch breast implants get FDA approval The FDA has approved a breast implant for women undergoing reconstructive or revision surgery. The Natrelle Inspira SoftTouch, from global pharmaceutical company Allergan, is a medium-firm cohesive implant. The FDA approved Natrelle for breast augmentation with silicone-filled implants in women aged 22 years or older. It has also granted approval to the implant line for augmentation with salinefilled implants in women age 18 and older. “Adding Natrelle Inspira SoftTouch breast implants to our already robust line of offerings gives Allergan the most extensive variety of implants in the industry and provides doctors with a wide range of options,” said David Nicholson, chief research and development officer of Allergan.

Nicholson added, “Now, the Inspira line of breast implants helps physicians to better meet diverse, patient-specific needs based on available breast tissue and desired outcomes.”

On the Scene

SkinCeuticals H.A. Intensifier launch, London Guests were welcomed to the SkinCeuticals new product launch, the H.A. Intensifier, at the Bulgari hotel in London on January 19. Canapés and drinks were provided to guests as they networked before the event commenced. The launch opened with the first speaker, MaÏk Lepatey, sales, marketing and education manager of SkinCeuticals, UK and Ireland. She introduced the new product and explained that H.A. Intensifier is a topical serum that aims to restore skin volume by fortifying the skin’s firmness and reducing the appearance of fine lines and wrinkles. Lepatey then introduced Megan Manco, global scientific director for SkinCeuticals, to discuss the tests conducted for the H.A. Intensifier.

Manco said, “We tested in vivo, it was inclusive of image analysis, biopsy analysis, clinical grading, tolerance and safety. We run these assessments to ensure that the message we are communicating to the consumer is correct and that our product is the most efficacious that it can be.”

Speaking on the findings from the tests undertaken, Manco said, “We took biopsy analysis application on the face and the arm and what we found was more than a 30% increase in HA content, we also saw improvements in skin ageing clinical parameters which is inclusive of sagginess, elasticity and plumpness.”

Dr Stefanie Williams, German board-certified dermatologist and medical director of Eudelo clinic, was the final speaker at the launch, and described the benefits of using the H.A. Intensifier. “Usually with HA gels or serums you have the HA which is fragmented or encapsulated but it only works in hydrating the skin, it can’t replace the declining HA that you lose in the dermis with age. This product contains several ingredients to not only hydrate with hyaluronic acid but also to stimulate HA production and to slow down the degradation of HA.” She further added that she believes the product works well for two types of patients, “One who is a younger patient who is not having procedures yet and sees visible signs of ageing and can use this product to counteract that. You also have patients who are having aesthetic procedures and it works perfectly well in combination with those.”

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Transparency in Aesthetic Treatment Aesthetics investigates why many patients still feel they are unable to speak openly about their aesthetic procedures For patients, admitting to having an aesthetic treatment is still a taboo, and this was highlighted by a recent online survey by pharmaceutical company Allergan. The consumer survey of 1,507 women in the UK (aged 25-55) had some interesting results.

Although the majority (88%) of women believed that they were free to express their beauty any way they choose, and 25% of women said they’ve had or would consider having facial injectables, well over a third of the latter group (38%) said they have or would keep their facial injectable treatment a secret.1 In an era where more people are seeking aesthetic treatment and there is more consumer press coverage than ever before, why are many patients remaining tightlipped about their treatments? And is this likely to change in the future?

Keeping quiet On 12 January 2017, the CEW (Cosmetic Executive Women) – a not-for-profit professional organisation that aims to address important topics in the beauty industry – in partnership with Allergan, held a panel debate titled ‘Breaking the taboo: can a feminist love fillers?’. The topic instigated various discussions from the panel on why patients seek treatment, what they want from treatment, and how they don’t feel they can discuss it. This was highlighted in the online survey, which indicated that 68% of women felt judged or treated differently just because of the way they look,1 a possible reason as to why patients might not want to discuss treatments.

“I see women who desperately don’t want anyone to know,” says aesthetic practitioner Dr Tatiana Lapa. “It almost becomes a game, to plan their week in a way so as if they get a small bruise from treatment no one will see them until it disappears. They want to make sure no one finds out.”

Aesthetic nurse prescriber Alison Telfer, a panellist at the CEW debate, said, “I have several couples that come to me that don’t 14

know that either have had treatment, I have several sisters that come that don’t know each other comes; one of these particular sisters is envious of how beautiful the other sister is and how she hasn’t developed any lines and wrinkles – that’s a shame.” She adds, “There is a fear that someone will say to them, ‘don’t be so stupid, you don’t have to do that’.”

But why might aesthetic treatment be something to feel embarrassed about? Dr Lapa explains, “I think the fact that there are high-profile figures and celebrities having injectable treatments and hiding it does perpetuate the cycle of it ‘not being okay’ and being ‘taboo’. If these people were more open about it, it could help.”

Does it matter?

Although many patients may feel uncomfortable discussing a procedure, more transparency could be of benefit to the industry and general public alike. Telfer says, “A patient will have fillers and two weeks later her friends will say, ‘you look great – is it that the new cream you’re using?

Then that patient will just say, ‘Yes!’. This could lead women to think they can gain unachievable results just from creams.”

Dr Lapa adds, “If patients were more open about the treatments they have had then people would realise the amount of possibilities there are; how advanced treatments have become. We can enhance a patient’s face without a stitch or cut – people aren’t aware of the potential.”

By not talking openly about it, Telfer is also concerned that this could lead some patients to go to the wrong practitioner, “Because patients don’t make recommendations, people may seek treatment from practitioners that aren’t experienced or fully trained.”

Could this change?

In recent years there have been many reports of a rise in younger patients seeking aesthetic treatment. Although official UK Aesthetics | February 2017

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statistics are hard to come by, research by the American Society of Plastic Surgeons (ASPS) suggests more than 100,000 combined botulinum toxin treatments were carried out on patients aged between 20 and 29 in the US in 2015, and this age group received more than 50,000 hyaluronic acid filler injections in the same year, which was up 8% on the previous year.2 Dr Lapa says, “My younger patients are much more open to discussing what they have had done and even recommend to their friends. I’d say a lot of that is probably to do with social media; for example, I will have patients come to me saying they follow a certain person on social media and want to know what they have had done and say they want something similar.”

Telfer agrees, “I see patients in their 20s who are very confident and come into clinic saying, ‘this is what I want’ – they almost see injectables as an extension of their beauty regime. Whereas women in their 40s are not so confident; ageing for them is like going through a loss, it is like a bereavement.”

Dr Lapa says, “Some of our younger patients seem to treat getting their procedures in the same was as their three-monthly hair appointment; they book in advance, as they know they will definitely be coming. I even have patients saying that their friend really ‘needs to have Botox’ done and that they’re going to ‘drag them in because they desperately need it’. To them, it is almost inexcusable to have a wrinkle or not to have fuller lips.”

Taking note of how patients find the clinic can be one way to assess how open patients are about treatment. Dr Lapa says, “My patients in their 40s, 50s or older tend to find me organically through internet searches, whereas the younger cohort find me through friend referrals. So just looking at this information makes me think the younger generation are happier to discuss and recommend treatments to friends.”

For now, many patients remain elusive about their aesthetic treatments, but if the younger demographic carries on being more forthcoming, could this lead to more transparency in older patients in the future?

REFERENCES 1. Data on file.

2. ASPS, 2015 Cosmetic Surgery Age Distribution, Age 2029, (2016) <https://d2wirczt3b6wjm.cloudfront.net/News/ Statistics/2015/cosmetic-procedures-ages-20-29-2015.pdf>

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companies featuring in this agenda will be international aesthetics distributor, Merz Aesthetics, global pharmaceutical company Galderma, skincare company SkinCeuticals, hyaluronic acid dermal filler manufacturer Teoxane UK, aesthetic pharmaceutical company Intraline, non-surgical equipment supplier Fusion GT, energy-based aesthetic device company Lumenis UK and antiageing treatment provider Laboratories Filorga. Each session will help you gain the practical skills and clinical knowledge you need to provide the best services to your patients. Every one-hour session is worth 1 CPD point and each will have unique learning outcomes to cater for a variety of practitioner interests from injectables, to threads to skincare and energy devices.

Maximise your ACE 2017 Masterclass Experience Aesthetics showcases the interactive Masterclass agenda and explains how you can make the most of the innovative content Live demonstrations, insights into the latest technologies and expert opinion are just a fragment of what you can gain by attending the Masterclasses at the Aesthetics Conference and Exhibition (ACE) 2017 on March 31 and April 1. The Masterclasses will encompass 12 aesthetic companies showcasing their latest and most innovative product offerings through interactive presentations from experienced and highly respected key opinion leaders (KOLs).

You will have the opportunity to observe expert injectors, device users and skincare specialists perform live treatments and share their top tips for successful results. Among the specialist aesthetic

Every one-hour session is worth 1 CPD point and each will have unique learning outcomes to cater for a variety of practitioner interests

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What will you learn at the Masterclasses?

Over the two days you can see cosmetic practitioner and KOL for Teoxane UK Dr Kieren Bong unveil his R+R technique for hand rejuvenation. During this session, Dr Bong will discuss the science behind Teoaxane products and considerations for achieving optimum results. Dr Bong said, "Delegates will gain a good understanding of the molecular structure of hyaluronic acid dermal filler and will get to know the unique features and specifications of Teosyal Redensity I and Teosyal RHA 2. They will witness, during the live demonstration, how to combine the benefits of these two products and the techniques for hand rejuvenation."

If you want to know more about PDO threads, aesthetic practitioner Dr Huw Jones will discuss how to use them effectively at the Intraline Masterclass. You will learn about their benefits for facial rejuvenation and how they should be used appropriately, recent clinical data that showcases the biological and physical changes, as well as the collagen production stimulated by PDO thread lifts in 40 UK patients. Dr Jones will complement his presentation with a live demonstration of treating the face and neck with threads.

In Fusion GT’s Masterclass, aesthetic practitioner Dr David Jack will provide you with the latest updates for combination treatments for facial rejuvenation through the use of the Plexr, CarbMix and Needle Shaping systems. Dr Jack will also discuss the development, science and clinical studies behind the technologies, as well as performing a live demonstration to showcase the speed and effectiveness of these procedures. Dr Jack said, “It will be a good way for delegates to experience a new range of very interesting and innovative new treatments, while building on the combined approach philosophy that most advanced practitioners adhere to for best patient outcomes.”

At the Lumenis UK Masterclass, aesthetic practitioner Dr John Quinn will examine the ResurFX fractional non-ablative device for skin resurfacing. You will discover how this system works and find out more about the CoolScan, an advanced scanner, which the company claims ensures precise and homogenous results. Dr Quinn will then demonstrate the machine’s benefits by treating a patient in front of the audience. You can also refine and broaden your skincare knowledge through helpful tips and advice from aesthetic practitioner and chairperson of the International Peeling Society, Dr Uliana Gout, in the SkinCeuticals Masterclass. Dr Gout will share her experience using the SkinCeuticals products and how to best utilise them in practice.

KOLs representing Merz Aesthetics, Galderma and Laboratories Filorga, as well as more companies yet to be announced, will also share their expertise at the Masterclasses. Register now to receive ACE 2017 email updates and keep up with all the latest developments.

Aesthetics | February 2017

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How do you make the most of the Masterclasses?

To maximise your Masterclass experience and get the best learning outcomes from ACE 2017, there are a few simple tips to follow:

is scanned upon entry to each session so you receive the appropriate amount of points, which will be uploaded to your Training Record on the Aesthetics website for easy access after the event.

• Visit the ACE 2017 website and click the orange ‘Register Now’ button. Registration is free and grants you access not only to the Masterclasses, but also the Expert Clinic and Business Track agendas, Exhibition Floor and Networking Event, sponsored by 3D-lipo.

• Check out the Programme and choose which sessions you want to attend. With so much on offer at ACE, we recommend that you view the Programme beforehand to decide what you want to attend. Click on each session to read about what it will include, who will speak and what company will be sponsoring it. There are also links to the speakers and companies so you can find out more about their expertise.

• Add sessions to your agenda. Once you’ve decided what you want to attend, click on the ‘Add to My Agenda’ button, which will create a personalised timetable for you that you can then print and bring along to the event. This will help you stay on track of the sessions you want to attend and ensure that you don’t miss any of the valuable learning opportunities on offer!

• Arrive early to guarantee your seat. With high demand for the free Masterclasses and limited space available in the Gallery rooms, it is vital you arrive early on the day to gain access.

• Collect your CPD points. Each one-hour Masterclass session is worth 1 CPD point so make sure the barcode on your badge

See you at ACE 2017 With continued learning a high priority for professionals in the aesthetics specialty, there has never been a better time to attend the most comprehensive educational medical aesthetics event in the UK. If you attended ACE last year, simply update your details on our website – aestheticsconference.com – or register now to make the most of the vast range of unmissable content on offer. See you at ACE 2017!

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Special Feature Hyperpigmentation

Hormonal influences: Most commonly, hyperpigmentation presents itself as melasma as a result of hormonal changes, due to pregnancy or taking contraceptive pills, and can be difficult to treat. As such, it is often referred to as ‘the mask of pregnancy’.1 “If patients are on the contraceptive pill you will have real trouble getting a good result,” says Dr Williams. “It is worth discussing this with the patient to see if they would consider changing their contraception ahead of treatment,” she adds.

Post-inflammatory hyperpigmentation (PIH): Following damage to the epidermis or dermis, inflammation can trigger melanocytes to increase melanin synthesis and transfer the pigment to the surrounding keratinocytes.3 Aesthetic practitioner Dr Xavier Goodarzian, founder of the Xavier G. Clinic in Southampton, says, “PIH is luckily easy to treat with skin lightening topicals and generally clears up well.” Although, it is important to note that the pigmentary changes as a result of PIH can occur with greater frequency and severity in Fitzpatrick skin types IV-VI.4

Treating Hyperpigmentation with Peels

Consultation

Practitioners share advice on how to safely and successfully treat hyperpigmentation with chemical peels Sun exposure, hormonal activity and general ageing can all contribute to the development of hyperpigmentation, which is often a significant concern for aesthetic patients. The darkened patches of skin that appear as a result of increased melanin production can vary in size and appear anywhere on the body,1 although, according to the practitioners interviewed for this article, patients generally request treatment for those on the face.

“My patients are often hugely stressed by hyperpigmentation; often placing more importance on treating it over lines and wrinkles,” says German board-certified dermatologist Dr Stefanie Williams, who runs Eudelo in London, and notes that hyperpigmentation is the most common reason people visit her clinic. Aesthetic nurse prescriber Kelly Saynor, founder of Renew Medical Aesthetics in Cheshire, agrees, saying, “They can become a bit depressed, in the same way as those patients suffering from acne, and feel the need to cover up their skin.”

While lasers are well known as an effective treatment for hyperpigmentation, this article will focus on key considerations when using chemical peels to treat the common aesthetic concern.

Aetiology Hyperpigmentation is a result of an overproduction of melanocytes, the pigment-producing cells that are located in the basal layer of the epidermis.2,3 According to the practitioners interviewed, there are three main causes for its occurrence. These include: Sun exposure: “I have found that the most common form of hyperpigmentation is sun damage,” says Saynor, noting that it can affect patients of any age. If skin is over-exposed to sunlight then it can increase pigment production, leading to hyperpigmentation.1 Aesthetic nurse and founder of MBA Clinics, Petrina Nugawela, explains that sun damage tends to be located superficially, so is fairly easy to treat.

Understanding your patients’ expectations from treatment should be the main priority of any consultation, says Dr Nick Milojevic, aesthetic practitioner and founder of the Milo Clinic in London.

Saynor highlights that many of her patients have unsuccessfully tried lots of over-the-counter (OTC) creams and other treatments before presenting to her clinic. “Patients may have over- or underused products, or just been using the wrongs ones,” she says. As such, Saynor emphasises that practitioners also need to find out how long they’ve had the hyperpigmentation, how they feel about it, what treatments they’re prepared to undergo and how much they’re prepared to spend – “Be tactful and go in with trepidation,” she suggests. Once you’ve established their expectations, the practitioners advise that you then need to carefully outline what can be achieved with chemical peels, the side effects that patients will experience and the complications that could occur.

Saynor adds that ensuring your patient understands that hyperpigmentation can never be completely eradicated is essential.

“We can suppress it with the products we put on topically, but it can come back. As long as patients understand that and comply with your pre- and post-procedure advice then they will be happy,” she says.

Then, you can move on to tailoring treatment to your patient’s individual requirements. “The best thing to do is to make sure you understand where the pigment has come from,” says Dr Goodarzian, advising that practitioners should ask for a past medical history, as well as a family history to try to establish an accurate skin type.

In addition, he advises practitioners to ask patients what products they currently use on their skin and what treatments they may have undergone in the past. “I would then recommend using something like a Wood’s lamp or an imaging device to look at deeper pigmentation under the skin, to understand and demonstrate to the patient the type and extent of their hyperpigmentation.”

Dr Williams agrees, adding, “The first thing I do is diagnose what type of pigmentation it is by thoroughly examining the skin and doing a digital face scan, with a Wood’s lamp where we can look under the skin, as well as on the surface. Once we have a diagnosis we then look at how the patient would be treated.”

Treatment The practitioners agree that having a thorough understanding of the different Fitzpatrick skin types and how they react to chemical peels

Aesthetics | February 2017

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Special Feature Hyperpigmentation

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“Patients underestimate the importance of sunscreen; one day of sun can essentially undo three months’ worth of treatment” Dr Stefanie Williams

is an essential part of your treatment approach.

As mentioned above, while using chemical peels on Caucasian skin is generally considered safe, treating darker skin types carries an increased risk of developing PIH.4 Nugawela explains that approximately 80% of her patients are Asian. She says, “If you are treating darker skin, you have to be able to make an assessment on skin colour and texture. You cannot always go with the basic instructions on a piece of paper, you need to be able to make that visual judgement for yourself and never take a risk with a patient.”

She continues, “With higher Fitzpatrick skin types, you have to be so careful and treat every patient as an individual. You could have 10 people in front of you who have the same colour skin tone, but they all react differently.” Nugawela advises that practitioners should apply a very thin layer of product to begin, and carefully watch how the skin reacts. “You don’t leave the patient; you don’t take your eyes off them,” she emphasises.

Superficial and medium-depth peels are used to treat hyperpigmentation, while deep peels are generally reserved for lines and wrinkles. Careful skin priming and the appropriate selection of peel is essential for successful treatment. However, it is important to note that the peeling solution alone does not necessarily determine the depth of the peel. Depth can be determined by a number of factors including the concentration of the solution, the pH, the availability of free acid, the length of time applied to the skin, the condition of the skin, and the method of application.5 Before

After

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Skin preparation Prior to treatment with chemical peels, practitioners advise priming the skin with topical de-pigmenting agents, which act as an adjunctive to treatment and can enhance the effect of the peeling agent.4 This also allows practitioners to identify any potential sensitivity to ingredients that may be used later with the peel. The ingredients included in such de-pigmenting agents usually contain a combination of ingredients such as hydroquinone, azelaic acid, kojic acid, licorice extract and retinoids, amongst others, which work to lighten the skin and create an even-toned appearance.6 In addition, Dr Williams recommends that patients use an antioxidant serum and an SPF. Her product of choice is Kligman’s Formula, a prescription-only formulation, which she describes as the ‘gold standard of anti-pigment treatment’. For Dr Milojevic, the Obagi Nu Derm System is his topical product of choice prior to a chemical peel. He recommends that patients use it every morning and night for three months, and visit their practitioner once or twice during this time to check the skin’s progress. “If the patient is examined thoroughly by a practitioner and appropriate dosages are prescribed for home use, then results can be hugely successful,” he says. Dr Goodarzian, on the other hand, has had particular success with Dermamelan, which aims to pause the skin’s melanin production to reduce the appearance of skin blemishes caused by excessive melanin.7Once a treatment approach has been decided, Dr Goodarzian explains that he creates a skincare programme for each of his patients. “I specifically write down a programme with one to four steps for the morning and night. I try not to make it too complicated as people generally don’t want to spend too long putting creams on their face,” he says, adding, “However, for treating hyperpigmentation, the routine does tend to be a little more complicated so I do try to ensure that patients understand the importance of following it precisely.”

Dr Goodarzian emphasises the importance of using sun protection in each of his programmes and recommends that patients use an SPF 30 or above every day. The practitioners agree that getting patients to comply with staying out of the sun and using protection on a daily basis, regardless of the weather, is one of hardest issues to combat. Dr Williams says, “Patients underestimate the importance of sunscreen; one day of sun can essentially undo three months’ worth of treatment.”

Superficial peels For patients suffering from mild hyperpigmentation, or for those who do not want the discomfort and downtime associated with a deeper Before

Figure 1: Front view of before and after treatment with one mediumdepth TCA SkinTech peel. Images courtesy of Dr Xavier Goodarzian.

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Figure 2: Side view of before and after treatment with one mediumdepth TCA SkinTech peel. Images courtesy of Dr Xavier Goodarzian.

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Medium-depth peels “Medium-depth peels have a better chance of being able to suppress and reset the skin,” says Saynor, although she does note that sometimes it will get worse before it gets better. Medium-depth peels are most commonly performed with trichloroacetic (TCA) acid and Jessner’s solution, in various combinations and concentrations.10 and typically result in a patient’s skin peeling for a week following treatment, so it is essential that they are prepared for the downtime. Dr Goodarzian says, “TCA can look weird but you can still go out – it just looks like you’ve got cling film on your face. Patients will start peeling after about two to three days, and on day three, four Figure 3: Before and after treatment with Blue Peel RADIANCE. Images courtesy of Healthxchange Pharmacy. and five it looks really obvious that the patient has had something done, so most patients prefer to stay at home.” peel, there are a number of types of superficial peels that can be Dr Williams uses peels from a range of different brands, including used with reliable results.

NeoStrata, Sesderma, Image Skincare and the SkinTech Easy Peel.

Alpha hydroxy acids (AHAs) and beta-hydroxy acids (BHAs) “I’m not saying these are the only good ones,” she says, adding, are applied as the peeling agents for superficial peels, as they “Practitioners should look at the clinical trials and evidence behind work to penetrate the epidermis, break the bond between the products before deciding on a peel brand – also, you can’t compare keratinocytes and allow for faster exfoliation of those skin cells. The peels directly, even if they have the same concentration of active most common AHAs are glycolic acid and lactic acid, although they ingredient on paper.” can use a number of different formulations including citric acid, For Saynor, her product of choice is The Perfect Peel, a product phytic acid and kojic acid. distributed by her company Medica Forte. The peel is made up Dr Goodarzian explains that while the AHAs main role is to of glutathione, vitamins and minerals, and five different types of exfoliate the skin, their secondary role is to lighten the skin acids, all at low percentages, that work together aiming to reduce by having an influence on the physiology of the melanocytes’ pigmentation, correct wrinkles, exfoliate the skin and reduce pigment production.9 According to Dr Goodarzian, patients usually inflammation.11 Saynor says, “It allows the practitioner to bridge the need a minimum course of four AHA-based peels, although it can gap between the old and new style peels.” be up to eight, spaced two weeks apart for effective results. His Following any type of peel, Saynor emphasises that patients should current products of choice include the Neostrata peeling range, aim to keep their skin hydrated, with the use of a cosmeceutical which he says offers different percentages of glycolic acid, as well hydrating product that has active ingredients, rather than an OTC as citric acid and mandelic acid packaged separately so that you moisturiser, to further enhance the results of the treatment. can mix with the glycolic acid as needed. “They’ve been around a long time and have got brilliant data in regards to efficacy,” he says. Side effects and potential complications At each clinic session, Dr Goodarzian advises that practitioners As expected, the main concern with undergoing a chemical peel should check that the skin is healing properly and is progressing treatment for patients is the peeling itself. “Following a superficial at the rate it should be. With superficial peeling there is minimal peel, there may be faint flaking after a couple of days, but very often downtime, he says, noting, “Patients won’t need to take time off not even that,” says Dr Williams. work, even if they’ve had six peels.”

Medium-depth peels, on the other hand, are associated with much Salicylic acid is the most frequently used beta hydroxyl acid (BHA). longer downtime, with skin peeling for, on average, up to three It is different to AHAs as it is lipophilic, whereas AHAs are waterweeks. In addition, the practitioners interviewed all say that patients soluble, which is why salicylic acid is often chosen to treat oily and are very often tempted to pick at the peeling skin, which can have acne prone skins.8 Nugawela says that she uses mainly glycolic Before After and salicylic acid-based superficial peels and highlights that she has had successful results with both the Jan Marini glycolic acid portfolio for its high safety record and the salicylic acid-based Obagi Blue Peel RADIANCE, which she says is a bit stronger than a glycolic acid-based peel but does not stress the skin. “I love Obagi Blue RADIANCE as patients feel like they’re having something done as there is a little burning sensation but it doesn’t irritate the skin,” she says. In addition, she notes that the fact that the peel changes colour (from a blue to white frosting on the skin) is a really good indication for how well the product is working and when to stop application.

While superficial peels are effective at treating the outer layers of the skin, particularly for sun damage, and taking a more gradual approach to skin improvement with minimal downtime, some patients may require a deeper treatment and request quicker Figure 4: Before and after treatment with the Blue Peel RADIANCE. Images courtesy of Healthxchange Pharmacy. results. As such, a medium-depth peel may be appropriate.

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NEW YEAR, NEW YOU

A-peeling for everyone Reveal younger, healthier-looking skin one layer at a time with the famous and original Obagi Blue Peels.

Clinically proven Obagi peels help reduce the visible signs of ageing such as fine-lines, wrinkles, melasma and pigmentation.

www.healthxchange.com

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“Do your homework, listen to your peers, attend as many courses as you can and really understand your patients’ skin” Kelly Saynor, aesthetic nurse prescriber Figure 5: Before and after treatment with Obagi Nu Derm and Obagi Blue Peel RADIANCE. Images courtesy of Petrina Nugawela.

serious implications. “If you’re picking at scabs, greatly increases the risk of scarring and can potentially also create an entry point for bacteria so, in theory, you have a higher risk of infection,” explains Dr Williams, although she notes that she has never seen this in practice.

Dr Goodarzian adds that infection is either bacterial or viral and the practitioner should treat accordingly. “You would normally see red patches or, in a worst-case scenario, pus-filled spots with a bacterial infection,” he says, noting that these are easily treatable with antibiotics. However, a viral infection could result in herpes simplex virus (HSV). “You should always ask patients if they have any cold sores and cover them with HSV treatment prior to the peel,” he says, adding, “If you don’t there is a risk that they do get herpes and it can spread across their entire face, which can lead to severe scarring and pigmentation problems.”

Dr Goodarzian notes that there is sometimes a misunderstanding that superficial peels can’t cause scarring. This is very wrong, he says, explaining that it is possible to get scarring as a result of a superficial peel if the skin has been too well prepared, is overly sensitive or if product has been left on for too long. “Even with a 50% glycolic acid peel it is Before After absolutely possible to get scarring so it’s important to stick to the protocols,” he says, adding, “Don’t leave the peel on for too long and if you do start to see a negative reaction then neutralise and remove the peel immediately.”

Before After Dr Goodarzian advises that practitioners should start using peels with a low percentage before working their way up. “I would recommend you stick to somewhere between 15-20% and Figures 6 & 7: Before and after treatment with The Perfect Peel. Images courtesy of layer it up, which will drastically Kelly Saynor. reduce the risk of scarring,” he says. Although rare and not something seen by the practitioners interviewed, they explain that some patients can suffer an allergic reaction to a chemical peel. As such, it is important to monitor the skin closely through both the preparation phase and the peeling phase, and remove the product used immediately if an adverse reaction begins to occur. Finally, Dr Goodarzian says, “A good consent form is really important, as well as good aftercare instructions that people take home, read and really understand what they need to be doing.

In addition, having a system where patients can call you or the clinic if there are any issues is hugely valuable.”

Education is key While chemical peels offer promising results and improvements to the appearance of hyperpigmentation, they do not come without their risks. Having thorough training in their application, as well as a high level of understanding of treating different skin types and how to manage complications is hugely important to safe and successful results. Dr Goodarzian says, “Please make sure you get training; don’t just think you can buy something off the internet and slap it on.

Educate yourself; read about it. The two textbooks I recommend are The Textbook of Chemical Peels by Dr Philippe Deprez and Obagi Skin Health Restoration and Rejuvenation by Dr Zein Obagi. If you read these books as background, they will really help you with the basics of peels.”

Saynor adds, “The skin responds differently from person to person, so make sure you do your homework, listen to your peers, attend as many courses as you can and really understand your patients’ skin.”

In addition she says, “Don’t think you can get into peeling overnight – everyone will get that patient who doesn’t respond as you think they will, so it is imperative that you armour yourself with knowledge so that you are able to look at the skin, assess it correctly and treat it appropriately.” Dr Williams concludes by emphasising the importance of also educating patients on the damage that can be caused by the sun, and how to make the most of their treatment.

She says, “In most cases, we can’t switch off the internal reasons why you have a predisposition to hyperpigmentation, however we can change patients’ attitude to the sun, which goes a long way.”

Disclosure: Kelly Saynor is the owner of Medica Forte, the distributor of the Perfect Peel.

REFERENCES 1. Hyperpigmentation (US: American Osteopathic College of Dermatology, 2017) <http://www.aocd. org/?page=Hyperpigmentation> 2. Melanocyte (US: Medical Dictionary, 2017) <http://medical-dictionary.thefreedictionary.com/ melanocyte> 3. Postinflammatory Hyperpigmentation (New Zealand: DermNet New Zealand, 2015) <http://www. dermnetnz.org/topics/postinflammatory-hyperpigmentation/> 4. Sarkar R et al., ‘Chemical Peels for Melasma in Dark-skinned patients’, Journal of Cutaneous and Aesthetic Surgery, 5(4) (2012), pp.247-253. <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3560164/> 5. Ravichandran S, ‘Medium and Deep Chemical Peels’, Aesthetics, 3 (6) (2016) <https:// aestheticsjournal.com/feature/medium-and-deep-chemical-peels> 6. Davis E, Callender V, ‘Postinflammatory Hyperpigmentation’, The Journal of Clinical and Aesthetic Dermatology’, 3 (7) (2010), pp.20-31. <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2921758/ 7. dermamelan (UK: mesoestetic UK, 2017) <http://www.mesoestetic.co.uk/dermamelan/> 8. Bowes L, Naeni J, ‘The Properties of Skin Peels’, Aesthetics, 3 (3) (2016) <https://aestheticsjournal. com/feature/the-properties-of-skin-peels?authed> 9. Alpha hydroxy acid (US: Glycolic acid, 2016) <http://www.glycolicacid.com/alpha-hydroxy-acid.html> 10. Marina Landau MD, ‘Chemical Peels’, Clinics in Dermatology, 26 (2008), pp.200-208.

11. The Perfect Peel, (UK: Medica Forte, 2017) <http://theperfectpeel.co.uk/the-perfect-peel/>

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Maintaining Compliant Marketing in Aesthetics Communications consultant Julia Kendrick examines the regulations and guidelines for aesthetic marketing and advertising to the public Abstract Latest figures indicate that the UK cosmetic surgery market is booming, with more than 51,000 surgical procedures taking place in 2015 – an increase of 13% compared to 2014.1 UK statistics for non-surgical interventions are hard to come by, but as an example, in the US in 2013, $5 billion was spent on non-surgical procedures.2 In recent years, aesthetic marketing practices have evolved and successful public relations and advertising can be critical to business differentiation and survival. This paper will examine the current marketing and advertising regulatory landscape, identifying key aspects for successful marketing and understanding regulations and guidance, whilst highlighting common pitfalls.

Introduction In 2012, the PIP (Poly Implant Prothèse) scandal laid bare the effects of unethical practices, inconsistent regulations and poor patient safeguarding.3 The UK Department of Health swiftly began a review, publishing the Keogh Review in April 2013.4 Among many other issues, this report raised concerns about unethical aesthetic marketing.4 This kick-started a cascade of tighter, clearer regulations for aesthetic marketing from several regulatory bodies, with the Committee for Advertising Practice (CAP) issuing updated guidance in November 2013,5 and industry-specific bodies like the General Medical Council (GMC),6 Royal College of Surgeons (RCS)7 and the Nursing Midwifery Council (NMC)8 following suit over the intervening years. The General Dental Council (GDC) also has a guidance document on ethical advertising, however this has not been updated since 2012.9 These regulations represent a change for practitioners who, if they hadn’t already, may be faced with re-shaping their marketing. An understanding of the guidance, regulations, and relevant industry associations can help practitioners to comply with these changes.

Regulations, guidance or legislation?

Firstly, it is important to understand the difference between regulations, guidance and legislation. Legislation refers to the creating and enactment of laws. Broadly speaking, contraventions of legislation involve breaking the law and as such are subject to more serious sanctions – including fines and jail sentences.14 Regulations are to ensure the legislation is executed and followed – where a rule or directive is made and maintained by a particular authority – such as the Medicines and Healthcare products Regulatory Agency (MHRA).12 The MHRA is the Government agency responsible for ensuring that medicines and medical devices work and are safe.12 Regulations can be underpinned by laws, but are not necessarily laws in themselves and depending on the governing authority, breaches may include banning of material and fines.13 Finally, guidance is based around best 24

practice, however it can be subject to scrutiny by the professional bodies. A guidance document comprises advice, standards or information given by a person or body in authority, aimed at instilling particular behaviours, standards or benchmarks.10 For example, the GMC states that part of its role is to provide ‘Detailed guidance on ethical principles that most doctors will use every day, such as consent and confidentiality, and specific guidance on a range of areas’.11 Severe breaches of guidance could lead to fines sanctions on registration and ultimately potential for removal from the medical register.10

POMs, medical devices and cosmetic products The complexity of the aesthetic marketing landscape lies in the fact that it deals with cosmetic products, medical devices and prescriptiononly medicines (POMs). Some aesthetic professionals can sometimes confuse these, however they have distinct differences.

A POM is a licensed drug regulated by law that must be prescribed by a doctor or nurse prescriber and is not licensed for sale to the general public. The term is used to differentiate it from over-thecounter drugs, which can be accessed without a prescription.15 In the aesthetics industry, common POMs include botulinum toxin injections, hyaluronidase and lidocaine.16 A medical device is defined as an instrument, apparatus, implant, in vitro reagent, or similar or related article that is used to diagnose, prevent, or treat disease or other conditions, and does not achieve its purposes through chemical action within or on the body (which would make it a drug).17 Examples in aesthetics include everything from gloves and thermometers to dermal fillers and injector pens.

Cosmetic products are classified as substances which are for external use on the body (or within the mouth) for the purposes of cleaning, perfuming, protection, maintenance and correcting or changing its appearance.18

Relevant associations and their standing Industry organisations have implemented their own guidance for professionals undergoing cosmetic treatments, which include guidance on marketing. In June 2016, the GMC released its updated aesthetic guidance, which included key points on marketing,

Advertising or promotion of POMs to the public is strictly prohibited

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including the need for it to be accurate, responsible and not misleading.5 It states, ‘Market your services responsibly, without making unjustifiable claims about interventions, trivialising the risks involved, or using promotional tactics that might encourage people to make ill-considered decisions’.6 When it comes to marketing and promotion of POMs, it is tightly controlled and enforced by the Human Medicines Regulations 201219 – which is legislation – and the MHRA, which provides regulations.20 The GMC, RCS, NMC, GDC and CAP advice are classified as guidance.

The MHRA can bring sanctions for breaches of the code, which can include ‘a fine and/or imprisonment for severe breaches’.12 Furthermore, these restrictions do not just apply to traditional ‘adverts’ but also to publicly accessible information, such as a website’s homepage or social media channels.21 The GMC, RCS, NMC and GDC recommendations are distilled from the more comprehensive CAP guidance, which has further standards in place that practitioners should consider.10 The CAP sets the overall standards for advertising practice, which apply to written materials, online (including social media) and broadcast (video and radio) – such as the need for proper substantiation, clear identification as an advert, promotions, incentives and targeting of specific audiences.10 Each industry association body is responsibly for breaches in its own guidance, however the CAP guidance is enforced by the Advertising Standards Agency (ASA), which has the ‘teeth’ in terms of responding to complaints of unethical or inappropriate advertising, by banning adverts and potentially issuing fines (regulation). Part of the ASA mandate is to proactively monitor marketing channels such as radio, TV and social media for non-compliant advertising.21 POM marketing example Botulinum toxin injections account for the vast majority of non-surgical cosmetic procedures, with more than 6.7 million procedures taking place in the US in 2015 alone.16 Despite the term ‘Botox’ passing into the common vernacular, under the Human Medicines Act (law), no reference to a POM can be made in marketing material such as a sponsored advertisement, website homepage, in logos or testimonials.21 In addition, any small print at the bottom of a homepage should not refer to POMs or directly link consumers to a page where they are referenced. Other POMs to consider include hyaluronidase and lidocaine.16 Advertising or promotion of POMs to the public is strictly prohibited: UK law states that ‘any advertisement wholly or mainly directed to the general public which is likely to lead to the use of a prescription-only medicine are prohibited’.21 So what CAN be done when marketing POMs? • Raise awareness of the ‘conditions’ treated, such as signs of ageing around the eyes, or frown lines16 • Talk in broad terms such as ‘anti-wrinkle’ injections or ‘cosmetic injections’ as these are non-specific to POMs and could also be deemed to include fillers, which are medical devices16 • To get more specific, information about a POM should only be provided in the context of a possible treatment option following a consultation16 Cosmetics and medical devices For the rest of aesthetic marketing, which includes marketing for cosmetics and medical devices, as well as POMs, the GMC, NMC, GDC and CAP guidance may be considered, important points mentioned can be broken down and combined into four key areas: it

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must be responsible, accurate, not mislead patients or the public, or encourage ill-considered treatment decisions.5,6

Responsible marketing Responsible marketing post-Keogh includes more focus on ensuring the psychological wellbeing of the patient. Promotional activities should not target or encourage those suffering from clear psychological disorders such as body dysmorphic disorder. This can be challenging in practice, as patients often investigate cosmetic procedures following a change in life circumstances (such as post pregnancy, wedding, divorce or a major birthday). However, the GMC guidance highlights the need to consider patients’ vulnerabilities and psychological needs when considering an intervention, alongside the need for certainty that the patient is requesting the procedure voluntarily.5 Best practice is to use two-week cooling-off periods to ensure advertising hasn’t encouraged them to undergo treatment too soon.7 Responsible marketing requires clear treatment information – whether in verbal, written, or video format – to ensure patients have realistic treatment expectations. They need to understand what the procedure, side effects, downtime and recovery periods will entail.

The root cause of many ASA complaints on cosmetic advertising is that procedures were trivialised: information was inaccurate or misleading, with procedures not being given their due gravitas and thereby implying to patients that a quick decision could or should be made.21 The new GMC guidance encourages cosmetic interventions to always be given their due gravitas and, by extension, has banned marketing gimmicks such as offering treatments as prizes.6

Accuracy Accuracy may seem self-evident, but the CAP guidance provides great detail about commonly used terms that are no longer appropriate for promoting cosmetic products or treatments. For example, colloquial phrases like ‘boob job’ or ‘tummy tuck’ are no longer permitted, as they can diminish the severity of the procedure and could lead to patient confusion.5 The key message is to ensure patients have absolute clarity on what treatments are and what they involve, in order to make an informed decision. Phrases such as ‘lunch-time fixes’, ‘non-invasive’, ‘safe’ or ‘no downtime’ can cause serious difficulties, so it is vital to substantiate all claims around the treatment process, results and post-procedure care. Substantiation means you need to have personally reviewed (and kept hard copies of) any claims, studies or evidence that you put into the public domain.23 This guidance applies to your own materials as well as those of manufacturers or suppliers.5 Practitioners are also encouraged to avoid hyperbole in their treatment descriptions, such as ‘revolutionary’ or ‘turns back time’, as these require substantiation.

However, you can use descriptions that are unlikely to be taken literally, such as ‘feel fantastic’ and ‘new you’.5

Not misleading Not being misleading revolves mainly around the validity of both verbal and visual claims. Critically, that aesthetic advertising should not exaggerate the effect that the cosmetic intervention alone is capable of achieving. Re-touching or digital manipulation tools such as Photoshop are permitted, but subject to stringent caveats and disclaimers. The CAP provides a separate help note specifically relating to production techniques in cosmetic advertising.16 However, disclaimers do not give a ‘carte blanche’. If Photoshop is used, as per the guidance, any retouched images should be kept on file alongside the originals, so that the alterations can be verified in the event of a claim.

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Not encouraging ill-considered treatment decisions Not encouraging ill-considered treatment decisions refers to the use of limited-time offers, promotions and incentives; anything which could encourage patients to make a treatment decision without appropriate consultation, consideration and cooling-off time. Special offers and promotions can be valuable tools to manage and maintain clinic revenue, and by nature must have an appropriate time limit.

The key point when marketing all aesthetic procedures is to ensure appropriate terms and conditions are clearly stipulated alongside any offers (such as ‘subject to consultation and cooling-off period’) and that the offers themselves follow the rest of the guidance, in terms of accuracy, not trivialising and being responsible. As stated in the CAP guidance, countdown clocks and wording such as ‘Hurry, offer ends on X date’ are deemed unsuitable.5 Raising your reputation When considering communications, the route to success begins with a strong foundation of compelling messages, which set you apart and establish a rapport with your audiences. Much of this boils down to ‘Unique Selling Points’ or USPs – and in the effort to differentiate, it can be easy to embellish credentials or encroach on other businesses’ positioning. Once again, the CAP guidance gives details as to how you can describe expertise and capabilities. For example:5 • ‘Experienced’ – deemed to mean at least six years in the field • ‘Specialist’ – must be the main area of practice • ‘Leading’ – must provide objective evidence of rank within the specialty • ‘Setting the Gold Standard’ – must be verified by relevant external evidence

Differentiation vs. defamation General statements for the purpose of clarity and differentiation are one thing, but beware of targeting specific practitioners or clinics as this can easily tip into disparaging language. Defamation refers to the action of damaging someone’s reputation – through slander (a spoken falsehood) or libel (a published false statement) and whilst it is not illegal, it is still a ‘tort’ – or civil ‘wrong’, which can be resolved through legal proceedings. If disparaging comments or written materials damage another businesses’ reputation to the point where actual or probable financial loss is incurred, then the party has grounds to sue for defamation as per the 2013 Defamation Act.22 As well as the CAP and ASA resources, when it comes to making responsible comparisons, referring to the Association of the British Pharmaceutical Industry Code of Practice may be useful.18 As the name suggests, this guidance is primarily intended for pharmaceutical communications, but Clause 8 delivers some sage advice: ‘the medicines, products and activities of other companies must not be disparaged’ and ‘the health professions and clinical and scientific opinions of health professionals must not be disparaged’.18 The bottom line is about taking an ethical approach; ensuring that any critical references made regarding another provider (or their products etc.) are firstly justified, as well as accurate, balanced, fair and able to be substantiated.

Discussion Marketing and advertising in medical aesthetics can present challenges for some practitioners and clinics who do not have specialist knowledge in this area or support from marketing or public relations agencies. Whilst the scope and clarity of guidance in 26

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aesthetics has improved in the wake of the PIP scandal and Keogh report, there seems to still be confusion as to what kind of promotion is appropriate for a POM versus a medical device. Unethical marketing in aesthetics may still be taking place – perhaps because the oversight and monitoring is split across so many different agencies and professional bodies. As a whole, the industry relies on a high degree of self-regulation and public reporting to identify and penalise any offences. Professional regulatory bodies should also be ensuring that medical practitioners within their organisation understand and comply with the resources offered by the CAP, ASA, GMC, RCS, NMC, GDC and MHRA. Julia Kendrick is an award-winning communications and PR consultant specialising in medical aesthetics.

With over 12 years’ experience, she aims to help brands, clinics and practitioners take a strategic approach to take control of their reputation, tangibly grow their business and cut through the competition. Kendrick is a regular industry media contributor, congress presenter and trainer.

Julia Kendrick will speak on Building a Brand with PR at the Aesthetics Conference and Exhibition 2017 on March 31.

Visit www.aetheticsconference.com/programme to find out more.

REFERENCES 1. British Association of Aesthetic Plastic Surgeons: Press Release – 8th February 2016, <http:// baaps.org.uk/about-us/press-releases/2202-super-cuts-daddy-makeovers-and-celebconfessions-cosmetic-surgery-procedures-soar-in-britain> 2. ASAPS, ‘American Society for Aesthetic Plastic Surgery Reports More Than $13.5 Billion Spent for the First Time Ever’, (2014) <http://www.surgery.org/media/news-releases/the-american-societyfor-aesthetic-plastic-surgery-reports-americans-spent-largest-amount-on-cosmetic-surger> 3. Department of Health; Review of the Regulation of Cosmetic Interventions - Final Report, (2013) <https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/192028/Review_ of_the_Regulation_of_Cosmetic_Interventions.pdf> 4. Bruce Keogh, ‘Review into the quality of care and treatment provided by 14 hospital trusts in England: overview report,’ 2006, <http://www.nhs.uk/NHSEngland/bruce-keogh-review/ Documents/outcomes/keogh-review-final-report.pdf> 5. Cosmetics Interventions Marketing (non-broadcast and broadcast), Committee for Advertising Practice, Marketing of Cosmetic Interventions, (2013) <https://www.cap.org.uk/~/media/Files/CAP/ Help%20notes%20new/CosmeticSurgeryMarketingHelpNote.ashx> 6. GMC, Guidance for Doctors Who Offer Cosmetic Procedures, General Medical Council, <http:// www.gmc-uk.org/guidance/ethical_guidance/28687.asp> 7. Royal College of Surgeons. Professional Standards of Cosmetic Surgery. Published April 2016. <https://www.rcseng.ac.uk/standards-and-research/standards-and-policy/service-standards/ cosmetic-surgery/professional-standards-for-cosmetic-surgery/> 8. Nursing and Midwifery Council, ‘Guidance’, (2015) <https://www.nmc.org.uk/standards/guidance/> 9. General Dental Council, Principles of Ethical Advertising, (2012) http://www.gdc-uk.org/ Dentalprofessionals/Standards/Documents/Ethical%20advertising%20statement%20Jan%20 2012.pdf 10. GMC, ‘Cosmetic Interventions Guidance – FAQs’, General Medical Council (2016) <http://www. gmc-uk.org/guidance/ethical_guidance/29168.asp> 11. GMC, ‘Our Role’, (2017) http://www.gmc-uk.org/about/role.asp 12. Medicines and Healthcare products Regulatory Agency, The Blue Guide: Advertising and Promotion of Medicines in the UK, 3(2014), <https://www.gov.uk/government/uploads/system/ uploads/attachment_data/file/376398/Blue_Guide.pdf> 13. Collins English Dictionary, ‘Regulation’, Harper Collins Publishers, (2017), <https://www. collinsdictionary.com/dictionary/english/regulation> 14. Collins English Dictionary, ‘Legislation’, Harper Collins Publishers, (2017), <https://www. collinsdictionary.com/dictionary/english/legislation> 15. ‘Healthcare Glossary, Prescription Only Medication’, PM Live, (2017) <http://www.pmlive.com/ intelligence/healthcare_glossary_211509/Terms/p/prescription_only_medicine_pom> 16. Committee for Advertising Practice. Use of Production Techniques in Cosmetic Advertising.

2011. <https://www.cap.org.uk/~/media/Files/CAP/Help%20notes%20new/use%20of%20 production%20techniques%20in%20cosmetic%20advertising.ashx> 17. World Health Organisation, ‘Medical Device – Full Definition’, WHO, (2017) <http://www.who.int/ medical_devices/full_deffinition/en/> 18. Cosmetic, Toiletry & Perfumery Association, ‘Definition of a cosmetic’, CTPA, (2017) <http://www. ctpa.org.uk/content.aspx?pageid=304> 19. The Human Medicines Regulations (2012), The National Archives on behalf of HM Government, <http://www.legislation.gov.uk/uksi/2012/1916/contents/made> 20. American Society of Plastic Surgeons, ‘2015 Plastic Surgery Statistics Report. Accessed Sept 2016,’ (2016) <https://www.plasticsurgery.org/news/plastic-surgery-statistics> 21. Advertising Standards Agency. Our Purpose & Strategy. 2015. Available from: <https://www.asa. org.uk/About-ASA/Strategy.aspx> 22. The Defamation Act 2013, The National Archives on behalf of HM Government, (2016) <http:// www.legislation.gov.uk/ukpga/2013/26/contents/enacted> 23. CAP, ‘Substantiation’, (2017) <https://www.cap.org.uk/Advice-Training-on-the-rules/Advice-OnlineDatabase/Substantiation.aspx#.WHinM7TicTs>

Aesthetics | February 2017

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Clinical Focus Hyperhidrosis

@aestheticsgroup

Aesthetics Journal

Aesthetics

aestheticsjournal.com

Treatments Treatments for palmoplantar hyperhidrosis vary from very simple, non-permanent topical treatments, through temporary botulinum toxin treatments, to permanent surgical sympathectomy for the most severe, refractive cases.

Palmoplantar Hyperhidrosis Dr David Jack details the treatment of overactive sweat glands in the soles of the feet and palms of the hands in an aesthetic practice Primary hyperhidrosis is a fairly common and troublesome condition, affecting around 2.8% of the European population.1 Primary axillary hyperhidrosis is frequently seen and is treated effectively by many aesthetic practitioners using botulinum toxin, however, a less commonly treated, but equally as troublesome and common problem is hyperhidrosis of the palms of the hands and the soles of the feet, known as palmoplantar hyperhidrosis. In this article I will outline a number of common approaches to this condition in patients seeking treatment and the pitfalls associated with these.

Background Palmoplantar hyperhidrosis is estimated to affect around 0.6-1% of the European population,1 including both men and women equally, and adults and children.2 Most often idiopathic, this condition can be troublesome for a variety of reasons both socially and psychologically. Idiopathic or primary palmoplantar hyperhidrosis often begins in childhood or puberty and is commonly familial, being inherited in an autosomal dominant pattern.3,8 Excessive sweating from the eccrine glands, which are most densely distributed in the palms and soles, is the core feature of this condition. In primary hyperhidrosis, the glands themselves are essentially normal, but in response to emotions or stress, there is an overproduction of sweat in comparison to unaffected individuals. This in turn is believed to be due to hypothalamic over-responsiveness to cortical signalling, secondary to emotional stimuli. Primary hyperhidrosis is not believed to be related to normal thermoregulatory sweating, so does not occur in sleep or sedation, but there is an association of excessive sweat production at higher temperatures.4 Secondary hyperhidrosis, i.e. hyperhidrosis secondary to a related systemic disorder, is observed in a number of conditions including malignancies such as pheochromocytoma and lymphoma, and a wide range of neurological and endocrine conditions. This tends to be less focal than primary hyperhidrosis.8 In South East Asia, where there is a higher prevalence of primary hyperhidrosis, there is a clear association of axillary hyperhidrosis and palmoplantar hyperhidrosis.9

Diagnosis More often than not, diagnosis is clinical, with a patient history and clinical examination forming the backbone of the diagnosis of this condition â&#x20AC;&#x201C; further testing is rarely required.

The Minor starch-iodine test may occasionally be used to confirm the diagnosis and location of hyperactive sweat glands. This involves use of a solution of 3.5% iodine in alcohol, applied to clean, dry skin and then lightly dusted with starch powder. Any areas of sweating cause this to turn dark blue, indicating the location of the hyperactive eccrine glands.3 30

Aesthetics | February 2017

Topical and oral treatments The most effective topical therapy is believed to be 20% aluminium chloride in absolute anhydrous ethyl alcohol, which is thought to obstruct the eccrine glands and induce atrophy of the secretory cells, reducing sweat production.8 Compliance issues are fairly frequent with this treatment, as it requires nightly application for several nights for six to eight hours, until sweating reduces, then maintenance treatment once this reduction has been achieved every few days, although this varies from patient to patient. In addition to the cumbersome nature of this treatment, it can cause irritation and hypersensitivity so is not suitable for all patients.

In the past, systemic oral therapies have been used, such as anticholinergic drugs and benzodiazepines, to reduce stress responses, however, these are not popular with patients given their side effect profile (due to systemic anticholinergic effects) and dependency with the latter group of medications.3 Iontophoresis Since the 1950s, iontophoresis has been used for the treatment of hyperhidrosis.

This technique, which can be performed by patients at home, involves the passage of a low level electrical direct current across the skin, either slightly immersed in tap water or 0.05% glycopyrrolate solution (or on a gauze soaked with either liquid).5 Usually around a 30-minute treatment at 0.2mA current per cm2 on a palmar or plantar surface area, with daily treatments over ten consecutive days, then â&#x20AC;&#x2DC;top-upâ&#x20AC;&#x2122; treatments once to twice per week thereafter. Iontophoresis has been indicated to be effective in around 80% of cases5 but many people notice a worsening of symptoms initially before improvement.

Results are temporary, lasting for only around 35 days in most cases, and further treatments are therefore required. The mechanism of action of this treatment is still unknown and side effects are rarely associated with this treatment. Combination treatments with topical aluminium chloride and iontophoresis are favoured by some patients but are fairly time consuming.3

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UPPER FACIAL LINES Now Available in 100u Vial

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

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

Horizontal Forehead Lines: The recommended total dose range is 10 to 20 units; a total injection volume of 0.25 ml (10 units) to 0.5 ml (20 units) is injected into the frontalis muscle in five horizontally aligned injection sites at least 2 cm above the orbital rim. An injection volume of 0.05 ml (2 units), 0.075 ml (3 units) or 0.1 ml (4 units) is applied per injection point, respectively. Glabellar Frown Lines: Total recommended standard dose is 20 units. 0.1ml (4 units) into 5 injection sites (2 injections in each corrugator muscle and 1 injection in the procerus muscle). May be increased to up to 30 units.

Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. Crow’s Feet lines: Total recommended standard dosing is 12 units per side (overall total dose: 24 units); 0.1mL (4 units) injected bilaterally into each of the 3 injection sites. Injections too close to the Zygomaticus major muscle should be avoided to prevent lip ptosis. Contraindications: Hypersensitivity to the active substance or to any of the excipients.

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

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not respond to Botulinum toxin products. Should not be injected into a blood vessel. Not recommended for patients with a history of dysphagia and aspiration. Caution in patients with amyotrophic lateral sclerosis, peripheral neuromuscular dysfunction, or in targeted muscles displaying pronounced weakness or atrophy. Bocouture should be used with caution in patients receiving therapy that could have an anticoagulant effect, or if bleeding disorders of any type occur. Too frequent or too high dosing of Botulinum toxin type A may increase the risk of antibodies forming. Should not be used during pregnancy unless clearly necessary. Should not be used during breastfeeding. Interactions: Concomitant use with aminoglycosides or spectinomycin requires special care. Peripheral muscle relaxants should be used with caution. 4-aminoquinolines may reduce the effect. Undesirable effects: Usually, undesirable effects are observed within the first week after treatment and are temporary in nature. Undesirable effects independent of indication include; application related undesirable effects (localised pain, inflammation, swelling), class related undesirable effects (localised muscle weakness, blepharoptosis), and toxin spread (very rare exaggerated muscle weakness, dysphagia, aspiration pneumonia).

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

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

Further information available from: Merz Pharma UK Ltd., 260 Centennial Park, Elstree Hill South, Elstree, Hertfordshire WD6 3SR. Tel: +44 (0) 333 200 4143

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

Adverse events should also be reported to Merz Pharma UK Ltd at the address above or by email to UKdrugsafety@merz.com or on +44 (0) 333 200 4143.

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

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

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

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

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

PURIFIED1,2 • EFFECTIVE3 • CONVENIENT1,2

Botulinum toxin type A free from complexing proteins

@aestheticsgroup

Aesthetics Journal

Botulinum toxin Palmoplantar hyperhidrosis may be safely and effectively treated with botulinum toxin injections.8,10 The mechanism of action of botulinum toxin is via its inhibition of acetylcholinergic transmission at postganglionic sympathetic presynaptic nerve terminals supplying innervation to the eccrine sweat glands in the local area treated.8,10 This use of botulinum toxin was approved by the Food and Drug Administration in 2004,8 and has been suggested to be effective for a mean duration of 6.7 months in patients treated,10 with some patients reporting symptom control for up to 12 months from a single treatment.6 In addition, quality of life as measured using the Dermatology Life Quality Index – a 10-question validated questionnaire – has indicated significant improvement in patients undergoing this treatment.12 Complications of botulinum toxin treatment for palmoplantar hyperhidrosis are rare, with minor post-procedural bruising being the most common. Grip weakness, as tested by the thumb-index finger pinch, has been reported in rare cases but this is transient, usually lasting only for a few weeks post treatment.12 Injection in the palms and soles is intradermal.

In these particularly sensitive areas, analgesia is therefore an important consideration.

Topical anaesthesia is often insufficient unless a high concentration local anaesthetic preparation is used for a prolonged time, therefore median and ulnar nerve blocks are often required. In a hospital setting, Bier blocks and sedation may also be options.

Experience in performing local blocks is essential to avoid nerve injury as a result of direct injury or haematoma.8 In comparison to facial botulinum toxin treatments, a slightly lower volume, higher concentration of dilution can be used to reduce diffusion of botulinum toxin in the area, thereby reducing the risk of local muscle weakness. A suggested dose of 50 units per palm or sole is generally recommended.11 Spacing of injections is approximately 1cm apart, with a circumferential area of approximately 1.2cm being rendered anhidrotic around each injection site. The effect is apparent over a period of four to seven days post treatment and persisting from around four to 13 months.3,8 Surgical management Surgical management of hyperhidrosis is traditionally considered only for severe cases shown to be refractive to

Aesthetics

aestheticsjournal.com

medical management, or for patients with severe hyperhidrosis who wish to have a permanent solution to their condition.

The basis of surgical management of palmar hyperhidrosis is destruction of the second and third thoracic sympathetic ganglia. Surgical management of plantar hyperhidrosis by contrast, would require destruction of lumbar sympathetic ganglia (which are involved in sexual function), so surgical intervention in these cases is rarely performed.13 A recent study, however, indicated a 0% rate of sexual dysfunction following lumbar sympathectomy.18 Several techniques have been described, with open sympathectomy rarely being used nowadays. Most often, surgical candidates will undergo either endoscopic T2/T3 sympathectomy or ganglionectomy involving either cauterisation or clamping, with clamping having the benefit of being theoretically reversible. Both treatments have high satisfaction rates and low risk of recurrence of symptoms.15 Dorsal percutaneous stereotactic thermocoagulation is a newer treatment with similar efficacy.9,14,15,17 Complications of such surgery are rare but include pneumothorax, haemothorax, injury to the stellate ganglion and resultant Horner’s syndrome, blunted bradycardia response to parasympathomimetic stimuli and compensatory sweating elsewhere in the body.14,16 The latter phenomenon may occur in up to 6-40% of cases and usually occurs in body segments just below the areas treated by sympathectomy.17 This may be treated with local botulinum toxin injections.3

Summary Primary hyperhidrosis is a particularly common dermatological condition, affecting a large number of people and resulting in significant social and psychological morbidity.

Treatment of axillary hyperhidrosis with botulinum toxin is well known in the world of medical aesthetics, however, treatment of palmar and plantar hyperhidrosis, which is often associated with axillary hyperhidrosis, is rarely treated by the aesthetic practitioner in everyday practice. There are many novel treatments being considered for treatment of axillary hyperhidrosis, such as fractional radiofrequency and microwave treatments, however there is no literature on the use of these for palmoplantar hyperhidrosis. In this article I have outlined the most common treatment modalities and treatment ladder for palmoplantar hyperhidrosis at present, however, it is likely that more advanced local Aesthetics | February 2017

Clinical Focus Hyperhidrosis

treatments will become available as we become more experienced in the treatment of axillary hyperhidrosis using more novel techniques.

Dr David Jack is an aesthetic practitioner based between his clinics in Harley Street in London and Scotland. He graduated from the University of Glasgow and later became a member of the Royal College of Surgeons of Edinburgh.

David trained in the NHS until 2014, mostly in plastic surgery, before leaving to establish his non-surgical aesthetic practice, having worked in this sector part-time for almost seven years.

Dr David Jack will present the Fusion GT Masterclass on facial rejuvenation at the Aesthetics Conference and Exhibition 2017 on March 31. For more information or to register, visit www. aestheticsconference.com REFERENCES 1. Adar, R, Kurchin, A, Zweig, A, and Mozes, M. Palmar hyperhidrosis and its surgical treatment: a report of 100 cases.

Ann Surg. 1977; 186: 34-41.

2. Murray CA, Cohen JL, Solish N. Treatment of focal hyperhidrosis, J Cutan Med Surg 2007 Mar-Apr; 11(20): 67-77.

3. Thomas, I, Brown J, Vafaie J, Schartz RA. Palmoplantar Hyperhidrosis: a therapeutic challenge Am Fam Physician.

2004 Mar; 69(5): 1117-1121.

4. Leung AK, Chan PY, Choi MC. Hyperhidrosis. Int J Dermatol.

1999; 38: 561-567.

5. Karakoç Y1, Aydemir EH, Kalkan MT, Unal G. Safe control of palmoplantar hyperhidrosis with direct electrical current Int J Dermatol. 2002 Sep; 41(9): 602-605.

6. Shelley, W.B., N.Y. Talanin, E.D. Shelley., ‘Botulinum toxin therapy for palmar hyperhidrosis’, Journal of the American Academy of Dermatology, 1998; 38(2): 227-229.

7. Rusciani L, Severino E, Rusciani A. Type A botulinum toxin: a new treatment for axillary and palmar hyperhidrosis. J Drugs Dermatol. 2002; 1: 147–151.

8. Eisenach JH, Atkinson, JLD, Fealey RD Hyperhidrosis: Evolving Therapies for a Well-Established Phenomenon Mayo Clinic Proceedings 2005, 80(5): 657-666.

9. Lin, TS, Kuo, SJ, and Chou, MC. Uniportal endoscopic thoracic sympathectomy for treatment of palmar and axillary hyperhidrosis: analysis of 2000 cases. Neurosurgery. 2002; 51: S84-S87.

10. Solish N, Bertucci V, Dansereau A, et al., ‘A comprehensive approach to the recognition, diagnosis, and severity-based treatment of focal hyperhidrosis: recommendations of the Canadian Hyperhidrosis Advisory Committee’, Dermatol Surg 2007; 33(8) 908-923.

11. Klein AW. Contraindications and complications with the use of botulinum toxin, Clin Dermatol, 2004; 22: 66-75.

12. Campanati, A, Penna, L, Guzzo, T et al. Quality-of-life assessment in patients with hyperhidrosis before and after treatment with botulinum toxin: results of an open-label study.

Clin Ther. 2003; 25: 298-308.

13. Stolman LP. Treatment of hyperhidrosis. Dermatol Clin. 1998; 16: 863-9.

14. Lin TS, Kuo SJ, Chou MC. Uniportal endoscopic thoracic sympathectomy for treatment of palmar and axillary hyperhidrosis: analysis of 2000 cases. Neurosurgery. 2002; 51(5 suppl): 84-87.

15. Reisfeld R, Nguyen R, Pnini A. Endoscopic thoracic sympathectomy for hyper-hidrosis: experience with both cauterization and clamping methods. Surg Laparosc Endosc Percutan Tech. 2002; 12: 255–67.

16. Shih, CJ, Wu, JJ, and Lin, MT. Autonomic dysfunction in palmar hyperhidrosis. J Auton Nerv Syst. 1983; 8: 33-43.

17. Atkinson, JLD and Fealey, RD. Sympathotomy instead of sympathectomy for palmar hyperhidrosis: minimizing postoperative compensatory hyperhidrosis. Mayo Clin Proc.

2003; 78: 167-172.

18. Singh S, Kaur S, Wilson P. Early experience with endoscopic lumbar sympathectomy for plantar hyperhidrosis. Asian J Endosc Surg. 2016 May; 9(2):128-34.

33

Treatment Focus Rosacea & IPL

@aestheticsgroup

Rosacea and IPL Aesthetic nurse prescriber Shelia Maclean details the symptoms of rosacea and how IPL can be used to treat the condition Rosacea is a condition often misdiagnosed and the causes are sometimes unclear. This is because neither the aetiology, genetics, pathophysiological basis of the vascular, inflammatory nor fibrotic changes are well understood.1 It manifests on the face, especially the cheeks, chin, nose and mid forehead, and although it is not a life threatening condition, it can cause enormous social and psychological problems.2,3 Patients with rosacea have reported a negative burden of their disease, such as low self-esteem, low self-confidence, and decreased social interactions. Improvement of the clinical symptoms of rosacea can improve the patient’s emotional wellbeing and quality of life.4,5 Rosacea is considered incurable due to its genetic connection,6 however, with the use of appropriate treatments, one can give a patient control over this common aesthetic concern.

Aesthetics Journal

Aesthetics

aestheticsjournal.com

There appears to be genetic and environmental factors involved in rosacea; frequently there is a history of family members having the condition. Some of the proposed possibilities are vascular irregularities, facial mites and bacteria, the use of steroids and other environmental factors.16,17 Hormonal imbalances in perimenopausal women may be a causative factor in vascular instability. According to Dr Wilma Bergfeld, head of the clinical research section of the dermatology department at Cleveland Clinic and former president of the American Academy of Dermatology, “it has been widely observed that rosacea is often aggravated at menopause and sometimes during mid-cycle.”18 Studies have suggested a link between Helicobacter pylori infection and rosacea.1920 Another theory is the existence of demodex folliculorum (facial mites) as a possible cause; the mite colonises enlarged sebaceous follicles that are found in rosacea sufferers.

Demodex mites are a natural part of the human microbiome but frequently occur in greater numbers in those with rosacea. There has been much debate as to whether their increased numbers are a cause or result of rosacea.21 Rosacea often flares-up when something causes the blood vessels in the face to expand, which causes redness. Common triggers are exercise, sun and wind exposure, hot weather, stress, spicy foods, alcohol, and hot baths. Swings in temperature from hot to cold or cold to hot can also cause a flare-up of rosacea.22

What is rosacea?

Treatment Rosacea symptoms consist of telangiectasia, erythema papules At the Pulse Light Clinic, our approach to the treatment of rosacea and pustules, and in some situations it can involve the eyes (ocular has evolved over the past ten years and includes state-of-the-art rosacea).7 Rosacea develops gradually; in a survey of 1,391 rosacea intense pulsed light (IPL) technology, and nutritional advice. A rosacea patients conducted by the National Rosacea Society (NRS), 43% of sufferer will often approach a consultation with great trepidation. patients said their rosacea first appeared between the ages of 30 They will most likely have already seen various doctors and have and 50, while 39% reported that the disorder occurred after age 50 had numerous treatments recommended by their GP, all to no and 17% said they developed rosacea prior to age 30.8 Mild episodes of facial blushing or flushing can lead to a permanent red face. Individuals with Different types of rosacea fair skin; particularly those of Scottish, Irish or Celtic descent are more predisposed to rosacea. As such, There are four main types of rosacea:14,15 the condition is commonly known as ‘the curse of the Celts’, although people with darker skin types Subtype 1: Erythematotelangiectatic rosacea can also suffer from it.9 This is the most common subtype and is mainly characterised by facial Rosacea is more common in women than men and erythema, especially at the centre of the face. The patient usually experiences a women often develop it earlier in life.10,11 However, burning feeling and often has flaking and changes to the texture of the skin. the condition is generally more severe in men where changes to the texture of the skin, skin thickening Subtype 2: Papulopustular rosacea and the nose appearing bulbous and enlarged may Accompanied by the redness, skin produces papules or pustules or both, occur, also referred to as rhinophyma.12 It is possible usually in the middle of the face. However, they may also occur around the nose that male hormones contribute to the development and mouth. It may be hard to identify this subtype as the papules or pustules of rhinophyma,13 although there isn’t solid evidence may be hidden by the erythema. to support this. To manage this condition, surgery is often necessary. The aims of surgical treatments are Subtype 3: Phymatous rosacea to remove the excess tissue and restore the natural In this subtype there are skin irregularities, and skin that looks ‘bumpy’ and red. shape of the nose. Additional treatments can reduce One of the most common features is rhinophyma, which is often misidentified the redness of the nose; depending on the severity as, ‘whisky flush’ – a condition linked to alcohol abuse. It can also affect the and extent of the rhinophyma a practitioner may cheeks, ears, and chin. offer dermabrasion or laser.

Subtype 4: Ocular rosacea What causes rosacea?

The person presenting with ocular rosacea will have symptoms caused by The causes of rosacea are not clearly understood. telangiectasia of the conjunctiva and around the eyelids and margins of the eye.

There are several possibilities but there isn’t enough The condition may occur even before there are any symptoms on the skin. evidence to support each theory as conclusive.

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avail. IPL becomes the last resort for many patients, so by the time they approach us they have usually adopted a negative mind-set regarding rosacea treatments. Therefore, it is important to address the emotional distress that the person is feeling. Our duty of care in the first instance is to reassure them that they can be helped. We do this by providing them with up-to-date information on all aspects of rosacea treatments. We then conduct a full assessment of their condition and needs, based on the knowledge and experience we have gained over the past decade. The patient is given detailed information on how IPL works in relation to rosacea. They are shown the different wavelengths used (the range is between 400 nm-1200 nm) and how many passes on the face will be done on each treatment. A package of normally six treatments is suggested, spaced three to four weeks apart. The more severe the rosacea, the more treatments are generally needed for optimal results.

In my experience, sometimes between six and eight treatments are required to achieve maximum clearance of blood vessels and redness. Then, an IPL patch test is conducted. An area of the face, normally the jaw line, is selected for the patch test and each wavelength (chosen by the practitioner based on their knowledge of the patient) is directed on that area for approximately five minutes.

All safety precautions are observed prior to the patch test. The patient is made familiar with the entire IPL procedure, which lasts on average 40 minutes per treatment. The success of IPL is heavily dependent on the skill of the practitioner, their knowledge of the physiology of rosacea and their technical expertise in the delivery of IPL. At our clinic we have evolved a successful IPL technique using different wavelengths of light to address various aspects of the condition, ranging from the vascular components to the facial mites. We customise the wavelength, number of pulses, duration of pulses, delay between pulses, and power delivered to best match the relative depth, size, and absorption characteristics of the targeted blood vessels. As each wavelength is used, the placement of the handpiece crystal on the face is varied throughout the treatment to ensure all vessels are reached. This flexibility and variability allows us to maximise results. Wavelengths are selected according to each individual patient, taking into consideration the subtype of rosacea, the colour of the skin, the calculated depth of the epidermis and location and direction of growth of vessels. These are just some of the factors involved in selecting parameters and wavelengths, which is done at the first consultation and throughout each subsequent treatment session.

We have seen dramatic results in as little as three treatments, where patients have reported the stinging and burning of the face has disappeared. Patients may come for top-up treatments as a preventive measure. We usually recommend once a year, but on occasion we have had patients return after five years with very few symptoms. This type of long-term result was a combination of IPL and nutritional therapy. We work closely with a nutritionist who specialises in rosacea. Each individual sufferer will usually have specific nutritional deficiencies and requirements and should always see a trained nutritionist. Certain minerals and vitamins recommended will include: hyaluronic acid, B vitamins, essential fatty acids, apple cider vinegar and avoiding certain foods.23 When we first began using IPL for rosacea treatment back in 2001, the patient would be advised to allow as much as four days of downtime due to swelling and redness of the face. Sometimes this was accompanied by slight bruising, which would take longer to disappear. However, as technology keeps improving, these after effects became less and less common; hence, today they have almost completely disappeared. Now, any redness

Treatment Focus Rosacea & IPL

will likely dissipate within 20 minutes following treatment. At the Pulse Light Clinic, we use IPL technology that is capable of producing excellent results without any downtime, after-effects or complications that were once associated with IPL. Conclusion The combination of intense pulsed light technology and nutritional therapy is a safe, highly versatile and effective method for the treatment of rosacea. The appropriate use of the wavelengths involved in this technology, coupled with the technical ability and experience of the practitioner, is vital to achieving optimum results.

A mere cosmetic approach to this condition will not suffice, rather years of research, training, expertise and commitment to obtaining long-term results is required and is the benchmark standard for the successful treatment of rosacea.

Shelia Maclean is an aesthetic nurse at the Pulse Light Clinic, which was initially founded in 2000. In 2002, Maclean discovered that IPL had better outcomes in the treatment of rosacea when nutritional therapy was used in combination with it. She developed a precise technique for the treatment of rosacea which evolved as IPL technology became more effective.

REFERENCES 1. Holmes AD and Steinhoff M, Integrative concepts of rosacea pathophysiology, clinical presentation and new therapeutics, Exp Dermatol, (2016) Jul 4.

2. Lynn Drake, Rosacra patients feel effects of their condition in social setting, (2017) National Rosacea Society <https://www.rosacea.org/rr/2012/fall/article_3.php> 3. Leah A Cardwell, Psychological disorders associated with rosacea: Analysis of unscripted comments, (2015) <http://www.sciencedirect.com/science/article/pii/S2352241015000298> 4. Tu T. Huynh, Burden of Disease: The Psychosocial Impact of Rosacea on a Patient’s Quality of Life, Am Health Drug Benefits, (2013) <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4031723/> 5. Barrington, The emotional impact of rosacea is often substantial regardless of subtype or severity, according to results of a new survey of 1,675 rosacea patients conducted by the National Rosacea Society, (2014) 6. Chang AL, Raber I, Xu J, et al, Assessment of the genetic basis of rosacea by genome-wide association study, J Invest Dermatol, (2015), <https://www.ncbi.nlm.nih.gov/pubmed/25695682> 7. Mayo Clinic, Ocular rosacea, (2015) <http://www.mayoclinic.org/diseases-conditions/ocularrosacea/basics/symptoms/con-20035058> 8. Lynne Drake, Survey Dispels Myth That Rosacea Usually Strikes Between 30 and 50, National Rosacea Society, (2007) <https://www.rosacea.org/rr/2006/fall/article_3.php> 9. National Rosacea Society, Where is Rosacea Worst? New Map Shows Geographic Prevalence, (2013) <https://www.rosacea.org/press/where-rosacea-worst-new-map-shows-geographicprevalence> 10. Aloi F, Tomasini C, Soro E, Pippione M: The clinic pathologic spectrum of rhinophyma. Journal of the American Academy of Dermatology. 2000;42:468-472.

11. Wilkin JK: Rosacea: Pathophysiology and treatment. Archives of Dermatology. 1994;130:359-362.

12. Review Clinical, cellular, and molecular aspects in the pathophysiology of rosacea., J Investig Dermatol Symp Proc, (2011) 13. Rohrich RJ, Griffin MD, Adams WP. Rhinophyma: Review and Update. Plastic and Reconstructive Surgery. Vol. 110, No. 3.

14. Wilkin J, Dahl M, Detmar M, et al. Standard grading system for rosacea: report of the National Rosacea Society Expert Committee on the Classification and Staging of Rosacea. Journal of the American Academy of Dermatology. 2004;50(6):907-12.

15. Riversol, Rosacea Treatment: The Complete Guide, (2017) <https://www.riversol.com/pages/ rosacea-treatment#_Toc421800619> 16. Turgut Erdemir A, Gurel MS, Koku Aksu AE, Falay T, Inan Yuksel E, Sarikaya E, Demodex mites in acne rosacea: reflectance confocal microscopic study, Australas J Dermatol. 2016 Mar 11. doi: 10.1111/ajd.12452 17. NHS, Rosacea – Causes, (2017) <http://www.nhs.uk/Conditions/Rosacea/Pages/Causes.aspx> 18. Lynne Drake, Women May Need Added Therapy, Rosacea Review, (2008) <https://www.rosacea. org/rr/2008/winter/article_2.php> 19. Hwan Herr, Chul Hee You, Relationship between Helicobacter pylori and Rosacea: It May Be a Myth, J Korean Med Sci, (2000) <https://pdfs.semanticscholar.org/9ba8/ d24186f92f5343180e14fa6cd81695dc6ef5.pdf> 20. Szlachcic A, The link between Helicobacter pylori infection and rosacea, J Eur Acad Dermatol Venereol, (2002), <https://www.ncbi.nlm.nih.gov/pubmed/12224687> 21. Murillo N, Aubert J, Raoult D. Microbiota of Demodex mites from rosacea patients and controls.

Microb Pathog 2014;71-72:37-40.

22. Canadian Dermatology Association, What can trigger rosacea to flare up? (2017) <http://www. dermatology.ca/skin-hair-nails/skin/rosacea/what-can-trigger-rosacea-to-flare-up/> 23. Pulse Light Clinic, Rosacea and Diet, (2017) <http://www.pulselightclinic.co.uk/rosacea-and-diet>

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How Sleep Affects the Skin Dr Rupert Critchley discusses the impact of sleep on the skin and how sleep deprivation can cause premature ageing It has been reported for years that adults need between seven and eight hours of sleep a night to maintain a healthy mind and body.1 It is also recommended that we should restrict our use of electronic devices 30 to 40 minutes before bed so we don’t confuse the light sensitive cells in our eyes and stop the production of the sleep-promoting hormone, melatonin.2 But many people are guilty of neglecting themselves in the sleep department and letting the pressures of work and play take precedence. In fact, data from the Centers for Disease Control and Prevention (CDC) in the US found that 35.3% of us report sleeping less than seven hours in a 24-hour period, and 37.9% have unintentionally fallen asleep during the day.3 The CDC even considers insufficient sleep a public health problem.4 Fewer hours spent sleeping is detrimental to your physical health and has been linked to serious issues including obesity, diabetes, cancer and immune deficiency, heart disease and depression.4 More recently, sleep deprivation has also been linked to damaging the skin, our bodies’ most important barrier from external stressors such as environmental toxins and sun-induced DNA damage.

Pittsburgh Sleep Quality Index The Pittsburgh Sleep Quality Index (PSQI) is an effective instrument used to measure the quality and patterns of sleep in adults. It differentiates ‘poor’ from ‘good’ sleep quality by measuring seven components: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medications, and daytime dysfunction over the last month.7

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Research surrounding sleep and ageing The link between sleep deprivation and common skin complaints has been suspected for years,5 however, only in a 2013 study at University Hospitals Case Medical Center did scientists find a direct correlation.6 This was the first clinical trial of its kind to evidence such findings.

The study, commissioned by cosmetics and skincare brand Estée Lauder, demonstrated that poor sleepers had increased signs of skin ageing and slower recovery from a variety of environmental stressors.

The study involved 60 women between the ages of 30 and 49, with half falling into the ‘poor quality sleep’ category (according to their average duration of sleep and the Pittsburgh Sleep Quality Index),7 and the other half in the ‘good quality sleep’ category.

Visual skin evaluations were conducted for each participant as well as several non-invasive skin challenge tests, including UV light exposure and skin barrier disruption.

The results indicated significant differences between the skin of the good and poor quality sleepers. Using the SCINEXA skin ageing scoring system,8 poor quality sleepers showed increased signs of intrinsic skin ageing including fine lines, uneven pigmentation, slackening of skin and reduced elasticity.6 Additionally, the study suggested that good quality sleepers recovered quicker from stressors to the skin such as sunburn.

The poor quality sleepers experienced erythema (redness) that remained higher over 72 hours, indicating that inflammation is less efficiently resolved. In another part of the study, participants had a piece of tape stripped from their skin and measurements taken 72 hours later. This skin barrier stressor test showed the recovery of good quality sleepers’ skin was 30% higher than poor quality sleepers (14% repaired vs. 6% repaired), demonstrating their skin’s ability to repair damage more quickly.6

SCINEXA skin ageing scoring system The ‘SCINEXA’ skin ageing test gives a validated score to simultaneously assess and differentiate between intrinsic and extrinsic skin ageing. The written test includes five items indicative of intrinsic skin ageing and 18 items highly characteristic of extrinsic skin ageing. These items are used to define an index that can be used to judge one person’s skin against another, or against an ideal.10

In a completely separate study conducted by Bensons for Beds,11 30 participants were asked to take just six hours sleep for five nights in a row. These participants had their skin tested by a skinimaging system, which measured elements such as spots, pores, red areas, brown spots and bacteria. Supermodel Jodie Kidd took part in the study and found that her pores increased by 56% in number and 83% in visibility; she had 11% more spots, which were 23% more visible; and the bacteria on her skin increased by 65% after the five-night experiment.

The skin’s actual appearance is one concern and the emotional impact of less sleep is another. In the Benson for Beds test, the poorer sleepers had a worse assessment of their own skin and facial appearance, with every single participant agreeing that they felt less attractive and had lower self-esteem after the experiment.

The results suggested that there was a 20% decline in self-esteem

Aesthetics | February 2017

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over the course of the study with participants feeling 33% less attractive at the end of the test. Participants’ perception of how others saw them also declined by as much as 35%.11 Conclusion Just as your body needs food and water, it also needs rest. Sleep is a time for the body to heal, renew and eliminate toxins from the skin. During the hours you spend asleep, your body’s hydration rebalances and there’s a rise in growth hormone as it repairs itself, allowing the skin to recover moisture and for damaged cells to be repaired.12 Reducing the amount of time you sleep to below the recommended seven hours may result in a chain of health issues,4 as well as causing damage to your skin. Not only will your complexion and aesthetic appearance suffer but also the skin’s ability to retain essential moisture and protect you from environmental stressors such as the sun’s rays and everyday pollution.6 To keep our patients’ skin looking and feeling its best, it is advisable that they stick to a healthy routine of between seven and eight hours sleep every night, ban the TV from the bedroom and make sure all night screens are switched off at least 30 minutes before bed.

Dr Rupert Critchley is the lead clinician and director of Viva Skin Clinics and clinical lead at The VIVA Academy Harley Street. After qualifying as a medical doctor in 2009, he has completed an array of courses in advanced non-surgical aesthetics; attained MRCS part A and is also a fully qualified GP. REFERENCES 1. Eric J. Olson MD., ‘How many hours of sleep are enough for good health?’, Mayo Clinic, (2016) <http:// www.mayoclinic.org/healthy-lifestyle/adult-health/expert-answers/how-many-hours-of-sleep-areenough/faq-20057898> 2. Dr Mercola, ‘Melatonin Regulates Our Cycles, Mood, Reproduction, Weight and May Help Combat Cancer’, Mercola.com (2013) <http://articles.mercola.com/sites/articles/archive/2013/10/10/melatonin. aspx> 3. Anon, ‘Insufficient Sleep Is a Public Health Problem,’ Centers for Disease Control and Prevention, (2015) <https://www.cdc.gov/features/dssleep/> 4. HR Colten and BM Altevogt, ‘Sleep Disorders and Sleep Deprivation’, National Academies Press, (2006) <https://www.ncbi.nlm.nih.gov/books/NBK19960/> 5. A. Kalsbeek, Eric Fliers, Michel A. Hofman, D.F. Swaab, Eus JW Van Someren, R.M. Buijs, Hypothalamic Integration of Energy Metabolism (Royal Netherlands Academy of Arts and Sciences, Elsevier, 2005), 318 – 321 6. ‘Esteé Lauder Clinical Trial Finds Link between Sleep Deprivation and Skin Aging’, University Hospitals, (2013), <http://www.uhhospitals.org/about/media-news-room/current-news/2013/07/esteelauder-clinical-trial-finds-link-between-sleep-deprivation-and-skin-aging> 7. Pittsburgh Sleep Quality Index form, PDF, <http://www.psychiatry.pitt.edu/sites/default/files/pageimages/PSQI_Instrument.pdf> 8. Buysse, DJ, Reynolds, CF, Monk, TH, Berman, SR, & Kupfer, DJ, ‘The Pittsburgh Sleep Quality Index (PSQI): A new instrument for psychiatric research and practice’, Psychiatry Research, 28(1989), pp.193-213.

9. Vierkötter A, Ranft U, Krämer U, Sugiri D, Reimann V, Krutmann J, ‘The SCINEXA: a novel, validated score to simultaneously assess and differentiate between intrinsic and extrinsic skin ageing’, J Dermatol Sci, (2008), pp.207-211.

10. Andrea Vierkötter, Tamara Schikowski, Ulrich Ranft, Airborne Particle Exposure and Extrinsic Skin Aging (Research Gate, 2010) <https://www.researchgate.net/figure/45389494_fig1_Figure-2-Appliedskin-aging-score-on-the-basis-of-SCINEXA-score-of-intrinsic-and> 11. Dr. Guy Meadows, Does sleep deprivation have any impact on our appearance? (Benson for Beds, 2015) <http://www.bensonsforbeds.co.uk/sleep-school/does-sleep-deprivation-have-any-impact-onour-appearance/> 12. Sanghee Chon, Ayurvedic Management of Sleep Disorders (Path to Ayuvedic, 2012) <http://www. pathtoayurveda.com/ayurvedic-management-of-sleep-disorders/> [Accessed November, 2016]

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39

CHEEKS Cheeks: Loss of fat can lead to a reduction of volume in the cheeks, giving a sunken appearance.

NOSE/ MOUTH FOLD Nose/Mouth Fold: Over time, the skin of our cheeks may drape or sag over the line between the nose and mouth (nasolabial line) to become a fold, which creates a tired look to the face.

TIRED EYES Tired Eyes: Ageing can lead to volume loss in the lower eyelid, accentuating tear troughs and giving the appearance of dark circles under the eyes.

LIPS Lips: Our lips lose definition and fullness over time - treatment can help enhance and balance this area.

Thin to Full

RES/032/0714(2)a Date of preparation May 2016

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Clinical Practice Filler Doses

similar in many ways to the ‘marionette’ lines and folds (Figure 2).

They are both formed when, through the natural ageing process, the central part of the face loses soft-tissue volume whilst the fat pads (Figure 3) from the lateral parts of the face, thin and drop downwards due to changes in the adipose tissue and a loss of elasticity in the demis.2 So, back to the original question: ‘how much filler should we use?’

Firstly, there is a facetious answer; ‘how long is a piece of string?’

There is also the more subtle, counter-question; ‘how deep are the lines?’ There is no point in helping a patient achieve the nasolabial lines of a 20-year-old if the rest of their face looks like that of a 50-year-old; balance is important when considering beautifying the face. There are many factors to consider and the decision as to how much filler to use usually needs to be made before the treatment has begun because it typically involves a complex balance between patient expectations, practitioner experience and patient budget.

Dermal Filler Doses

Technique

Dr Michael Aicken considers quantities of filler in the treatment of nasolabial and marionette lines With treatments such as botulinum toxin, there are standard injection doses that most practitioners use as their starting point and that are recommended according to the type of product.1 Noting the top-up dose required makes botulinum toxin dosing relatively straightforward. But with dermal filler, we don’t tend to have ‘standard’ doses as both the desired outcome of treatment and the volume of filler required to achieve that desired outcome can vary greatly between patients. Because of this, in the training courses I run, I often suggest that botulinum toxin administration is more ‘scientific’, whereas dermal filler treatments are more of an ‘artform’. So, how do I answer the common question, ‘how much filler should I use?’ In this article, I will address this very question regarding nasolabial folds and marionette lines, discussing one of many techniques for both, based upon my own clinical experience.

What causes nasolabial folds and marionettes lines?

The ‘nasolabial’ or ‘nose-to-mouth’ lines and folds (Figure 1) are

There are a few issues to deal with when treating the nasolabial and marionette lines with dermal filler. The first is volume loss and the second is folds. Here, we’ll discuss each in turn.

Volume loss The shadow cast by the step down from the more elevated lateral face, to the relatively less elevated medial face, causes the dark line that we notice whenever someone has nasolabial or marionette lines.2 Reduction of these ‘steps’ with dermal filler will reduce the shadow and therefore the appearance of the lines themselves. The process is virtually the same with nasolabials and with marionettes.

How can we achieve this?

There are two possible techniques: bolus injections – best given at the proximal end where there tends to be the greatest volume loss – and linear injections – given either deeply or superficially along the lines themselves.5 When injecting, always ensure that filler is not injected above or lateral to the lines, as doing so would potentially increase this shadowing effect by increasing the size of the step indicated in Figure 4. Think of the nasolabial or marionette line as a comet (Figure 1), with the top end, where we administer bolus injections as the ‘head’ of the comet and the rest of the lines, where we use linear injections, as the ‘tail’ of the Middle forehead compartment

Before

Central forehead compartment Superior orbital compartment Inferior orbital compartment Nasolabial compartment After

Medial cheek compartment Lateral orbital compartment Lateral temporal-cheek compartment Middle cheek compartment

Figure 1: Think of the nasolabial or marionette line as a comet – the nasolabial fold consists of the ‘head’ and the ‘tail’ of the comet

Figure 2: Before and after images taken 10 minutes apart, showing 1ml of dermal filler injected into the marionette lines. There was a combination of small folds as well as volume loss present; these have both been treated successfully.

Aesthetics | February 2017

Figure 3: The facial fat pads, which slide down and contribute to the nasolabial and marionette folds with increasing age.3,4

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Light Source

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Light Source

by ed eat ller t cr al Fi f i L rm De

ow ad Sh Lateral Face

Lateral Face

Medial Face

Medial Face

Figure 4: The role of dermal filler in reducing the shadow that light casts as it shines across from the lateral to the medial face

comet. When deciding upon how much filler to use, as a rule-ofthumb, I start by giving around half of the total volume into the head and then seeing how much of an improvement is achieved before deciding how to use the remainder. So, if we have decided to use 1ml in total for both the nasolabial folds, I’d begin with injecting 0.2ml into each ‘comet head’ for starters. The remainder will be administered during the same procedure, using any combination of deep linear, superficial linear, cross-hatching (see below) or further bolus injections into the comet head.6 Folds ‘Folds’ are the overhanging part of the nasolabials and marionettes. Not everyone who has lines has folds and potentially, someone might have folds and not an underlying line, but generally, folds come after the development of lines. I use the ‘cross-hatching’ technique – this is when filler is injected perpendicular to the direction of the fold.6 It’s a principle borrowed from engineering, known as ‘bracing’.7 Lines of filler can hold and support the tissue they are injected into, reducing the amount of unwanted movement in that tissue. Cross-hatching therefore, can also be used for lines elsewhere on the face, which are more pronounced with movement, such as perioral lines and lateral forehead lines. Obviously we don’t want to see lines of filler through the skin, so these injections are generally given a little deeper within the dermis than those of the linear injections mentioned above. If we can see the lines however, I have found that it is easy to remedy this by applying gentle pressure to the lines at the time of treatment. My general rule is that as each line of cross-hatching increases, the larger the volume in each line and the closer together the lines become. Also, the thicker the product, the stronger the cross-hatching will be at withholding the pressures applied to it, such as gravity of facial muscle movement.

Product selection I recommend using a firmer/thicker cross-linked hyaluronic acid gel filler for marionettes/nasolabial lines, where it is important to withstand the effects of gravity. Some examples of fillers you could use include Dermal Revolution DEEP, Belotero Plus Intense, Restylane Perlane or Juvéderm Ultra 4. Although product should last nine to 12 months according to most manufacturers, in my experience, they seem to last much longer when injected into the nasolabial folds and almost as long in the marionette folds area. Often I find that whilst someone may require 2-4ml for deep 42

nasolabial lines the first time around, when they return a year or more later, they might only require 1-2ml to keep the lines at bay.

I believe that this could possibly be because the nasolabial folds are well protected by the zygomatic arch, chin and the nose from pressure applied inadvertently to the face, for example, whilst sleeping.8

Complications Of course, no treatment is without risk. Bolus injections particularly should be administered slowly and only after aspirating the syringe.

Anytime the needle tip is moved, the injector should aspirate again.

This technique of regular aspiration should, in theory, reduce the risk of serious complications of dermal filler use, such as blindness and skin ischaemia.3 Although, there are some who dispute this because of the inability of some practitioners to accurately control the location of the needle tip or due to the collapsibility of some blood vessels whenever aspiration pressure is applied.3

My process So, what’s the answer? How much filler should you use when treating nasolabial and marionette lines? Here’s my thought process: • What is the patient’s budget? If they haven’t told me outright, I’ll need to sensitively find out.

• What are their treatment priorities? Is it their nasolabials and their marionettes in general, or is it just one side or one line?

• What can I realistically expect to achieve with the treatment provided?

It can be awkward discussing budgets and treatment priorities, especially when some patients will expect you to perform miracles with tiny budgets, but it’s far more uncomfortable to end up with an unhappy patient who has spent several months saving for a treatment, which they don’t see as giving any significant benefit.

As we all know, we don’t always have a budget in mind when we enquire about a service, so it can be a sensitive question to be asked outright. Most of us will be prepared to pay more for a better quality product or service, but we would need to have some confidence that it will be worth it.

For addressing budgets, my suggestion is that if the patient states outright that they have only X amount to spend (e.g the cost of 1ml dermal filler), and they would like both their nasolabial and

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marionettes areas treated, I recommend that you focus on the area that bothers them the most and consider what you can realistically expect to achieve with a certain amount of filler. For example, you might say, ‘I’m not sure that you’ll see a significant result with just 1ml but with 2ml you should see a real difference – but I do recommend that we use the full amount I‘ve quoted so that you can see the best results possible.’ I urge them to choose between the nasolabials and marionettes and we decide together to treat that area within their budget. It is far better for them and for your repeat business that you do a good job on a focused area rather than doing a minimally impressive job on many areas. Of course, we have to be careful that in advising this, we don’t cause an unnatural imbalance in the facial features – but for many patients, there will be a single problem area, which if corrected effectively, will give an excellent overall improvement in their appearance.

Summary

Clinical Practice Filler Doses

Dr Michael Aicken graduated in 2006 from the University of Aberdeen with a degree in medicine and a bachelor of medical sciences. Dr Aicken established Visage Academy and has also been involved in the development of an aesthetic clinic management app.

REFERENCES 1. ‘Highlights of Prescribing Information,’ Allergan, (2016) <http://www.allergan.com/assets/pdf/botox_ pi.pdf> 2. Guyuron B &Michelow B, ‘The nasolabial fold: a challenge, a solution’, Plast Reconstr Surg, 93(1994) pp.522-9 <https://www.ncbi.nlm.nih.gov/pubmed/8115507> 3. Kenneth Beer, ‘Avoiding Complications with Fillers’, The Dermatologist, 22(2014) <http://www.thedermatologist.com/content/avoiding-complications-fillers> 4. McCleve DE, Goldstein JC, ‘Blindness secondary to injections in the nose, mouth, and face: Cause and prevention’, Ear Nose Throat J, 74(1995) pp.182–188.

5. Maya Vedamurthy and Amar Vedamurthy, Dermal Fillers: Tips to Achieve Successful Outcomes, J Cutan Aesthet Surg, 1(2008), pp.64-67 <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2840909/ 6. CM Burgess, PA Moynahan, ‘Dermal Filler Injection Technique – Perspectives From a Plastic Surgeon and a Dermatologist: An Expert Interview With Paula Moynahan, MD, and Cheryl M. Burgess, MD’, Medscape, () < http://www.medscape.org/viewarticle/709469_2> 7. Engineering Dictionary, ‘Bracing’ (2009) <http://www.engineering-dictionary.org/NCRS-ConstructionDictionary/BRACING> 8. Babak Jahan-Parwar, Keith Blackwell, ‘Facial Bone Anatomy’, Medscape, (2013) <http://emedicine. medscape.com/article/835401-overview>

It is important to consider technique(s), line depths and patient budget when determining filler dosage. Practitioners should focus on areas of primary concern first to ensure maximum results. It’s the ‘wow-factor’ that brings patients back and entices them to tell their friends what they’ve had done and it is this same factor that makes patients satisfied that they made a wise decision in choosing you as their practitioner.

Disclosure: Dermal Revolution is owned by Visage Aesthetics UK LTD, of which Dr Aicken is the managing director.

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The Impact of Winter on the Skin Aesthetic nurse prescriber Sylvia Chrzanowska discusses the adverse effects of the winter season on skin conditions and outlines non-surgical treatments to combat these aesthetic concerns Season and climatic changes can affect the skin and exacerbate some existing skin conditions. The extremes of temperature experienced in the summer and winter months can be difficult for the 54% of UK residents who suffer from conditions affecting the skin, as according to a study in 2013 on the psychological and social impact of skin disease on people’s lives.1 It is generally known that excessive sweat, UV light, wind and cold can aggravate skin that is already dry, cracked and inflamed.2 Add to this a change in diet, increased layers of clothing, the necessity for protective emollients such as aqueous cream BP or corticosteroids, and frequent temperature variance from outdoors to indoors, and this can exacerbate conditions that already react poorly to even the mildest disruption in routine.3 While the summer can be the worst time of the year for those who experience bouts of rosacea,4 the winter months bring their own challenges. For those with eczema, psoriasis and acne, the colder months can be particularly problematic.5 This article will address how these conditions react to weather typical in winter and outline some practical steps that can be taken to reduce the worst of the effects. It will also explore some of the non-invasive aesthetic treatments currently on the market that can be used to treat and reduce the adverse influence of winter weather on skin conditions such as eczema, psoriasis and acne.

Cold weather and effects Cold weather, especially cold wind during these periods, combined with increased use of central heating has a drying effect on the skin.3 Even people with ‘normal’ skin will notice this change – perhaps experiencing red cheeks, taut skin and cracked lips. For people with dry skin conditions, the change can often be enough to cause increased incidences of flare-ups.6 Cold air tightens the skin’s pores and reduces blood circulation.7 This reduces the naturally occurring oil known as sebum, which acts as a protective layer and traps moisture next to the skin.8 With humidity in the air lower during winter, the cumulative effect is that skin starts to dry out. This can aggravate existing conditions that already make the skin prone to cracking and flaking.9

Skin conditions commonly affected by cold weather Acne is the result of hair follicles becoming blocked with dead skin cells and sebum. Bacterial infection in these blocked pores results in the appearance of small cyst-like pimples. As the sebaceous oil that protects the skin is reduced during winter, this allows bacteria

Clinical Focus Winter Skin

to enter the pores easily, resulting in outbreaks.10 Other skin conditions such as eczema, psoriasis and rosacea are associated with dry, flaky skin caused by the body’s allergy and inflammatory responses.11 Though many forms of eczema are a response to exogenous stimuli that can be managed or avoided, atopic eczema, also known as atopic dermatitis, is a congenital disease which reacts particularly badly to cold weather due to the previously mentioned problems associated with winter.12,13 In my experience, sufferers generally complain of increased irritation in the affected areas, along with expanded areas of dryness and inflammation.

Prevention The most important thing that sufferers can do during periods of cold weather is avoid the ‘triggers’ that are known to exacerbate their condition. Winter is not the only irritant for skin conditions, other common irritants that may trigger or aggravate the skin include certain foods, some chemicals, perfumes and sprays, animals and dust.19,20 It is important for patients to take steps to avoid these ‘triggers’ and potential flare-ups to the aforementioned skin conditions by making simple changes to their daily routine.

Realistically, this will mean a reduction in exposure to the previously identified irritants, rather than a complete avoidance.

Steps to reduce exposure to irritants I would recommend advising patients of the following steps that may be employed to lessen the effects of winter weather on common skin conditions, which include: • Turning the heating to the lowest setting when indoors and wearing extra clothing to compensate.

• Limiting exposure to hot/dry environments such as air-conditioned rooms and cars, or rooms containing open fires or wood-burning stoves as these can all further dry out the skin.

• Omega 3 and 6 oils have been found to play a role in reducing inflammation. Many sufferers say they see a marked improvement when eating foods rich in such oils, and make a point of adjusting their diet during the winter months to take this into account.14 • Drinking plenty of water, since a lot of moisture is lost through dry skin (because the skin barrier is not working properly). Each person is different, but a conscious effort should be made to drink water with every meal and throughout the day.

• Using fabric material that does not ‘catch’ against the skin. Pillow cases and under garments made of silk are not only soft and less irritating, they also don’t steal moisture from the skin like cotton articles tend to. 15 • Avoiding hot baths and showers at all cost, instead opt to use warm baths and showers. Hot water strips what little oils there are on the skin.16

Treatments There are a number of non-surgical treatments that can be used to repair weather-damaged skin, which are outlined below.

IPL and laser treatments Intense pulsed light (IPL) systems can treat a variety of benign skin conditions such as rosacea and chronic erythema.19 A study in the journal Science states that: ‘Individual light pulses have a specific duration, intensity, and spectral distribution allowing for a controlled and confined energy delivery into tissue. IPL used in dermatology relies on the basis that certain targets for energy absorption

Aesthetics | February 2017

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(chromophores) are capable of absorbing energy from this broad spectrum of light wavelength (absorptive band) without exclusively being targeted by their highest absorption peak. The working basis of the IPL rests on the principle of selective photothermolysis, in which thermally mediated radiation damage is confined to chosen epidermal and/or dermal pigmented targets at the cellular or tissue structural levels.’20 The process works by contracting blood vessels, making them less visible, as well as boosting the production of younger healthier skin.21 Treatment for seasonal acne, especially adult acne, depends on the severity. Non-surgical solutions in the form of laser treatments can help to produce a noticeable difference to skin tone, texture and radiance. Porphyrins that reduce the growth of bacteria known as P.acnes can be activated through the absorption of red and blue light.21 Sebaceous gland size and/or function can also be impaired when the blood vessels supplying sebaceous glands are damaged because endogenous chromophores in the skin absorb broad-spectrum light produced by IPL.21 Possible drawbacks of such treatment include itching and redness of the targeted site, a change of skin colour, either darker or lighter, and possible infection.

Microneedling Another technique, designed to stimulate poor-quality skin so that it regenerates and repairs itself naturally, is known as microneedling or ‘collagen induction therapy’. The principle behind microneedling is the artificial creation of collagen through the stimulation of certain growth factors.24 The treatment forms micro-channels in the dermis that trigger the production of platelet derived growth factor (PGF), fibroblast growth factor (FGF) and transforming growth factor alpha and beta in order to heal the wounds by promoting collagen deposition.25 Cosmeceuticals While non-surgical treatments can help to stimulate collagen within the skin to repair itself and rejuvenate, these skin improvements can be further enhanced by cosmeceutical skincare ranges.

Cosmeceutical products that contain higher concentrations of active ingredients that feed, nourish and thicken the skin, such as topical vitamin C serum and vitamin A, improve the quality of the skin and work in synergy with in-clinic treatments.28,29 This form of cosmeceutical skincare is applied topically and can penetrate deeper into the skin where the collagen, elastin and cellular activity take place.30 In addition, other topical treatments such as doxycycline, ivermectin, azelaic acid, brimonidine and isotretinoin have been found to reduce the effects of acne and rosacea.29

Conclusion Winter is clearly a difficult time for those with skin conditions.

However, by combining practical steps and with the use of additional non-surgical cosmetic treatments, you can advise patients that this season does not have to be a jail sentence of prolonged misery.

For those people who suffer badly in cold weather, pre-emptive courses of non-invasive cosmetic treatments are an excellent way of tackling the problem before it begins. By staying prepared, those suffering from skin conditions cannot only manage them effectively, they can make the most out of the winter season.

Clinical Focus Winter Skin

Sylvia Chrzanowska qualified as an RGN in 1999 and became a medical aesthetic nurse in 2004. She has been working at the forefront of advanced non-surgical treatments for more than 10 years and has been based at the Cosmetic Skin Clinic in Buckinghamshire since 2014 as a senior aesthetic nurse prescriber.

REFERENCES 1. All Party Parliamentary Group on Skin, The Psychological and Social Impact of Skin Disease on People’s Lives, 2013 <https://www.appgs.co.uk/publication/view/the-psychological-and-socialimpact-of-skin-diseases-on-peoples-lives-final-report-2013/> 2. John Fuller, Eczema and Exercise, National Eczema Association <https://nationaleczema.org/ eczema-exercise/> 3. National Eczema Society, Household Irritants Fact sheet, 2015. <www.eczema.org/downloadeczemafactsheets---home-environment> 4. National Rosacea Society, Changing Seasons Can Trigger Flare-Ups, Survey Shows, 2014 <https:// www.rosacea.org/weblog/changing-seasons-can-trigger-%E2%80%A8flare-ups-survey-shows> 5. Vanessa Lindsay Pascoe, MD, Alexandra Boer Kimball, MD, MPH, ‘Seasonal variation of acne and psoriasis: A 3-year study using the Physician Global Assessment severity scale’, Journal of the American Academy of Dermatology, 2015 <http://www.jaad.org/article/S0190-9622(15)01740-5/ abstract> 6. Uter W, Gefeller O, Schwanitz HJ, ‘An epidemiological study of the influence of season (cold and dry air) on the occurrence of irritant skin changes of the hands’ British Journal of Dermatology, 1998, https://www.ncbi.nlm.nih.gov/pubmed/9602872, 266-72.

7. ‘Out in the cold’, Harvard Health Publications Harvard Medical School, 2010 <http://www.health. harvard.edu/staying-healthy/out-in-the-cold> 8. Dr Amanda Oakley Dermatologist & Vanessa Ngan, ‘Sebum’ Dermatology Education New Zealand, 2014 <http://www.dermnetnz.org/topics/sebum/> 9. Nina Goad, Professor David J Gawkrodger, The impact of ambient humidity on healthy and diseased skin, 2015<https://www.skinhealthalliance.org/wp-content/uploads/2016/02/ theimpactofambienthumidityonhealthyanddiseasedskin.pdf> 10. ‘Acne’ Mayo Clinic, 2015 http://www.mayoclinic.org/diseases-conditions/acne/basics/causes/con20020580 11. ‘Inflammation’ DermaMedics Professional <http://www.dermamedics.com/inflammation_id55.html> 12. ‘Atopic eczema’, NHS Choices, 2016 <http://www.nhs.uk/conditions/Eczema-(atopic)/Pages/ Introduction.aspx> 13. Dr Tony Woolfson & Professor Ian White, ‘Ministry of Defence Synopsis of Causation Dermatitis (Eczema) including Occupational Dermatitis’ Ministry of Defence, 2008 <https://www.gov.uk/ government/uploads/system/uploads/attachment_data/file/384493/dermatitis.pdf> 14. C. Anandan & U. Nurmatov, et al., ‘Omega 3 and 6 oils for primary prevention of allergic disease: systematic review and meta-analysis’, European Journal of Allergy and Clinical Immunology, 2009 <http://onlinelibrary.wiley.com/doi/10.1111/j.1398-9995.2009.02042.x/full> 15. Ian Peate, ‘Caring for people with eczema’, IndependentNurse, 2013 <http://www.independentnurse. co.uk/clinical-article/caring-for-people-with-eczema/63475/> 16. ‘Fighting back against dry skin’ WebMD Medical Reference, 2016 <http://www.webmd.com/beauty/ dry-skin-13/cosmetic-procedures-skin-care-dry-skin 17. ‘What you eat can fuel or cool inflammation’ Harvard Health Publications Harvard Medical School, 2007 <http://www.health.harvard.edu/staying-healthy/what-you-eat-can-fuel-or-cool-inflammation-akey-driver-of-heart-disease-diabetes-and-other-chronic-conditions> 18. ‘Glycemic index and glycemic load for 100+ foods’ Harvard Health Publications Harvard Medical School, 2015) <http://www.health.harvard.edu/diseases-and-conditions/glycemic_index_and_ glycemic_load_for_100_foods> 19. Levy JL. M.D, ‘Intense Pulsed Light Treatment for Chronic Facial Erythema of Systemic Lupus Erythematosus: A Case Report’, Journal of Cutaneous Laser Therapy, 2000; Vol. 2, pp. 195-198 <https://www.ncbi.nlm.nih.gov/pubmed/11350676> 20. Anderson RR, Parrish JA, ‘Selective photothermolysis: precise microsurgery by selective absorption of pulsed radiation’ Science, 1983) 220(4596) pp. 524-7 <https://www.ncbi.nlm.nih.gov/ pubmed/6836297> 21. Lee S Y $ You C E et al., ‘Blue and red light combination LED phototherapy for acne vulgaris in patients with skin phototype IV’ Lasers in Surgery and Medicine, 2007, 39(2) pp.180-8 <https://www. ncbi.nlm.nih.gov/pubmed/17111415> 22. Raulin C, M.D., Greve B, M.D., Grema H, M.D, ‘IPL Technology: A Review’, Lasers in Surgery and Medicine, 2003; Vol. 32, 78-87 <https://www.ncbi.nlm.nih.gov/pubmed/12561039>Imran Majid, Gousia Sheikh, Microneedling and its applications in dermatology, PRIME, 2014 <https://www.primejournal.com/microneedling-and-its-applications-in-dermatology/> 23. Ali MM, Porter RM, Gonzalez ML, ‘Intense pulsed light enhances transforming growth factor beta1/ Smad3 signaling in acne-prone skin’ Journal of Cosmetic Dermatology, 2013 12(3) pp. 195-203 <https://www.ncbi.nlm.nih.gov/pubmed/23992161> 24. Imran Majid, Gousia Sheikh, Microneedling and its applications in dermatology, PRIME, 2014 <https:// www.prime-journal.com/microneedling-and-its-applications-in-dermatology/> 25. Fabbrocini G, De Vita V, Monfrecola A, De Padova MP, et al. ‘Percutaneous collagen induction: an effective and safe treatment for post-acne scarring in different skin phototypes’ Journal of Dermatology Treatment,2014; 25(2): pp. 147–52 <https://www.ncbi.nlm.nih.gov/pubmed/23216209> 26. Jih MH, Kimyai-Asadi A, ‘Fractional photothermolysis: a review and update’ Seminars in Cutaneous Medicine and Surgery, 2008) 27, pp.63–71 <https://www.ncbi.nlm.nih.gov/pubmed/18486026> 27. Cohen BE, Elbuluk N, ‘Microneedling in skin of color: A review of uses and efficacy’, J Am Acad of Dermato, 74 (2016) <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4976400/>, 348–55 28. Alexander J. Michels, Ph.D, Vitamin C and Skin Health (Oregon State University) <http://lpi. oregonstate.edu/mic/health-disease/skin-health/vitamin-C> 29. Reza Kafi & Heh Shin R. Kwak et al., ‘Improvement of Naturally Aged Skin With Vitamin A (Retinol)’ Archives of Dermatoogy, 2006 &lt; https://www.lifecellcream.com/University%20Ingredient%20 Study%20Report.pdf> 30. Esther J van Zuuren & Zbys Fedorowicz et al., ‘Interventions for rosacea‘, Cochrane Library, 2015 &lt;http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003262.pub5/full>

Aesthetics | February 2017

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Chemical Peeling Biochemist and clinical trial co-ordinator Peter Roberts explains how different chemical peel ingredients can effectively treat common facial skin concerns Chemical peels have made somewhat of a comeback in the past few years. There used to be more concern amongst practitioners about the effects of harsh ingredients in the peels, leading many to err on the side of caution. Around the same time, a variety of lasers started to come on to the market and peels were seen as less favourable.

However, more recently, rather than being predominantly utilised for their exfoliating properties and influence on collagen matrix turnover, peels are being used to achieve significant results in common skin concerns.

There are many chemical agents available for skin peeling due to the advent of new ‘carrier’ systems,1,2,3,4,5 which vary in impact from exfoliators to deep skin re-modellers, through to treatments for acne, rosacea, lines and wrinkles, pigmentation and stretch marks. Used properly, I believe they can have substantial effects comparable to lasers and radiofrequency, and are far less likely to cause post-inflammatory hyperpigmentation (PIH).

In this article, I shall discuss the different types of peeling agents and the results that can be achieved.

Treating the skin with peeling agents The newly developed carrier solutions take the acids and associated treatment ingredients (protected from degradation by the acid by the carrier solution) across the stratum corneum and deep into the skin before being released to target skin concerns.

I recommend all peels are used in conjunction with creams – pre, post and in between peel treatments – which contain the same ingredients as those held in the peels. The peels will therefore boost activity of the creams.1,2,3,4,5 Below are some case study examples of multiple skin conditions that patients may present with and the appropriate peel treatments: Case study 1: Patient A • Sun damage • Dark and puffy under eye

• Reddening prone to rosacea • Spots and acne

Patient A has sun damage on the forehead, is prone to reddening and has some intermittent or permanent redness/vascularity in the central portion of the face. She also has recurrent outbreaks of spots around the chin and has dark and puffy areas under the eye – a delicate area of skin that needs a different approach. I would use specific solutions best suited to each of the above indications, rather than a ‘cocktail’ peel or glycolic acid. Glycolic acid is a general-purpose acid, it’s not lipophilic, and I believe other acids have better properties for specific skin issues. One might argue, if a patient had various skin issues in different areas of the face, that a ‘cocktail’ peel, i.e. a peel with multiple acid or peeling ingredients, may be ideal; but each acid in the cocktail will be applied to all areas of the face and some may have a negative effect on some of the skin issues mentioned, while being positive in others. The ‘cocktail’ combination could cause increased pigmentation on the forehead as well as exacerbate the central area and increase erythema and redness.

The diagram below represents a preferred choice of peels for Patient A. Please note that this is for a patient whereby we have assessed them for risk issues, such as skin ethnicities, dehydration and trans epidermal water loss (TEWL) issues, and found them to be low risk.

Mandelic acid is better for erythema control, salicylic better for oil reduction, Jessner’s (resorcinol, lactic and salicylic acid), is better for sun damage. Glycolic would not be my choice for any of these.9,10 Case study 2: Patient B (Fitzpatrick 2) • Wrinkles • Dark and puffy under eyes • Poor skin tone and sagging jaw line • Sallow skin and open pores

These indications are commonly presented and would all respond to a variety of different individual solutions. My preferred choice would be to use pyruvic acid, which is an alpha keto acid, on all facial areas, whereby the pyruvic acid is applied for one to three minutes, and depending on skin type and discomfort scores, I would consider a second layer for a further two minutes and then neutralise.

Around the eye I would suggest a lactic acid (tyrosinase inhibitor) and a resorcinol (preferential substrate for tyrosinase)-based multi layered gel. The number of layers applied would depend on skin sensitivity and PIH risk. Each layer would be applied for one to

Case Study 1

Case Study 2

Skin conditions

Treatments

Sun damage

Jessner or Mandelic - depending on ethnicity, Fitz type, skin history

Dark and puffy under eye Reddening prone to rosacea

Spots and acne

Ingredient Focus Chemical Peels

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Lactic Acid/ Resorcinol and Alpha bisobiol Mandelic Salicylic Acid / possibly Pyruvic

Skin conditions

Treatments

Wrinkles

Pyruvic Lactic

Dark and puffy under eyes Pyruvic Sallow skin and open pores Poor skin tone/ sagging jaw line

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Pyruvic

Fitzpatrick skin types 1-3, low PIH risk and good skin hydration

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two minutes before the next one, and the last layer would be applied for up to five minutes, before the gel is wiped away and the area neutralised.

Both of these substances are tyrosinase-influencing and support a reduction in pigmentation manufacture.1,2 It is important to maintain levels of resorcinol containing creams going forward to continue to divert the tyrosinase away from melanin manufacture.

Patient B (Fitzpatrick IV-VI/skin problems) Mandelic Although you may see many patients with the exact same skin problems, it is not possible Mandelic to treat everyone with the same solution. The patient’s Mandelic skin sensitivity, Fitzpatrick skin type, ethnicity, and the Mandelic severity of photo damage and wrinkles, should all be taken into consideration. The choice of Fitzpatrick skin types 4-6, higher PIH agent will also vary depending risk and good skin hydration on whether the patient has good skin moisture levels; for example, a high rate of TEWL coupled with low hydration may indicate poor lipid density, and this may lead to a higher sensitivity to the remodelling agent and increase risk of adverse events such as erythema and PIH. In this situation, I may revert to using a sequence of mandelic acid peels. The results may take longer to achieve but I would be mitigating for increased PIH risks.

Case Study 3

Skin considerations As mentioned, certain aspects should be taken into consideration before using any chemical peel.

Skin ethnicity Patients with a mixed race background, who, for example, have a Celtic mother and an Arab father, where the patient may be a Fitzpatrick type 1, 2, 3 or 4, are traditionally assessed and treated as the darker parent would have been regardless of their Fitzpatrick type. This is because of concern about the level of inflammation the peel may cause and the risk of post treatment pigmentation increase.

However, there is good data to suggest this may not be the most appropriate course of action. Fabil Fanous defined that facial features were more important than skin colour in determining PIH risk in mixed race patients. In simple terms, PIH risk is based on which parent the patient looked most like, irrespective of skin colour.7 For example, Celtic skin has high erythema sensitivity whereas Arab skin has a high PIH risk. The offspring and patient with this mixed ethnic background may have the same Fitzpatrick skin type as a southern European; but the patient would be treated differently and the choice would be based on facial features not just Fitzpatrick type.

If their features looked like the Celtic parent, then their PIH risk would be lower. Ultimately, one size does not fit all. You need to ensure you do not cause long-term damage when treating the various skin types with peels, as you would with lasers.

Below is a useful table from the Fanous study:

Phototype

Description

Phototype 1

Subjects with very pale skin, often with freckles, blond or red hair, blue or grey eyes. They generally develop obvious erythema on any unprotected exposure to the sun. tanning is very slight or nonexistent. There is extreme reaction to the sun’s rays, with high risk of permanent damage.

Phototype 2

Subjects with pale skin, dark blond or light brown hair. They tend to get sunburnt easily. They develop a light (golden) tan.

Phototype 3

Subjects with fairly dark skin, brown hair. They only get sunburnt after prolonged exposure. They develop a deep, even tan.

Phototype 4

Subjects with olive complexion, dark eyes and black hair. They rarely get sunburnt. They quickly develop a very deep, chocolate-coloured tan.

Phototype 5

Subjects with very dark complexion dark eyes and black hair. They very rarely get sunburnt.

Prototype 6

Subjects with black complexion, dark eyes and black hair.

Figure 1: Fitzpatrick skin type classifications

propensity for photodamage. This relates to their likely risk level and response when exposed to skin challenging procedures.11 For facial chemical peels, this classification can also be used to define the risk of pigmentary changes (e.g. dyschromia, post inflammatory hyperpigmentation, permanent hypopigmentation) and erythema when using resurfacing procedures.

Glogau scale The Glogau scale of photoageing consists of four age-range levels where each level is defined by describing how a typical person’s skin would appear in that age range and what visible symptoms they would typically manifest. Depending on the level of ageing, the depth and degree of treatment to the skin may need to be modified. More challenging skin concerns would traditionally need more of the same agent and also possibly for a longer exposure time; this would result in more trauma. An alternative approach is to expose the patient’s skin to either a lower level of treatment and/or a shorter exposure time but to spread out the treatments over five to eight sessions instead of the usual four. So it may be necessary to offer a different number of treatments, where the exposure time can be modified and the results will become prominent over a longer time period.

Scale

Age

Description

Slight

28 - 35

Characterised by small wrinkles, without keratosis

Moderate

35 - 50

Characterised by small wrinkles, sallow complexion with presence of actinic keratosis

Advanced

50 - 65

Characterised by deep wrinkles, presence of teleangiectasis, pigmented lesions and actinic keratosis

Severe

60 - 75

Characterised by dynamic and gravitational wrinkles, photoageing and actinic keratosis

Figure 2: Glogau scale

Fitzpatrick skin type The Fitzpatrick classification categorises skin type according to its reactivity to the sun without UV protection rather than the degree of photodamage. This classification helps identify patients who have a

Important considerations • If patients present with a poor skin condition, such as low hydration, TEWL, pigmentation issues and

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Ingredient Focus Chemical Peels

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Possibly most difficult to treat effectively

Severe

Advanced

Erythema issues

How far are you willing to push this boundary

Increased risk of PIH

Moderate Safe Mostly treatable

Slight 1

2

3

4

5

6

Figure 3: This graph combines the Fitzpatrick skin types with the Glogau scale

damaged blood vessels, then consider no peel, but use creams for boosting skin structure, repair processes, priming and preparation, regardless of skin type. Then, an appropriate sequence of peels may be considered, interspersed with creams and serums to boost their response but also to limit complication development, such as pigmentation increase.

• Peels need water to move through the skin, therefore, skin with poor hydration is more likely to react to the acid component of the peel (hydrogen ions) and experience localised damage to the surface, is more irritating and more likely to lead to complications.

This is because poor hydration causes less mobility for the hydrogen ions.13 • The periorbital skin is much thinner than the rest of the face; hence this needs to be taken into consideration. The type of agent used can be similar, but the strength and surface activity needs to be lower. Phenols and high strength TCAs or pyruvic acid would not be appropriate. In my opinion, it is better to use lighter concentrations and add more layers. The number of layers used would vary depending on the patient’s skin type and sensitivity.

Length of peel time Due to the ability to transport remodelling agents into the skin using specialised patented carrier technology,1,2,3,4 this can reduce surface trauma normally seen with traditional peel solutions by up to 50%. Exposure time is set prior to application and the peel is neutralised or removed regardless of visible erythema or frosting.

However, the visible symptoms of the peel and also patient response in terms of pain are still taken heed of, if trauma becomes apparent.

Exposure for mandelic is traditionally ten minutes, for pyruvic it is one to three and then if considered appropriate a second layer for up to a further two minutes, depending on layers and patient response, and for trichloroacetic acid (TCA) it is one to three minutes, before being neutralised. All other peels have varying exposure times.

Ideally, practitioners should use a neutraliser that can not only neutralise any surface acid, but also neutralise acid released in the skin. I use alkaline amino acids as a neutraliser as they can be attached to the same carrier molecules as used with the acids; in other words, wherever the carrier has taken the acid in the skin, the neutraliser can follow and neutralise both on and in the skin.

Something like sodium bicarbonate is too big a molecule to carry into the skin and hence only neutralises on the surface.12 Mandelic usage has become more varied from a traditional 52

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ten-minute exposure and then neutralised, to also include now a partially extended or fully extended peel like a Jessner’s, whereby the solutions are left active in the skin and only any remaining unabsorbed solution is removed at ten minutes. The mandelate attached to the carrier is allowed to be released in the skin and convert to mandelic acid and is still active post the patient leaving the clinic, thereby extending the peels activity and boosting the results.1,2,3,4 With Jessner’s, the peel is not neutralised and only the salicylate white powder is removed that forms on the surface; as the salicylic acid deactivates and converts to this analgesic powder leaving the lactic acid and resorcinol components active to continue to target the tyrosinase enzyme to help reduce excess pigmentation.

The value of bespoke treatment protocols When you have a range of different peels rather than one type of peel solution, such as glycolic, you have the opportunity to change the focus of the treatment to target other issues during a course of treatment, should the patient’s initial skin condition be resolved during the course of treatment, allowing you to focus on other skin issues. Bespoke peels allow the practitioner to switch and change peel choice during a course of treatment, depending on the patient’s skin journey and what changes take place during the treatment programme.

The correct patient assessment, prescription for the right areas and using the right exposure time leads to optimum outcomes for all patients.

Peter Roberts majored in microbiology and biochemistry in London and Sheffield. He is the founder and medical director of SkinMed, and has previously held roles with SmithKline Beecham and GlaxoSmithKline.

REFERENCES 1. Enerpeel 50% Pyruvic Acid Comparison with 70% Glycolic Acid – Shuller Petrovic,Mayr-Kanhaauser - UnivGraz, Austria 2003 2. Enerpeel PA efficacy and safety evaluation versus 50% pyruvic acid - Prof Bonina - Univ Catania, Italy, August 2003 3. Clinical evaluation of Enerpeel PA - Prof Beradesca S. Maria e S. Gallicano Derm. Institute, Rome – July 2004 4. Berardesca E, Cameli N, Primavera G, Carrera M. Clinicaland Instrumental Evaluation of Skin Improvement after Treatment with a New 50% Pyruvic Acid Peel. Dermatol Surg. 2006;32:526–31.

5. Salicylic Acid peel incorporating Triethyl citrate and Ethyl linoleate (ENERPEEL SA) in the treatment of acne: a new therapeutic approach. Raone B, Patrizi A Internal Medicine, Aging and Nephrologic Diseases Department, Division of Dermatology, Sant’Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy. Data on File 6. Open Multicentric Study to test the efficacy of a new therapeutic protocol of acne vulgaris Data on File 7. Journal of Aesthetic. Plastic. Surgery. 26:99-104, 2002 Fabil Fanous – Montreal, Quebec, Canada) 8. Tasaka K, Kamei C, Nakano S, Takeuchi Y, Yamato M. Effects of certain resorcinol derivatives on the tyrosinase activity and the growth of melanoma cells, Methods Find Exp Clin Pharmacol. (1998) https:// www.ncbi.nlm.nih.gov/pubmed/9604851 9. Mark B Taylor, Summary of Mandelic Acid for the Improvement of Skin Conditions, <http://dermage. com.br/dermage/paginas/article.pdf> 10. Shannon Farrell, Control oily skin with a skin peel, (2015) http://stylecaster.com/beauty/how-to-controloily-skin/ 11. Canadian Dermatology Association, Know your skin type, (2017) http://www.dermatology.ca/skin-hairnails/skin/photoaging/know-your-skin-type/ 12. CQConcepts, Sodium Bicarbonate Technical Grade, (2007) http://www.cqconcepts.com/chem_ sodiumbicarbonate.php 13. Libre Texts, The Hydronium Ion, (2016) <http://chem.libretexts.org/Core/Physical_and_Theoretical_ Chemistry/Acids_and_Bases/Aqueous_Solutions/The_Hydronium_Ion>

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Clinical Papers Abstracts

A summary of the latest clinical studies Title: Clinical Outcomes and Complications Associated with Fractional Lasers: A Review of 730 Patients Authors: Cohen S, Goodacre A, Lim S, Johnston J, et al.

Published: Aesthetic Plastic Surgery, December 2016 Keywords: Complications, fractional lasers, wrinkles, pigmentation, laser complications, laser Abstract: The medical records of 730 patients (>90% females, age ranged from 50.5. to 59.9 years) who had been treated at FACES+ Aesthetic Facility were reviewed. Seven hundred and thirty patients underwent procedures using fractional lasers in our center. Procedures were carried out with 3 different laser wavelengths, depending on the condition(s) treated (wrinkling vs. pigmentation issues, etc.) and the patients’ desired length of downtime. The Fraxel CO2 laser showed greater improvement in wrinkles and naso-labial fold (p < 0.001). The greatest improvement in pigmentation was seen with the Fraxel 1927-nm laser (p < 0.001). Adverse events and complications occurred in 31 of 730 patients (4.2%). There was no significant difference in the rate of complications among the three treatments (p = 0.26). Complications were generally minor, and all resolved completely with treatment. Complications occurred in 4.0% of patients having the fractional Fraxel 1927-nm laser, 3.3% of patients having the fractional Fraxel 1550 nm and 6.4% of patients having the fractional Fraxel CO2 laser.

Title: Clinical Application of Earlobe Augmentation with Hyaluronic Acid Filler in the Chinese Population Authors: Qian W, Zhang YK, Cao Q, Hou Y, Lv W, Fan JF Published: Aesthetic Plastic Surgery, December 2016 Keywords: Hyaluronic acid, injectable, tissue augmentation, earlobe, dermal filler Abstract: Larger earlobes, which are a symbol of “richness” in traditional Chinese culture, are favoured by Chinese patients. The objective of this paper is to investigate the application of earlobe augmentation with hyaluronic acid (HA) filler injection and its clinical effects in the Chinese population. A total of 19 patients (38 ears) who received earlobe augmentation with HA filler injections between March 2013 and March 2015 were included. The clinical effects, duration, and complications of these cases were investigated. All patients who received earlobe HA injections showed immediate postoperative effects with obvious morphological improvement of their earlobes. The volume of HA filler injected into each ear was 0.3-0.5 ml.

The duration of the effect was 6-9 months. Two of the 19 cases (3 ears) demonstrated mild bruising at the injection site, but the bruising completely disappeared within 7 days after the injection. No vascular embolism, infection, nodule, or granuloma complications were observed in the studied group. The application of earlobe augmentation with HA filler injection is a safe, effective, simple procedure for earlobe shaping. It has an easy clinical application with good clinical prospects.

Title: Green Tea and Other Tea Polyphenols: Effects on Sebum Production and Acne Vulgaris Authors: Saric S, Notay M, Sivamani RK Published: Journal: Antioxidants, December 2016 Keywords: Acne vulgaris, catechin, polyphenol, sebum, tea, dermatology Abstract: Recent studies suggest that tea polyphenols may be used for reducing sebum production in the skin and for treatment of acne vulgaris. This review examines the evidence for use of topically and orally ingested tea polyphenols against sebum production and for acne treatment and prevention. The PubMed database was searched for studies on tea polyphenols, sebum secretion, and acne vulgaris. Of the 59 studies found, eight met the inclusion criteria. Two studies evaluated tea polyphenol effects on sebum production; six studies examined tea polyphenol effects on acne vulgaris. Seven studies evaluated topical tea polyphenols; one study examined systemic tea polyphenols. None of the studies evaluated both topical and systemic tea polyphenols. Tea polyphenol sources included green tea (six studies) and tea, type not specified (two studies).

Overall, there is some evidence that tea polyphenols in topical formulation may be beneficial in reducing sebum secretion and in treatment of acne. Research studies of high quality and with large sample sizes are needed to assess the efficacy of tea polyphenols in topical and oral prevention of acne vulgaris and lipid synthesis by the sebaceous glands.

Title: Effect of different types of therapeutic trauma on vitiligo lesions Authors: El Mofty M, Esmat S, Hunter N, Mashaly HM et al.

Published: Dermatologic Therapy, December 2016 Keywords: Chemical peel, vitiligo, fractional C02 laser, dermapen, koebnerization Abstract: New treatment modalities for vitiligo acting by changing certain cytokines and metalloproteinases are newly emerging. The aim of this work is to assess the efficacy of trichloroacetic acid (TCA) chemical peel, dermapen, and fractional CO2 laser in treatment of stable non-segmental vitiligo and to detect their effects on IL-17 and MMP-9 levels. Thirty patients with stable vitiligo were recruited in a randomized controlled study. They were randomly categorised into three equal groups. Group 1: TCA peel, Group 2: dermapen machine, and Group 3: Fractional CO2 laser. Skin biopsies were taken from treated areas and from control areas for which MMP-9 and IL-17 tissue levels were measured using ELISA. The 30 vitiligo patients had low basal tissue MMP-9 levels and high baseline IL-17 tissue levels. As regards the three different used modalities, all of them caused rise in MMP-9 as well as IL-17 levels and almost their levels were much more elevated with repetition of the previously mentioned traumatic procedures. TCA 25% peel proved to be the most effective modality both clinically and laboratory and it can be used prior or with other conventional therapies in the treatment of vitiligo.

Aesthetics | February 2017

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Digital Website Mistakes

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Avoiding Website Mistakes Marketing consultant Adam Hampson outlines seven common aesthetic website mistakes and how to correct them Why is it that some aesthetic clinics attract a steady stream of new and repeat patients via their website while others struggle to be seen? For a website to perform well, and consequently, for a clinic to flourish, the devil is in the detail.

When new clients come to me, I always begin by looking at their current website. Without exception, most aesthetic websites that are failing to attract patient enquiries are making one or more of the following seven common mistakes. If your website isn’t attracting visitors or new patient enquiries, even if you have a steady flow of traffic (the figures used to measure this will vary from one practice to another), it could be that you’re making these mistakes too: 1. The website layout appears messy When your latest website was created by a design company or if you have just used a wordpress site to create a free website, you may have used a content management system, (CMS)1 i.e software that allows you to add fresh pages and content without their input. Although this is great in theory, it can be a disaster in practice.

Some CMS can provide a lot of freedom in terms of layout, style and website structure/ navigation. This freedom can potentially lead to the addition of pages that all look different and are at odds with the website’s design and branding at large.

An appealing design is about small touches; the spaces on the page as much as the images and text, a choice of font that reflects your brand and is easy to read, the design and position of calls to action. A CMS must be properly set up, including style sheets – a coded piece of information about the main design elements of each web page, such as the fonts and colours – to ensure that any new content fits within the overarching design of the website. Style sheets are used to add layout and formatting to your templates and are created through your website settings.2 Overall, a site that looks messy, inconsistent or is hard to navigate from one page to another is going to cause people to leave your site and look for a better user experience elsewhere.

If you’re having a new website built, discuss the CMS with the developers from the outset to ensure that it will help you maintain long-term consistency across the design. Also, talk to them about navigation and how you can provide the best user experience if you add new pages in the future. If you have an existing website, you may need to discuss with the web developers whether the CMS can be improved, which, of course, may involve cost but, in my opinion, is well worth it in the long run.

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2. There’s too much marketing and no conversion We consistently see websites that are all about marketing, often with multiple marketing messages per page, but aren’t set up for conversions. By this, we mean getting visitors to take a measurable action such as filling out an enquiry form. It’s better to promote one or two focused marketing messages and make sure that every page has a conversion mechanism rather than overwhelming website visitors with content that screams, ‘Buy Everything’. Such conversion mechanisms might be an enquiry form visible on any page, a ‘Book now’ or ‘Request a call back’ facility.

3. It’s generic, not personal Many aesthetics websites are built around a widely available template design and feature stock images, i.e. royalty-free professional photographs that can be used and reused for commercial design purposes. You may have opted for this approach to keep costs down, deciding that it would be cheaper to use a template design and pay for an annual stock photo subscription than to build a bespoke website or hire a photographer. However, if multiple clinics are using the same stock images or website template, it may not be as effective, because the website ends up looking and feeling generic.

The decision to have any sort of aesthetics treatment is hugely personal, so a marketingby-numbers approach that’s the same as the clinic down the road is likely to drive potential patients away. When potential patients view your website, they want to have a sense of what it will be like at your clinic.

They want to be able to visualise stepping into the reception, talking to you, and what they will look like post treatment. They want to understand what makes your clinic the right fit for them. One of the ways to achieve this is incorporating video content on your website that contains imagery of your clinic that you can use as a marketing tool to attract potential patients viewing your website.

Feature images of your clinic’s interior and exterior, show your staff giving treatments, and showcase genuine before and after images as it will help people to connect with the reality of your clinic. Ultimately, you want to make a patient feel comfortable the first time they step through your door.

4. Not prioritising other types of users People may find you initially on their mobile phone but, before they decide to go ahead and book a consultation, they’re likely to

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spend some time on their laptop or desktop carrying out research. An aesthetic treatment isn’t something people take lightly and booking probably won’t be spontaneous.

Knowing this, it’s essential to make sure that your website provides an equally excellent experience across all devices and that the desktop user accesses your website information with ease to assist them in choosing your clinic for a treatment.

The first step is to view your website on different devices to see how it looks.3 Do the menus display properly? Is your enquiry form visible? Does the content display in a logical, easy to read way? What do the images look like on a large screen as opposed to a mobile screen? If you spot any problems, make it a priority to discuss them with your web developer.

5. Promoting low price offers Against the General Medical Council’s (GMC’s) guidelines,4 some clinics may still choose to promote time-limited treatment deals on their websites. If you’ve ever received a Groupon or Wowcher email, you’ll see that they’re peppered with aesthetics offers aimed at people who are shopping solely on price. If your website reflects this approach, it could be seriously damaging to your long-term conversion rates, as someone who is seeking the cheapest deal is unlikely to form a long-term relationship with just one clinic. They will most likely go where the next offer takes them. Although this may at times occur in the aesthetics industry, it is important to emphasise that promoting time-limited treatment deals within the aesthetics industry is against GMC guidelines and vehemently discouraged. In my experience, I found that the clinics that concentrate on adding value rather than lowering price are usually more successful in the long run, and so are the websites that communicate this. Instead of talking to your potential patients about the money they might save by coming to you, talk to them about what they will gain.

6. Your social media inactivity on your website It is important for businesses to have a social media presence, especially on Facebook, YouTube and Twitter as they are the three largest platforms.5 Many clinics know they should have a social media presence but are not sure what to do with that presence or how to grow it once it’s created. This can result in a lack of strategy and consistency. It’s also common for clinics to be active on social media but to forget to

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Digital Website Mistakes

“Use your website to answer common questions about each treatment” link this activity to their website.

Simple touches such as featuring icons linking through to your social media pages in your website’s header, or including ‘social share’ buttons to let people share your content to social media, can help to build engagement with your audience. You can use widgets to add your latest Facebook and Twitter posts to your website. A widget is an application with limited functionality that can be embedded within a web page they are allows you to turn your personal content into web apps that can be shared on websites.6 It’s also a good idea to feature Facebook or Google reviews, according to recent findings in 2016 by The BrightLocal Local Consumer Review Survey where a US based consumer panel of 1,062 individuals competed a survey that revealed revealed 84% of people trust as these types of reviews as much as a personal recommendation.7 7. Not considering your target audience Who is your website for? It’s amazing how many businesses forget to ask this crucial question and therefore fail to implement marketing strategies that focus on their target audience.

When creating a new website, it’s advisable to highlight the credentials of your clinic to show potential patients what you offer, but only to a point. If the content is all about you, it can come across as intimidating. Talk to ‘your’, reader, and focus on how visiting your clinic will benefit them, instead of saying ‘this is who we are and why we’re great’.

Someone who is familiar with aesthetic treatments, having had some in the past, probably has an established relationship with a practitioner and is unlikely to be your main target audience. This is unless they are unhappy with their current practitioner or seeking a treatment that their usual clinician doesn’t offer. Many of your new patients will be people who lack confidence about one or more aspect of their appearance that they might be seeking to correct through treatment. This may be the first time they’ve actively looked for a treatment and they may not know a lot about the treatment protocols.

On the flipside, they may have researched one treatment in depth without realising that Aesthetics | February 2017

another treatment may be more suitable for their needs.

These people may be seeking advice on the best course of treatment. They may feel vulnerable about venturing into the unknown and will therefore be looking, not just for your qualifications or industry accolades, but for a clinician who is approachable, professional and trustworthy.

You can communicate these qualities by providing clear, jargon-free information about your treatments. Be realistic about the results and transparent about potential side effects. Use your website to answer common questions about each treatment. Most importantly, let them know that you will listen to them and give them appropriate advice.

Conclusion One of the most significant things you can do to correct mistakes on your website is to take the time to consider your target audience and their behaviour. It isn’t about you or your clinic but about your potential patients and what you and your clinic can do for them.

Keep in mind the design of your website and maintaining a structure for your content throughout your pages that is clear and concise, user friendly and easily accessible to your existing and new users.

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

REFERENCES 1. Business Dictionary, content management system (CMS) definition, <http://www.businessdictionary.com/definition/ content-management-system-CMS.html> 2. ‘Stylesheets’ CMS Made Simple, 2017 <https://docs1. cmsmadesimple.org/layout/stylesheets> 3. Nimrod Flores, 8 Free Online Tools to Test Your Website on Different Screens & Devices, (2013), <http://nimrodflores.com/ web-dev/8-free-online-tools-to-test-your-website-on-differentscreens-devices> 4. General Medical Council, ‘Rules about advertising cosmetic procedures’, (2013) < http://www.gmc-uk.org/guidance/ethical_ guidance/29191.asp> 5. EBiz MBA, Top 15 most popular social networking sites, (January 2017), <http:/www.ebizmba.com/articles/socialnetworking-websites> 6. htmlwidgets, ‘Creating a widget’ 2014. <http://www.htmlwidgets. org/develop_intro.html> 7. Bright Local, Local Consumer Survey Review 2016, (2016), <https://www.brightlocal.com/learn/local-consumer-reviewsurvey/

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Clinic Business Sales

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Aesthetics Journal

Selling Your Business Aesthetic clinic managing director Ralph Montague provides an overview of the various options for those looking to sell their clinic Ever worry about how you’re going to sell your business when the time is right?

One reason why you may want to sell your business could be retirement, or maybe you feel that you need a fresh challenge.

If you haven’t ever sold a business before then it’s certainly not straight-forward. Even if you are a few years off selling, putting the right systems and procedures in place, combined with speaking to the right people now, means that when the time is right, you will be in a position to leave when you want to.

The options Trade sales Trade sales, whereby you sell to another company in your industry or a complementary industry to yours, are great if you want a fast sale.1 You might be able to structure the sale of your business so that you can completely walk away from it when you exit (clean exit). However, typically if you’re looking for such a clean exit, you’ll get a lot less value for your company than if you’re prepared to do an earnout,1,2 which is where your final pay-out is based on hitting pre-agreed targets for the business (see below).2 If you decide to do a trade sale, you need to be prepared to do a lot of research to find someone who will buy your business. A list of things you may want to consider: 58

1. Look at competing clinics both locally and nationally that are aiming to increase their presence in your area.

2. NHS doctors and nurses might be looking to open their own aesthetic practice.

Taking on an existing clinic with reliable staff, an established patient base and a history of success may be a good option for them.

3. Similar businesses, such as a clinic more focused on injectable treatments compared to your laser offering, may want to expand and/or offer new services that your clinic has. It is far easier to buy an existing clinic, already setup, rather than to start from scratch.

4. Consider friends or acquaintances that may be looking for a new challenge.

Your clinic could present an exciting new venture for them.

5. Research equipment and product suppliers. Some may be interested in running their own clinic without the hassle and cost of setup to showcase their products in a real-life clinical setting.

Advertising: you may choose to use free listing websites or business brokers for advertising trade sales. Business brokers are an option, but will take a percentage (often starting at 10%) of your business profits. After contacting a broker, which can usually be found by searching online, they will review and verify your business through looking at Aesthetics | February 2017

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things like finances and tax documents. They would then advertise your business online and may research potential buyers, organise viewings and oversee the settlement and closing of the deal.

There are also some websites such as Businesses for Sale or Dalton’s Business, which allow you to upload your details and create your business profile for a fee. These can be very cost effective, but they very much depend on others finding you, so ensure you swiftly follow up any potential leads. The advantage of a trade sale is that it enables you to walk away from your business in a shorter time than some alternative options, such as the earnout option. The disadvantage is that you may miss out on extra profits, as explained below.

Earnouts An earnout is when your final pay-out is based on hitting pre-agreed targets for the business.2 For example, you may want to stay with the clinic for two to three years.

During that time, if you can take sales over a certain predetermined amount per annum, then the buyer might agree to pay you extra for your business. In my experience, many companies like owners to stay to help maintain the success of the business when they first purchase it, however, many sellers want to leave straight away, which is why such financial incentives exist to help meet both the buyer’s and seller’s needs. Earnouts may work well for someone who doesn’t want to leave the business just yet, but at the same time does have a suitable offer and would be happy to leave in a few years, plus, in the process, get a higher valuation for their business. However, if you’ve reached a point in your life where you’re sure you want to sell your clinic, then continuing to work there as an employee of somebody else can sometimes be challenging if you don’t agree or have little experience in their new strategies for the business.

Competitors Being approached by a competitor can work well as there is little work for sourcing buyers and getting the business sale ready.

Similarly, actively approaching competitors can also be a good strategy. There will also be no agents’ commissions to be paid as you will be working with the buyer directly.

Agents can be ideal if you are stuck for time as they do the majority of the work for you, and can be involved in many of the other selling options listed; however, it is often work that you can do yourself and may be

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Having a detailed system or checklist in place helps ensure that tasks are done in a timely manner and that they are done correctly every time a good way to save money. The challenge for many practitioners here is the fact that you may not want to sell to a competitor out of principle or may not agree with their strategies for the future of the business, which may affect some of your long-standing patients. This could be the case for any buyer, so is an important point to consider before listing your clinic for sale. Ensure you weigh up the benefits of selling with the possible disadvantages and judge what is most important to you.

Initial public offering (IPO) IPOs are when you float or list your company on a stock exchange.3 These are generally reserved for larger companies with sales greater than £5m per year. However, you will need a full-time staff member just to manage the complex and time-consuming process, combined with bank and legal fees, meaning even for companies of that size, the costs both financially and time-wise are often too overwhelming.3 The advantage is that because the company is listed on the stock market, it will increase the value of your business and you can sell shares to the public. The disadvantage is that the company is more open to public and media scrutiny than a private company and your levels of accountability increase.3 Mergers and acquisitions Mergers and acquisitions take place when two or more companies come together to create a new and larger company.3 By getting in touch with other clinic owners in the industry who may also be looking to sell, you can look at ways to create a larger business. This is often a lot easier to sell, due to it now being a bigger company and of more interest to the corporate sector, which is generally large clinics or other companies looking for a good investment who have £20m plus turnover and the

money to buy your business.3 One challenge with mergers and acquisitions is that it can cause debates in things like the naming of the merged or acquired business as well as the titles of individuals working at the new company. For example, trying to determine who gets the director, chairman or managing director title and who has the power in the business may be debated.

What if you can’t sell?

When trying to sell a business, it is important to consider that not all businesses sell, or will not sell straight away. In my experience, the clinic should sell within three to 18 months if it has been marketed correctly and all the information for the sale is correct and complete. If you can’t sell within the time frame you had planned for, you may consider to continue to run your business on a part-time basis, while you focus on developing your other goals, be that a new career or retirement.

To achieve this two important aspects to consider are the systems you have in place and the reliability of your staff. Employ a clinic manager who will ensure smooth and successful management under your direction. You could consider promoting an existing member of staff who knows the fine details of your clinic, or hiring externally.

Look for someone who has experience in managing a clinic, managing staff and a consistent record of reaching sales targets.

For systems, I recommend referring to the book E-Myth by Michael Gerber, which provides some fantastic advice for businesses.5 A system is essentially a list detailing things that need to be done and having a clear structure on how to do them.

Having a detailed system or checklist in place helps ensure that tasks are done in a timely manner and that they are done correctly every time. A simple example of Aesthetics | February 2017

Clinic Business Sales

creating a system to save time is for a clinic cleaner. Instead of sending in a cleaner to simply clean, have a checklist that has a systemised approach so that they can do the same things in the same order without the need to think about what they are doing – this will save them time and ensure the jobs are completed.

It is important to monitor key performance indicators to ensure all systems are working successfully. I recommend checking the number of sales, total value of sales, value and number of any purchase orders, number of bookings made and sales value of bookings made on a weekly basis, so you can deal with any concerns in a timely manner. For other clinic matters, set alert levels so your staff know when action needs to be taken and when to involve you in anything of concern.

The benefit of continuing your business instead of closing it down is that you will receive continued income, instead of simply nothing at all compared to if you cease trading. As well as this, an active clinic can be easier to sell, and so by doing this you can continue to try to make your clinic appealing to potential buyers and eventually sell.

Summary Like most things, there is no right answer to how you might go about selling your business and some approaches will work better for others. However, understanding your options will help to increase the chance of you selling your business successfully as well as how to manage your business in a way that allows you to work on it part time if you cannot sell.

Ralph Montague is managing director of The Skin Repair Group, a national training and aesthetic equipment supplier which operate two clinics in the South West. He is the author of The Profitable Clinic, a newly released book on how to make your clinic more profitable and considerations for selling your business.

REFERENCES 1. Syndicate Room, Trade Sales, (2017) <https://www. syndicateroom.com/learn/glossary/t/trade-sale>Investopia, ‘Earn Out’ (2017) <http://www.investopedia.com/terms/e/ earnout.asp> 2. Jeremy Harbour & Callum Laing, Agglomerate - From Idea to IPO in 12 Months, (2016).

3. Simpson, N, ‘PROPERTY FINANCE: Putting a new business on the house’, Daily Mail, (2010). <http://www.dailymail.co.uk/ property/article-1329838/PROPERTY-FINANCE-Putting-newbusiness-house.html> 4. Michael Gerber, The E-Myth Revisited: Why Most Small Businesses Don’t Work and What to Do, (2001).

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Growth-focused Marketing Strategy Marketing consultant Kayas Fayyaz outlines how to create a marketing strategy targeted at current clients to drive sales and build brand authority Are you a practitioner who has recently taken on commercial responsibilities, such as increasing sales and revenue? This is a common responsibility for today’s aesthetic practitioners, operating both in-clinic and independently, and with the rise of on-demand services, it is only set to grow as a primary responsibility. Therefore marketing should play a crucial role for practitioners aiming to build a loyal client-base and ensure steady cash flow across the financial year. So, the natural question this leads one to ask is: how can I utilise marketing to help grow my business and make sure that I am ahead of the competition?

To make things simple to begin with, I suggest four core areas to prioritise. These are areas where marketing should be initially prioritised as part of integrating it into your growth strategy and leveraging it to drive increased sales. These four areas are: sales alignment, insight-led decisions, customer centricity and storytelling.

Business Growth Marketing

Campaign calendar A campaign calendar is the vehicle to shift marketing from being reactive to proactive.

By breaking the calendar year into four quarterly cycles, use each quarter to promote a specific growth-focused campaign that incorporates both seasonal and industry trends, and invest both sales and marketing efforts in that campaign. Typical questions to help identify quarterly campaigns are: is there a correlation between season and treatments sold that can be capitalised on? When are new treatments or products scheduled to be rolled-out? How can brand narrative be seamlessly communicated against (related) current events of interest to customer personas? The key thing to consider is that the calendar is your marketing framework, giving you full visibility of your marketing priorities, which will help to enable strategic direction for the business and third-party agencies, and smooth campaign delivery.

2. Power your marketing with data and insights

1. Align your marketing with your sales plan Marketing was once regarded as the ‘fluffy stuff’ of business, primarily because it operated a solely marketing-focused agenda, as opposed to being a key player around the strategic planning table. Marketing would typically have a marketing-focused agenda that differed from the sales (revenue) agenda, resulting in two disjointed agendas within one business, i.e. sales was responsible for growing steady revenues at a healthy profit, whereas marketing was responsible for external communications and driving experimentation and adoption across channels (e.g. TV, print, paid search, display, social), typically operating as a cost centre, and – unlike sales – not a profit centre. This is certainly not the case anymore, whereby sales-led growth strategy is evolving to marketing-led growth strategy, thanks to the huge increase in digital-powered campaign tracking and customer targeting capabilities that marketing has in its arsenal, as part of identifying, engaging and converting prospect customers. Inevitably, the ideal evolution is a hybrid sales-and-marketing growth strategy that leverages the benefits of both functions to drive sales growth through increased collaboration. The relationship needs to be symbiotic, as it is marketing that can describe to the sales team who the target customer is, where they are, what they want, how we can engage with them and drive customers towards sales. Sales can utilise this information to align with growth targets, which both functions can then execute against, to achieve the all-important long-term business goals.

To align your marketing with sales, it is a good idea to collaborate on campaign planning and build a single campaign calendar.

Campaign planning When planning a campaign, I believe there are a few fundamental ingredients that cannot be overlooked: proposition and price; segmentation and targeting; build, delivery and nurture.2 For each campaign, know what is being promoted, how much it costs and that it aligns with your customer persona. Then move on to building a campaign prospect list by reviewing your database and, depending on your customer journey (to be explored in this article), begin to build the assets you need, e.g. tweets, email, Instagram posts etc. Once the campaign is up-and-running, the goal is to not only drive sales, but to also capture contact details for new prospects so that they can be added to the database and retargeted for future campaigns. Delivering robust campaigns requires a lather-rinserepeat process, applied learnings from failures and rigorous discipline. It’s worthwhile to conduct further reading – the Government Communication Service website released a great two-page guide on campaign planning, which includes a list of great online tools to make the most of.1 Aesthetics | February 2017

Data is a huge topic in today’s world and much of this can be attributed to the digitisation of almost everything but the challenge lies in how best to leverage it.

There first needs to be an understanding of what marketing data is. Following this, it is worthwhile to start turning data into insight that can either directly influence marketing activities or enable accountability in terms of marketing performance. A great starting point is to know the types of marketing data available.

Marketing data There are two categories of marketing data: customer and performance. The former consists of: contact information (name, email etc.); demographic (age, gender etc.) and; behaviour (product interest, most recent purchase etc.) and will help to identify which customers to contact as part of campaign targeting. The latter consists of a range of campaign performance metrics around audience, reach, engagement, conversion and value. A starting point for collating data can be: • Use enquiry/booking web forms to capture data on website product pages and track social media • Ask customers to fill out a feedback form, either straight after treatment or via followup email • Deliver a quarterly incentivised, goalorientated survey email to existing customers 61

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Marketing database A marketing database is the engine behind long-term growth.

In short, it is less costly to target someone you’ve previously engaged with than to go and find completely new customers to target for each new campaign. At the very least, a database should include the following details for each customer: name, address, email, telephone, recent purchases and total revenue you have generated from them. With these data sets, revenue-focused email campaigns can be delivered quickly and in a targeted manner maximising the opportunity to create new sales.

3. Place customer-centricity at the heart of your marketing Marketing needs to deliver impact through targeted content-led campaigns, which serve to educate and influence the intended audience via meaningful positioning and persuasion. In order to execute this successfully and maximise impact, priority must be placed on the customer, i.e. ensuring the following is understood: · Who exactly are the customers, demographically and behaviourally? · Through which virtual and physical marketing channels can they be best engaged? · How can a meaningful relationship be built with them?

A great starting point is to focus on creating customer personas and map out the customer journey.

Customer persona A customer persona is a profile of an ideal customer, consisting of both demographical and behavioural data. The number of personas a business should have will vary – how diverse are the products and services? Is the business targeting consumers, businesses or both? How many personas can (realistically) be managed, in terms of personalising marketing campaigns?

Personas are mapped against a particular product set or service, and all associated marketing should resonate with the persona to ensure consistent messaging. A good starting point for building personas is to emulate a Facebook profile of an ideal customer and use that framework to build a customer persona.

Consider you are looking to launch a new treatment in your clinic and take the following persona for example: Lauren: ‘Aged 28, Lauren is a professional social media vlogger and typically spends £700 per month on lip fillers and skin rejuvenation treatments as she works in front of the camera. She is flexible in terms of appointment times and open to trying new treatments.’

From this persona, the following can be hypothesised: customers that fall within this persona have a need for services and – with relevant additional services – are an existing pool to crosssell to, increasing customer lifetime value and revenue. The subsequent action, in this case, would be to identify the contact list size (number of customer email addresses within the ‘Lauren persona’), deliver a personalised email campaign to them, which not only introduces the new treatment, but also highlights why this treatment complements their existing regime. Adding an incentive to the campaign, e.g. free consultation, would act as a catalyst to support take-up. What’s really important is to ensure messaging resonates with the persona, e.g. is the additional treatment becoming the norm for professionals working in a public position?

If so, use the email to concisely inform ‘Lauren’ exactly why this new treatment is right for her. Parallel to this, you would duplicate the email campaign created for the ‘Lauren’ persona and update 62

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accordingly, so that the messaging and incentive aligns with your other personas, and then build supporting mailing lists (you should not have the same contact/email address in two separate persona mailing lists). If you are working with a marketing or PR agency then they should work with these personas as well.

Customer journey The customer journey is an understanding of the typical marketing channels a customer would navigate, as part of working their way through awareness, interest, desire and action for a purchase decision.2 By knowing your customer journey, you are able to prioritise efforts by channel importance. For example: is social media where your customers conduct their research, but email tends to be the channel that prompts action in the form of purchase or booking? A good starting point for mapping your customer journey is to review what has worked well so far for inbound web traffic (sources directly driving users to your website) and conversion tactics performance (sources directly driving treatment bookings and product sales). There are many web analytics tools available, but Google Analytics (GA)3 is the most common platform used for capturing and interrogating web data – it’s free, reliable and provides all tracked data in raw numerical format, visualisation graphs and automated reports that can hit your inbox at a frequency of your choice (lots of customisation available). There are lots of free online resources for becoming confident with GA, including Google’s very own ‘Analytics Academy.’4 Knowing which channels are driving the most relevant traffic can help to identify where to place efforts in terms of growing online presence and external communications. The same methodology can be applied to conversion tactics performance – to streamline marketing, focusing solely on the channels of importance. Upon evaluating the data, a hypothetical – but by no means unrealistic – conclusion could be:

1) Facebook is the biggest website traffic source 2) Face-to-face is the most successful driver of sales, measured by how many treatments are carried out after a consultation Therefore, in this scenario treatment promotions should be communicated via Facebook, with a ‘book a free in-clinic consultation’ call-to-action to enable face-to-face engagement.

4. Differentiate your marketing through storytelling The popularity and inevitable rise of social media as a marketing channel has created a new host of opportunities. Though this democratisation of outbound communication can be liberating for individuals and start-up businesses, it has resulted in by-products that can frustrate audiences. For example: being contacted by multiple businesses offering similar products over short periods of time, and receiving lots of contradictory ‘expert’ opinions that – inevitably – create confusion. Therefore a clear narrative is needed, and one that acts as the backbone to all future marketing efforts. Typically focusing narrative positioning across: product/ service value, brand reputation and industry authority. To be in a position to realistically achieve this, it’s important that the narrative’s purpose is truly understood, embraced and owned. A great starting point is to focus on knowing how you want to position your brand and build its reputation as an authority. These tactics will not only ensure brand consistency, but also help to shape audience perception through authority over the long-term.

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Business Growth Marketing

Brand narrative A brand narrative is a set of orchestrated messages socialised across the year to promote an overall industry theme that the brand is championing, e.g. issues of safety, sustainability, technology etc. This is a highly pro-active way not just to raise brand visibility for certain themes, but also to help customers identify with your brand and, thus, help you to differentiate from competitors. When aligned to your customer personas, brand narratives can be a powerful communication tool for creating long-term brand loyalty. Choosing the most appropriate narrative/issue to champion is crucial, as there is long-term commitment involved, which requires motivation, belief and consistency as fuel for success. A recommendation for approaching a narrative to champion is to select an issue or topic that resonates with you, the practitioner: either a particular treatment that empowers a certain audience – PRP therapy for young men and women who are concerned about hair thinning – or an issue you’ve identified from conversations with existing customers, for example, a consumer aesthetic treatment educational series, arising from customers expressing lack of knowledge/long-term impact of treatments and knowing which experts to trust.

1. Create industry content through blogging and academic journal

Industry authority Tactically very similar to the brand narrative, but in this instance the narrative is aiming to raise the profile of the practitioner (as opposed to the business’ brand). There is huge value in building industry authority, as it can create new B2B opportunities for your business as well as building trust and respect within the patient community. The quickest way to start building authority as a practitioner is to:

REFERENCES 1. Ray Perry, How effective is your marketing, The Guardian, (2001), <https://www.theguardian.com/ media/2001/nov/12/mondaymediasection3> 2. GSN, A guide to campaign planning, (2015), <https://gcs.civilservice.gov.uk/wp-content/ uploads/2015/09/OASIS-Campaigns-Guide-.pdf> 3. Annmarie Hanlon, Digital Marketing Trends for 2017, Smart Insights, (2016) <http://www.smartinsights. com/traffic-building-strategy/offer-and-message-development/aida-model/> 4. Google Analytics Academy, (2017) <https://analyticsacademy.withgoogle.com/>

contribution

2. Be visible across social channels and be confident in sharing relevant opinions and insight

3. Build brand advocacy through existing-customer testimonials Summary By embracing the four areas covered in this article, the guidelines may help to provide better results aimed at accelerated growth.

Whether you choose to approach the guidance in its entirety or phase adoption over the course of a year, it is important to be realistic by setting achievable expectations over a period of time and maximising efficiency through the resources you have available to you.

Kayas Fayyaz is a strategic marketing consultant for London-based agency Beautiful PR and has a decade’s experience in leading digital-led customer acquisition for international businesses. Passionate about helping start-up businesses leverage marketing to drive longterm commercial growth, Fayyaz is also a specialist business mentor for the Prince’s Trust Enterprise Programme.

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contractor would be unable to collect it, resulting in a delayed process and inconvenience for the clinic. The same consequences could be experienced in the event that a pre-acceptance audit is incomplete or incorrect, so care should be taken to ensure everything is as accurate as possible.

Clinical waste advisor Rebecca Waters explains how to simplify the audit process Like many obligatory processes in the aesthetic clinic, waste management is not the most exciting of topics. It is, nonetheless, very important for the safety of patients and professionals alike, and meticulous protocols must be followed in order to meet the high standards set out by the relevant governing bodies to meet their Duty of Care.1 It is also important for the appropriate processes to be performed as efficiently as possible, enabling staff to complete waste management tasks effectively while still focusing their attention on their patients.

The Government department, the Environment Agency, has imposed a legal requirement in the Environmental Permitting Regulations 20152 whereby waste generated at a property that provides healthcare services is subject to an audit, prior to its collection via a contractor and disposal at an appropriate incineration or alternative treatment plant.

Why is it necessary?

The pre-acceptance audit is essential for every aesthetic clinic as it allows disposal or recovery centres to treat the waste sent to them in the most appropriate way. Ultimately, this means minimising the harm caused to human health and the environment during waste treatment processes. Therefore, all waste streams must be audited, documented and communicated to the final disposal site and compliance with these requirements will help ensure you meet your Duty of Care obligations.

Failure to perform a sufficient pre-acceptance audit will constitute a breach in your Duty of Care responsibilities and you could be subject to enforcement action by The Environment Agency, which can lead to legal prosecution and an unlimited fine (details of any possible enforcement are contained with the Environmental Act 1990).3 In addition, if the waste disposal, treatment or recycling plant does not have the relevant information on your waste, they will be unable to accept it; a stipulation of their waste disposal permit is that they are required to obtain the correct pre-acceptance audit from waste providers before they can receive the waste.3 Without the documentation, the plant would not accept your waste so the waste

Duty of Care in respect to waste, according to the Environmental Protection Act 1990, states1 it is the duty of any person who imports, produces, carries, keeps, treats or disposes of controlled waste to take all reasonable measures: • To prevent any contravention by yourself or any other person • To prevent the escape of waste from your control or that of any other person • On the transfer of waste, to ensure a) that the transfer is only to an authorised person and b) that a written description of the waste is transferred too

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When is it required?

The pre-acceptance audit data must be received and assessed by the disposal or treatment site prior to the first delivery of waste to them. A new audit must be conducted at least every five years for every aesthetic clinic.7 The only exceptions to this requirement would be if you operate from a medical practice that produces five tonnes or more of clinical waste in a calendar year – in this case, the pre-acceptance audit must be repeated every 12 months. Audits are required every two years for veterinary practices, dental practices and laboratories that produce less than five tonnes of clinical waste in any calendar year and every five years for other healthcare producers of clinical waste.7 The pre-acceptance audit is no longer valid once the above stated time periods have elapsed, so care should be taken to ensure continued compliance. What’s more, if the type or quantity of waste produced by your clinic changes significantly, the audit will need to be repeated before the end of the stated time intervals.7 What’s involved?

As the producer of waste, your company is ultimately accountable for making sure the pre-acceptance audit is performed correctly and efficiently. There are a number of options as to who can physically conduct the audit:4

1. You or an allocated member of your clinic’s team may perform the audit and collect the data. If proceeding in this way, it is crucial to ensure that the designated person fully understands what is required before commencing the process, and that the information recorded will be sufficient for the waste to be accepted at the appropriate site in accordance with its environmental permit. This can be achieved through training provided either in-house or by an external source such as your waste contractor. The Environment Agency Clinical Waste EPR 5.07 also states that, “These staff must have a clear understanding of the clinical waste, its composition, classification, packaging and transport, the wastes associated with specific healthcare activities, any conditions with the permit that relate to these, and the requirements for the completion of waste consignment and transfer notes.”5 2. You could employ a third party to collect the relevant data on your behalf, such as a specialist waste management consultant. This can be useful if you have little time or are not totally confident with what’s involved, although cost will vary depending on the fees involved.

3. Your waste contractor may offer a pre-acceptance audit as part of their waste collection and disposal service.

This is the ideal opportunity to review all waste management processes within the clinic. Checking the current policies and procedures that are detailed and implemented in the practice, while also evaluating staff training records and protocols, are all necessary. What’s more, it’s important to ensure that all waste consignment documentation is being completed correctly – your careful procedures and audits would be in vain if waste is described

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incorrectly when packaged and stored ready for collection. All this can be recorded as a simple table within your pre-acceptance audit.

If you operate a large clinic with various clinical rooms, a summary is a particularly important aspect of the final audit report, although it should always be included no matter the size. This should provide an overview of your findings, set out the general standards of waste segregation and packaging for each waste stream generated, state areas of good and poor practice and include recommendations for improvement where appropriate. Any protocols working particularly well can be highlighted here to recognise the team’s hard work and commitment – perhaps the clinic’s waste segregation is highly efficient due to various explanatory posters around the premises?

Regarding areas in need of improvement, an action plan should be drafted to show how you aim to address any areas of concern with deadlines for improvements to be achieved by. For example, this might involve planning more regular staff training opportunities and setting a date for the next meeting, or repositioning waste bins closer to the point of production to help prevent accidents and encourage more effective segregation.

Once complete, your waste contractor must be supplied with a copy of your pre-acceptance audit and the information must be transferred to the final waste disposal facility, by post or electronically.

Pre-acceptance audit – what is it?

There are two key stages that need to be addressed: waste preacceptance and waste acceptance. The former is most relevant for aesthetic clinics and it involves the ‘pre-acceptance audit’ – the primary purpose of which is to identify waste contents and provide sufficient information for the appropriate facilities to treat or incinerate the waste they receive in the correct manner. Waste acceptance is for waste disposal centres to perform, so do not need to be a concern to aesthetic clinics. The pre-acceptance audit needs to confirm the presence of:6 • Clinical infectious waste (including contaminated gloves, masks, aprons, paper towels, dressings or swabs) • Anatomical waste, human tissues and blood products • Medicines and medicinally contaminated waste (such as anaesthetic cartridges, blister packs, tablets in containers, unopened medicine vials, waste pharmaceuticals or out-of-date / denatured drugs) • Chemicals and chemically contaminated waste (including any items that have been contaminated with cytotoxic or cytostatic substances) • Microbiological cultures and related laboratory wastes to which additional controls may apply (for example, to ensure microbiological aerosol containment) • Mercury and amalgam • Non-hazardous waste such as municipal waste (including packaging, tissues, disposable cups and food wrappers) Of the above waste streams, anatomical waste and chemically or medicinally contaminated waste require incineration. Clinical infectious waste may be treated to render it safe prior to disposal and mercury, amalgam, and non-hazardous waste may be recycled or disposed of by recovery.

The pre-acceptance audit itself involves detailing the contents of waste produced by the clinic, as well as information on the business and when the audit itself was completed.3,7 This should include:

In Clinic Waste Audits

• Information on the waste producer such as type of provider (aesthetic/medical practice), address and contact details.

• Description of the specific processes from which waste is created – such as primary care and laboratory etc.

• An indication of what types of waste streams are produced – for ease, these can be separated according to the Department of Health’s best practice waste colour coding guidelines outlined in HTM 07-01: Safe Management of Healthcare Waste8 (while not mandatory, effective waste segregation can offer various time and cost benefits for the business). Information should also be provided on the estimated quantity of each waste stream produced, its physical form, composition, properties, classification and a further description as needed.

• For pure product chemicals or pharmaceutical waste, the audit may include reference to the product data sheets or provide an extrapolation of the information on the product data sheets.

• The type, size and labelling of containers used for each waste stream, information on the segregation practices employed.

• The date of commencement and completion of the preacceptance audit.

• A description of the audit, the procedures followed, the auditors and their affiliation with the waste producer.

Audits simplified While this may all seem like a lot of information, getting preacceptance audits right is a fairly straightforward process when approached methodically. The key is to understand its purpose and know everything that it involves before you begin – then it is simply a case of working through the clinic, recording what type of waste is produced, what containers it is stored in and whether it requires incineration or can be treated or repurposed safely, or, simply finding a third party to do this for you, if you so choose.

Once all of this is clear, the pre-acceptance audit should be a relatively smooth process and can very often be completed by an internal member of staff to ensure your compliance without requiring too much of their time. Constant reminders to the team about the protocols in place will ensure safe and effective waste management procedures are followed between audits and, most importantly, you can be confident that you are doing your part to protect your patients, your colleagues and the environment from potential harm.

Rebecca Waters has worked in the healthcare sector for the past 13 years and was a research chemist with Bayer Cropscience prior to joining Rentokil Initial in 2003. She keeps up to date on all developments within the clinical waste management industry and is an active member of the CIWM, SMDSA and BDIA. REFERENCES 1. Environment Protection Act 1990. Duty of Care as respects waste. Section 34. Link http://www. legislation.gov.uk/ukpga/1990/43/section/34 2. The Environment Permitting (England and Wales) (Amendment) (England) Regulations 2015. <http:// www.legislation.gov.uk/ukdsi/2015/9780111125601> 3. The Environmental Protection Act 1990. Link http://www.legislation.gov.uk/ukpga/1990/43/contents 4. The Environmental Agency. Briefing. Clinical Waste Pre-acceptance Produce Update – October 2010. Version 6. Link http://www.initial.co.uk/files/file_226926.pdf 5. Environment Agency. How to comply with your environmental permit. Additional guidance for: Clinical waste (EPR 5.07) Version 1.1 January 2011. Page 28, 13. Link https://www.gov.uk/government/ uploads/system/uploads/attachment_data/file/296418/geho0710bsvi-e-e.pdf 6. Environment Agency. How to comply with your environmental permit. Additional guidance for: Clinical waste (EPR 5.07) Version 1.1 January 2011. Link https://www.gov.uk/government/uploads/ system/uploads/attachment_data/file/296418/geho0710bsvi-e-e.pdf 7. Department of Health. Safe management of healthcare waste. Version 1.0. Link http://webarchive. nationalarchives.gov.uk/+/www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/ digitalasset/dh_126348.pdf 8. Environment and sustainability. Health Technical Memorandum 07-01: Safe management of healthcare waste. Link https://www.gov.uk/government/uploads/system/uploads/attachment_data/ file/167976/HTM_07-01_Final.pdf [Accessed December 2016]

Aesthetics | February 2017

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In faIrness

The professIonal’s vIew of TreaTIng skIn pIgmenTaTIon Pigmentation sPotlight Skin hyperpigmentation is a common complaint, takes many forms and is caused by a number of factors – exposure to the sun, hormonal changes, use of photo-sensitising medications or it can be hereditary. In its most common form, it presents itself as freckles caused by the sun, and may not pose a problem to the individual. At its worst it can be life-altering brown patches of skin on the face and neck that simply won’t go away without treatment.

What the exPerts say Practitioners are already realising the benefits that a blended, medium depth peel containing Glutathione can achieve when treating clients with hyperpigmentation.

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90% of those affected by skin pigmentation issues are women, just 10% are men. an individual aPProach Kelly Saynor, Clinical Director, Medica Forte says: “When looking to address skin pigmentation issues, it’s imperative that we determine what’s caused it in the first place, so it’s possible to treat it correctly and to set the right expectations with the client.”

“As a practitioner it’s crucial to understand that there may be no permanent cure for an individual’s pigmentation issue, it may reoccur due to exposure to the original stimuli that caused it. However treatment will help to considerably reduce, temporarily eradicate or completely remove it, lessening the impact upon everyday life.”

“Determining the route cause of pigmentations also allows us to better manage the level of treatment and further intervention required. The most obvious examples of re-occurrence would be further exposure to the sun or, in the case of melasma in pregnant women, hormonal changes brought on by further pregnancies.”

“The Perfect Peel® offers measurable results for Fitzpatrick 1-6 skin types when improving hyperpigmentation issues, and is extremely effective in delivering a vast improvement for most individuals, often in just one treatment.”

Dr Esho, Esho The Clinic “Peels are perfect for alleviating one of the most prevalent skin issues – hyperpigmentation. I’ve found that using The Perfect Peel® as part of a long-term process where the client returns for repeat applications over a period of time whilst keeping sun exposure to a minimum can reduce or completely eliminate pigmentation issues. The results are some of the best I’ve seen compared with other leading peels in the market. In a short time it’s become my top recommended product.”

Dr David Jack, Harley Street “In my own experience, this is one of the most effective peels for hyperpigmentation that I have used so far – it is extremely simple to use and the results I have seen are relatively impressive.”

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Aesthetics Journal

Aesthetics

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In Profile Dr Sean Lanigan

“What we need, as an industry, is more scientific rigour” Consultant dermatologist Dr Sean Lanigan explains how he became group medical director of sk:n clinics and discusses the importance of scientific research “My career wasn’t planned; I didn’t go to medical school thinking, ‘this is where I need to be in five years time’,” says Dr Sean Lanigan, adding, “Every step has come along far more fortuitously than planned.”

Dr Lanigan, who grew up in Birmingham, had no intention of becoming a dermatologist when he studied medicine at the University of Wales, Cardiff in 1978, but after particularly enjoying a work placement in this field, his mind was made up.

Dr Lanigan trained in dermatology at University College Hospital, London in 1983, where he developed an interest in the use of lasers. “The professor in charge of the unit was a specialist in gastroenterology but he used a laser for skin disease. I began to learn how to treat birthmarks and blemishes with lasers and I got really involved in a lot of research.” Dr Lanigan then continued his dermatology training and work with lasers in the NHS in Leeds in 1986, gaining as much experience as he could before moving back to Wales in 1989 to set up his own dermatology unit and become a consultant.

In 2000, Dr Lanigan was offered the chance to become group medical director of aesthetic company Lasercare, based in Birmingham, which would later change its name to sk:n. He says, “Accepting the post really did increase my exposure to the sort of aesthetic treatments that were available.

Lasercare was growing rapidly, doing a lot of hair removal treatments, and they had practitioners starting to use botulinum toxin and skin peels.” Around 2006, Lasercare was sold and rebranded as sk:n and the company rapidly grew, Dr Lanigan comments, “We launched clinics throughout the UK and, at present, we have 43 clinics nationwide and are still growing.”

Dr Lanigan now focuses on managing the two Birmingham branches of sk:n and runs a private clinic once a week. “Outside of sk:n I have other duties, primarily related to the British Cosmetic Dermatology Group (BCDG) where I am the president – we try and improve the education of doctors’ training

in dermatology.” This, he says, is a part of his career he really enjoys as it promotes education and training, “One of the biggest problems for dermatologists is how to learn about cosmetic dermatology, because it isn’t covered by the NHS. Cosmetic dermatology is a massive field now and it is very difficult to get good training in it, so that’s what the BCDG is all about, trying to make sure cosmetic dermatologists get some knowledge of this field outside of their practice.”

Education is fundamental, says Dr Lanigan, and he believes that the most important thing practitioners can do is to attend conferences and keep up-to-date on all the latest clinical research. “I’d say attend a couple of good conferences and read lots of peer-reviewed research. We are quite lucky in the UK that we now have some very good conferences running throughout the year. In the past you had to go to Europe or the US.” Dr Lanigan spent a lot of time researching, studying and presenting his findings regarding the treatment for port-wine stain birthmarks; something he says is without a doubt his biggest achievement. “When I first got involved in aesthetics, the treatment at the time wasn’t very good. Prior to lasers, the treatment of these birthmarks was either to inject yellow tattoo ink into them to make them look less obvious, or to cut them out.

The pulsed dye laser came out in the mid-80s and that really transformed the treatment. But there were lots of things we needed to learn to do it well and to make the best out of it. I feel that I made some significant contributions to the knowledge of what we can do to treat port-wine stain birthmarks now.”

Scientific evidence is something that Dr Lanigan feels very strongly about and he hopes that as the aesthetic specialty continues to grow, so will the level of scientific data. He says, “The evidencebased material needs to continue to improve – you need proper scientific research to prove what you are saying.

You need controlled trials, objective measurements, and, if you can do that, you Aesthetics | February 2017

can then convincingly indicate whether things work or not. What we need, as an industry, is more scientific rigour.” He concludes, “I do think the aesthetics specialty will keep on growing, there will be a limit to it, but I don’t believe we are anywhere close at the moment.”

What treatment do you enjoy giving the most?

I really enjoy doing lip enhancement – it looks great when you do it, the results are immediately visible and patients are really pleased with the results. I also think laser treatment for facial redness is really good because there are not many options available.

It works and you can really see the difference.

Do you have an ethos or motto that you follow?

I don’t tell people what they need; they need to tell me what they want.

If someone comes to see me with a big furrow on their forehead then they have to say that it’s a problem, it’s not for me to say ‘do you want some treatment for that?’

Looking back, is there anything you would have done differently?

I don’t think so and it’s nice to say that. I was lucky because I was involved with lasers in aesthetics at the onset; it was growing at the same time that I was learning.

What aspects of the industry do you enjoy the most?

What I really like is that it is a growing field, you’re not doing the same thing all the time, it changes constantly and there are lots of challenges.

TO WATCH THE VIDEO INTERVIEW VISIT WWW.AESTHETICSJOURNAL.COM

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Aesthetics Journal

Aesthetics

aestheticsjournal.com

The Last Word Consultant trichologist Iain Sallis argues the reasons why aesthetic practitioners and trichologists need to build more of a rapport If you were to lose every single hair on your head and body, it would not have an impact on your physiological health.

Yet, there are very few other aesthetic issues that can be as psychologically and emotionally devastating as hair loss.

Broadly speaking, many aesthetic practitioners do not have a vast knowledge of the causes and treatment of hair loss and the appropriate training needed. Yet, patients may open up to an aesthetic practitioner, as hair is still classed as ‘cosmetic’.

There are many reasons for hair loss, such as lifestyle, diet, hormones, medication, autoimmune or genetic conditions (or a mixture of any of the above),1 and to add to this, the reasons for losing hair has many ‘myths’ attached to it, meaning it would be easy for someone without the required expertise to give the wrong advice. Everything from sea kelp to stimulating the scalp with magnets to improve blood circulation to the hair follicles has been reported as a ‘cure’ for hair loss, with no or extremely limited scientific evidence to support their efficacy.2,3 Unfortunately advising your patient to go directly to their GP usually achieves very little, as they typically have little training regarding general thinning hair. Is it time aesthetic practitioners turned to trichologists to begin a new working partnership that could be beneficial for patients?

Acknowledging the issue Hair loss is a common aesthetic concern for both men and women. At my hair loss clinic, approximately 75% of my patient-base is female, which may be of surprise to many, who would presume it is a male-dominated sector. The majority of my patients are suffering from general diffuse, thinning hair.

Once patients have reached the point where they know they have a hair loss problem they may turn to an aesthetic practitioner, before or after seeing a GP to no avail. However, I have seen many patients that have been to aesthetic practitioners and not been given the most appropriate treatment for their condition and, instead, appear to be given the currently ‘popular’ hair treatment or the only one that is available at that clinic.

Aesthetics clinic who specialise in mesotherapy will likely swear that this is the best treatment for hair loss, and those clinics that specialise in PRP will likely say that that is the best course of therapy. These treatments may very well work, however, if treatment is undertaken without proper investigation, it could likely be the wrong treatment for that patient, may not work, and will lead to dissatisfied patients. Hair loss is not one single problem with one single treatment option.

Why may some aesthetic practitioners be wary?

Aesthetic practitioners may not consider approaching trichologists if they are not fully aware of our expertise. Hair loss is a big issue and a big business. Hair loss clinics can be set up by people without any qualification and can promise the earth at a costly price. But this is not the case with ethical and appropriately qualified trichologists.

Qualified trichologists, from the Institute of Trichologists, are trained in a plethora of subjects over a two to three year period.

They are not medically qualified but are medically trained in areas pertaining to the health of the hair and scalp. General chemistry, biology and genetics underpin more detailed subjects about diseases and disorders of the hair and scalp as well as its pathology, anatomy and physiology.4 It is important for qualified trichologists to set the bar, earn a good reputation and earn the respect of clinical and medical practitioners.

Why it’s time to come together An aesthetic practitioner does not always have the in-depth training of the issues that can affect hair, as a trichologist could not do an aesthetic practitioner’s job.

Many forms of hair loss are caused either by underlying medical issues, which, first and foremost, need to be investigated in a medical/evidence based-way such as using blood tests. In some cases, blood tests have been performed by a concerned GP/ aesthetic practitioner but misinterpreted, simply because they lack the specialist Aesthetics | February 2017

Last Word Trichologists

knowledge to realise what is affecting the hair. In many cases, aesthetic practitioners are looking for deficiencies rather than insufficiencies. There is a great opportunity for aesthetic specialists to team up with a local qualified trichologist, to ensure the correct bloods are taken and help with interpreting the results afterwards.

How it should work Trichologists can sift through the small detail of the patient’s problem, taking into consideration lifestyle, diet, medication and blood results. After we have investigated the issue, we can diagnose it and either help the aesthetic practitioner correct the long term medical issue, help the patient directly, correct simple vitamin/mineral disorders or refer the patient to a general practitioner if the problem is serious and requires specialist medical assistance. Local qualified trichologists can be found through the Institute of Trichologists website and practitioners can call them directly to discuss setting up a referral system.

Conclusion It is in everyone’s best interest that qualified trichologists and medical professionals start working more closely together to overcome what is a huge problem for men and women alike. Hair loss is a taboo subject; it is difficult for patients to talk about it and even harder to find the right person to talk to. If aesthetic practitioners and trichologists could build more of a closer working relationship with each other where they can advise one another, then hair loss can be treated much more effectively.

Iain Sallis has been a clinical trichologist for 17 years and consults in 11 clinics throughout the UK. Sallis is the founder of the Hairmedic Trichology clinics and Hairmedic Solutions Product Company.

He is also a member of the Institute of Trichologists, International Association of Trichologists, the European Hair Research Society Expert witness and associate member of the British Association of Hair Restoration Surgeons.

REFERENCES 1. D. J. Verret, Hair loss and Hair Restoration, Causes of Hair Loss, (2009) WSJ Publishing; Plano TX 2. Marie Claire, Sea Kelp for Hair Loss: does it work?, (2016) <http://www.marieclaire.co.uk/news/beauty-news/sea-kelpfor-hair-3889> 3. Dr. Carlos Puig, Myths About Hair Loss Treatment for Men (2013) <https://www.hairrestorationhouston.com/hairrestoration-blog/myths-about-hair-loss-treatment-for-men/> 4. The Institute of Trichologists, Trichology Training, (2017), http:// www.trichologists.org.uk/index.php/about-us/trichology-training

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UK/0721/2015

Date of Preparation: October 2015