Aesthetics September 2016

s d tic 16 ce he 20 n st ds ou Ae ar ann Aw ists l na Fi

VOLUME 3/ISSUE 10 - SEPTEMBER 2016

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Epidermal Barrier Treatment CPD Dr Ahsan Ullah details the function of the epidermal barrier

Facial Augmentation Practitioners discuss how they would augment the face of a hypothetical patient

Treating VVA Dr Suren Naidoo explains how to treat vulvovaginal atrophy with CO2 fractional laser

16/08/2016 11:08

Online Professionalism Victoria Vilas shares advice on maintaining a professional profile on social media

Preserve the identity of your patients with natural-looking results.1 Azzalure is proven to reduce the severity of glabellar lines.2 It provides fast onset of action (median 2-3 days)2 and long-lasting efficacy (up to 5 months)2, and almost 90% of patients felt the results “surpassed” or “met” their expectations.1 References: 1. Molina B et al. J Eur Acad Dermatol Venereol. 2015;29(7):1382-1388. 2. Azzalure Summary of Product Characteristics.

Actual Azzalure user. Fictional model name. Results may vary.

Azzalure Abbreviated Prescribing Information (UK & IRE) Presentation: Botulinum toxin type A (Clostridium botulinum toxin A haemagglutinin complex) 10 Speywood units/0.05ml of reconstituted solution (powder for solution for injection) Indications: Temporary improvement in appearance of moderate to severe glabellar lines seen at frown, in adult patients under 65 years, when severity of these lines has an important psychological impact on the patient. Dosage & Administration: Botulinum toxin units are different depending on the medicinal products. Speywood units are specific to this preparation and are not interchangeable with other botulinum toxins. Reconstitute prior to injection. Intramuscular injections should be performed at right angles to the skin using a sterile 29-30 gauge needle. Recommended dose is 50 Speywood units (0.25 ml of reconstituted solution) divided equally into 5 injection sites,: 2 injections into each corrugator muscle and one into the procerus muscle near the nasofrontal angle. (See summary of product characteristics for full technique). Treatment interval should not be more frequent than every three months. Not recommended for use in individuals under 18 years of age. Contraindications: In individuals with hypersensitivity to botulinum toxin A or to any of the excipients. In the presence of infection at the proposed injection sites, myasthenia gravis, Eaton Lambert Syndrome or Amyotrophic lateral sclerosis. Special warnings and precautions for use: Use with caution in patients with a risk of, or clinical evidence of, marked defective neuro-muscular transmission, in the presence of inflammation at the proposed injection site(s) or when the targeted muscle shows excessive weakness or atrophy. Patients treated with therapeutic doses may experience exaggerated muscle weakness. Not recommended in patients with history of dysphagia, aspiration or with prolonged bleeding time. Seek immediate medical care if swallowing, speech or respiratory difficulties arise. Facial asymmetry, ptosis, excessive dermatochalasis, scarring and any alterations to Adverse events should be reported. For the UK, Reporting forms and information can be found at www.mhra.gov.uk/yellowcard.

For Ireland, Suspected adverse events can be reported via HPRA Pharmacovigilance, Earlsfort Terrace, IRL - Dublin 2; Tel: +353 1 6764971; Fax: +353 1 6762517.

Website: www.hpra.ie; E-mail: medsafety@hpra.ie.

Adverse events should also be reported to Galderma (UK) Ltd. Azzalure and Galderma are trademarks owned by Galderma S.A Date of preparation: May 2016 AZZ/003/0216(1)

facial anatomy, as a result of previous surgical interventions should be taken into consideration prior to injection. Injections at more frequent intervals/higher doses can increase the risk of antibody formation.

Avoid administering different botulinum neurotoxins during the course of treatment with Azzalure.To be used for one single patient treatment only during a single session.Interactions: Concomitant treatment with aminoglycosides or other agents interfering with neuromuscular transmission (e.g. curare-like agents) may potentiate effect of botulinum toxin. Pregnancy & Lactation: Not to be used during pregnancy or lactation. Side Effects: Most frequently occurring related reactions are headache and injection site reactions. Generally treatment/injection technique related reactions occur within first week following injection and are transient and of mild to moderate severity and reversible. Very Common (≥ 1/10): Headache, Injection site reactions (e.g. erythema, oedema, irritation, rash, pruritus, paraesthesia, pain, discomfort, stinging and bruising). Common (≥ 1/100 to < 1/10): Facial paresis (predominantly describes brow paresis), Asthenopia, Ptosis, Eyelid oedema, Lacrimation increase, Dry eye, Muscle twitching (twitching of muscles around the eyes). Uncommon (≥ 1/1,000 to <1/100): Dizziness, Visual disturbances, Vision blurred, Diplopia, Pruritus, Rash, Hypersensitivity. Rare (≥ 1/10,000 to < 1/1,000): Eye movement disorder, Urticaria. Adverse effects resulting from distribution of the effects of the toxin to sites remote from the site of injection have been very rarely reported with botulinum toxin (excessive muscle weakness, dysphagia, aspiration pneumonia with fatal outcome in some cases). Prescribers should consult the summary of product characteristics in relation to other side effects. Packaging Quantities & Cost: UK 1 Vial Pack (1 x 125u) £64.00 (RRP), 2 Vial Pack (2 x 125u) £128.00 (RRP), IRE 1 Vial Pack (1 x 125u) €93.50, 2 Vial Pack (2 x 125u) €187.05 (RRP) Marketing Authorisation Number: PL 06958/0031 (UK), PA 1609/001/001(IRE) Legal Category: POM Full Prescribing Information is Available From: Galderma (UK) Limited, Meridien House, 69-71 Clarendon Road, Watford, Herts. WD17 1DS, UK. Tel: +44 (0) 1923 208950 Fax: +44 (0) 1923 208998 Date of Revision: April 2016

Contents • September 2016 06 News

The latest product and industry news

12 On the Scene

Out and about in the industry this month

14 News Special: Filming Procedures

Aesthetics investigates the growing trend of sharing patient treatment videos on social media

CLINICAL PRACTICE 19 Special Feature: Facial Augmentation

Three practitioners share their individual approaches to treating and augmenting the face of a hypothetical patient

25 CPD: The Epidermis

Dr Ahsan Ullah details the function of the epidermal barrier and explains how cosmetic treatments can affect this

28 LPT for Hair Loss

Consultant trichologist Sally-Ann Tarver discusses the science behind laser phototherapy

33 Lip Augmentation Part Two

Dr Lee Walker provides technique advice for treating the perioral area

36 Aesthetics Awards 2016

The finalists for the Aesthetics Awards 2016 are announced

42 Spotlight On: Juvapen

Aesthetics explores the efficacy of the new botulinum toxin injection system

44 Treating Vulvovaginal Atrophy

Dr Suren Naidoo details common vulvovaginal concerns and explains how to treat atrophy with CO2 fractional laser

46 Henna Tattoo Complications

Dr Anjali Mahto and Dr Derrick Phillips discuss the risks of black henna tattoos

51 Fat Reduction

Dr Tatiana Lapa and Mr Rishi Mandavia provide an overview of the different types of non-invasive fat reduction treatments

54 Bioidentical Hormone Therapy

Dr Marion Gluck details how bioidentical hormones can be used in aesthetic practice

56 Advertorial: Radara

A Micro-Channelling Approach to Skin Rejuvenation

57 Abstracts

A round-up and summary of useful clinical papers

IN PRACTICE 58 Staying Professional Online

Victoria Vilas shares advice on maintaining a professional profile on social media

63 Opening a Franchise

Aesthetic franchisor Rudi Fieldgrass shares advice on franchising a clinic

67 Writing an Effective Blog Post

Mike Nolan shares advice on creating engaging content for your blog to retain and gain new aesthetic patients

71 In Profile: Dr Tracey Bell

Dr Tracey Bell shares the experience of her first visit to an aesthetic clinic and explains how it encouraged her to join the specialty

73 The Last Word

Mike Murphy argues that professionals need to take more care to ensure they are using the correct laser safety glasses appropriately

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Business Develoment Franchising a Clinic Page 63

Clinical Contributors Dr Ahsan Ullah is the medical director at My Skin Clinic. He specialises in facial rejuvenation for women and male facial masculinisation, alongside antiageing treatments. Dr Ullah is a member of the BCAM and AAAM. Sally-Ann Tarver is a trichologist with 20 years’ experience in hair loss diagnosis and treatment. She established Cotswold Trichology in 1998 and also practised in Harley Street, London. Tarver is a past president and fellow of The Trichological Society.

Dr Lee Walker is a former cosmetic dental surgeon who has more than 14 years’ experience in nonsurgical facial aesthetics. He is clinical director at B City Clinics in Liverpool and speaks at many industry conferences, and also lectures for Teoxane UK. Dr Suren Naidoo has been in general practice since 1973. He has special interests in dermatology and since 2004 has worked as an aesthetic practitioner at the BMI Cavell Hospital in Enfield.

Dr Naidoo is an associate member of the BCAM. Dr Anjali Mahto is a medical and cosmetic dermatologist at The Cadogan Clinic. She has an interest in acne, rosacea, injectable and laser therapies. Dr Mahto is a member of the British Cosmetic Dermatology Group and a spokesperson for the British Skin Foundation.

Dr Derrick Phillips graduated from UCL Medical School in 2011. He completed four months of dermatology as a junior doctor, was awarded the St John’s Dermatology Prize, and has presented dermatological cases at international and national conferences.

Dr Tatiana Lapa is the medical director of The Studio Clinic on Harley Street. She is a fully qualified doctor and an experienced aesthetic practitioner with a background in surgery, dermatology and general practice.

Mr Rishi Mandavia is a trainee ENT, head and neck surgeon and NICE scholar with academic interests in ENT health policy research. He is also a NICE specialist advisor for its guidelines and quality development programmes.

Dr Marion Gluck trained as a medical doctor in Hamburg more than 30 years ago and has worked all over the world as a women’s health specialist. Dr Gluck is passionate about the use of bioidentical hormones and runs a training course on their appropriate use.

Vote now for the Aesthetics Awards 2016 www.aestheticsawards.com

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

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Editor’s letter September is one of those months that signals new beginnings; whether it be a new school, a new season or a new business. For me, it is a great time to evaluate, restart or just continue with all the great stuff that is going on. Here Amanda Cameron at Aesthetics, September represents the start Editor of the Awards countdown. Finalists for the Aesthetics Awards are announced on p.36 of this issue (for those of you who haven’t already gone straight there) and planning has really turned up a notch. If you haven’t already booked your tickets, now is the time to do so – visit www.aestheticsawards.com today!

This month we chose augmentation as our topic for our Special Feature – you can imagine the fun the team had when brainstorming what to cover! You would be surprised at the number of areas we came up with, which really shows the versatility of aesthetics. Eventually, we decided to be innovative and look at different approaches to augmenting one face. We spoke to a surgeon, a dermatologist and an aesthetic doctor to really offer you a variety of options and demonstrate the choice we have in the marketplace today. We hope you enjoy reading this

alternative feature on p.19.

Dr Ahsan Ullah has written September’s CPD article, which takes a close look at the skin and, in particular, the importance of maintaining the epidermal barrier – check out this useful read on p.25. Another particularly interesting article in this month’s issue has been written

by Dr Anjali Mahto and Dr Derrick Phillips, who take a close look at the complications that can occur as a result of henna tattoos. This was a complete revelation to me as I had not realised the extent of the issues that they may bring – we focus so much on tattoos administered with a needle that, generally, the temporary ones tend to be forgotten. Read up on how you can successfully manage henna tattoo complications on p.46.

Whatever stage you are at with your business, we hope you enjoy reading the journal each month. One of our main objectives at Aesthetics is to publish a wide range of articles, which educate and inform the whole range of professionals working within the specialty.

We hope you all learn at least one new thing after reading each issue!

Let us know your thoughts on this issue by tweeting us @aestheticsgroup or emailing editorial@aestheticsjournal.com

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

Dr Raj Acquilla is a cosmetic dermatologist with more than 12

Sharon Bennett is chair of the British Association of

Dr Tapan Patel is the founder and medical director of VIVA

Dr Christopher Rowland Payne is a consultant

Mr Adrian Richards is a plastic and cosmetic surgeon with

Dr Sarah Tonks is a cosmetic doctor, holding dual

Dr Maria Gonzalez has worked in the field of dermatology

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

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

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

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

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

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

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Skincare

Talk #Aesthetics Follow us on Twitter @aestheticsgroup #Acne Dr Stefanie Williams @DrStefanieW Age distribution for our #Roaccutane patients at #Eudelo.

You can see what a massive problem #AdultAcne is! #Acne 3.2% 50.8%

14.3%

Age <20 Age 21-30 Age 31-40 Age 41-56

31.7%

#Celebration S-Thetics @MissBalaratnam Thanks @MondrianLDN for a fantastic evening celebrating our clinic 1st year anniversary #glam #slick #London #Condolences Sharonbennettskin @sharonbennettuk RIP Ivo Pitanguy. A pioneer, generous and talented. #Journal The Faceologist @the_faceologist Catching up on the latest with @aestheticsgroup great article from Dr Kieren Bong on how not to burn out at work #aesthetics

Medik8 launches Retinyl Retinoate Youth Activating Cream Global skincare brand Medik8 has launched a new retinol product aimed at treating ageing skin without the irritation. The Retinyl Retinoate (r-Retinoate) Youth Activating Cream is a hybrid vitamin A compound made with a condensing reaction of retinol and retinoic acid. It is claimed that by fusing these two actives together into one hybrid molecule, patients can gain the effects of both, but without the potential drawbacks, including irritation to the skin. Kim et al conducted two clinical studies on Korean women with periorbital wrinkles. In the first clinical study, the efficacy of retinyl retinoate was compared with a placebo. Twenty-four patients completed a 12-week trial of 0.06% retinyl retinoate applied twice-daily to one side of the face and a placebo applied to the other side. In the second clinical study, the efficacy of retinyl retinoate was compared with retinol. Twenty-two patients completed an eightweek trial of 0.06% retinyl retinoate applied twice daily to one side of the face and 0.075% retinol applied to the other side. Efficacy was based on a global photodamage score, photographs, and image analysis using replicas and visiometer analysis every four weeks. The results from the studies indicated that the wrinkles treated with retinyl retinoate improved compared with a placebo or retinol, as assessed by both the investigators and the subjects. The r-Retinoate Youth Activating Cream will be available in October 2016.

Body contouring

Report suggests the body contouring market will rise to almost £1 billion #Training Dr Simon Zokaie @ssz2011 Thank you to Allergan and Sherina for a fantastic training day on helping patients! #liniaskinclinic #allergan #Feedback Dr Razwan @Skyn_Doctor Gaining clients by word of mouth is the biggest compliment one can receive! #Injectors Dr Apul Parikh @ApulParikh The new generation of injectors!

Delegates from Oman, Ireland and good old Blightly! #dermalfillers #botox #training

A report by research and consulting firm GlobalData has suggested the body contouring sector across 15 major markets (mm) is set to rise in value from £500 million in 2015 to almost £1 billion by 2022. The company’s latest report states that the growth from the 15mm, which are the US, France, Germany, Italy, Spain, the UK, Japan, China, India, Brazil, Australia, Canada, Mexico, Russia and South Korea, will be driven by rising obesity rates, increasing numbers of men seeking cosmetic procedures, and advancement in the availability and quality of non-surgical procedures. “The global obesity epidemic is significantly increasing the number of people seeking body contouring procedures,” said Brigitte Babin, analyst at GlobalData. “Despite the fact that it is only recommended as a method to remove small pockets of fat, people continue to look for easier alternatives to diet and exercise for reducing their body fat content.” The number of men who underwent non-invasive body contouring treatments in the US increased from 14,598 in 2012 to 26,902 by 2015; an annual increase of 22.6%.

Reproduced from Aesthetics | Volume 3/Issue 10 - September 2016

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Awards

Alumier Labs UK announced as Aesthetics Awards sponsor Skincare developer Alumier Labs UK will sponsor the Clinic Reception Team of the Year category at the Aesthetics Awards 2016.

The award is for reception teams of any size working in a clinic in the UK or Ireland. It recognises strong commitment to ongoing outstanding consumer service, a continuous training programme, strong practitioner support and effective teamwork for the benefit of the clinic and its patients.

Marketing manager at Alumier Labs UK, Samantha Summerfield said, “We know the difference great people can make to our customers and we are thrilled to have the opportunity to sponsor the Clinic Reception Team of the Year as that will be a team that deals with all aspects of the patient’s experience.”

Booking for the Aesthetics Awards 2016 is open, with the ceremony taking place on Saturday December 3.

For more information visit www.aestheticsawards.com Melanoma

Study suggests patients with skin of colour are less likely to survive skin cancer The Journal of the American Academy of Dermatology has released a study indicating that patients with skin of colour are less likely to survive melanoma than Caucasians. US researchers in Cleveland used the country’s National Cancer Institute’s Surveillance, Epidemiology and End Results database to study almost 97,000 patients diagnosed with melanoma from 1992 to 2009. According to the report, African-American patients were more likely to be diagnosed with melanoma in its later stage compared to Caucasians and other ethnicities. They were also less likely to survive, having had the worst prognosis for every stage of melanoma despite the stage of which they were diagnosed. Study co-author and dermatologist, Dr Jeremy Bordeaux said, “Everyone is at risk from skin cancer, regardless of race. Patients with skin of colour may believe they aren’t at risk, but that is not the case – and when they do get skin cancer, it may be especially deadly.”

Training

New course dates announced for Marion Gluck Training Academy Bioidentical hormone specialist Dr Marion Gluck will be running more training courses in London to help practitioners understand the role and benefits of hormones. Among the topics discussed in the course, Dr Gluck will explain bioidentical hormone therapy (BHRT) and how it differs from hormone replacement therapy, how to understand the menstrual cycle, and how to incorporate this knowledge into practice. Delegates will also receive six CPD points over the six-hour course. Nurse prescriber Caroline Hill, who attended Dr Gluck’s course in July, said, “This course was exceptionally well structured.

It was exciting, informative and armed you with the skills and knowledge to consult, diagnose and treat women with PMS, peri-menopause and menopausal symptoms within your own practice.

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

BACN AUTUMN AESTHETIC CONFERENCE 2016 Headline speakers have been confirmed for the 2016 Conference in Birmingham: Mr Ash Labib: The 15-minute nose job Anna Baker: Commonly encountered skin lesions Dr Raj Acquilla: The MD Codes Visionary Programme Mrs Sabrina Shah-Desai: The Anatomical Lift Dr Emma Ravichandran and Dr Stefanie Williams: Contouring the Jawline and Lower Face NEW for 2016: Alongside the clinical presentations and demonstrations we also have specialist business workshops from a range of industry leaders covering The Aesthetic Patient, IndustryWide Initiatives and The Customer Experience. In addition, there will be 50 exhibitors showcasing their medical aesthetic services for delegates at the exhibition. The BACN Conference is open to all medical professionals and bookings can be made via the BACN website.

COSMETIC REDRESS SCHEME (CRS) The BACN has signed up to the newly launched Hamilton Fraser-led CRS. This independent redress scheme has been established to manage patient service complaints and is now being offered to all BACN members. The scheme enables independent expert arbitration of patient service complaints to avoid escalation and aims to benefit all parties.

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

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

MEET A MEMBER Adrian Baker is an aesthetic nurse prescriber working at the MBNS Clinic and Qutis Advanced Skin Clinic in Oxfordshire. In 2014 and 2015 he led the BACN competency group for the annual RCN accreditation update, which helps steer and integrate the future accreditation and educational routes for the BACN – this is still available on the BACN website. Baker is also a co-author of The BACN Aesthetic Nursing Competency Framework.

This column is written and supported by the BACN

Reproduced from Aesthetics | Volume 3/Issue 10 - September 2016

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Events diary 17th September 2016 British Association of Cosmetic Nurses Autumn Aesthetic Conference, Birmingham www.bacn.org.uk

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

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

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

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

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

Aesthetics Journal

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Skincare

Alumier Labs launches new cosmeceutical line Skincare developer Alumier Labs UK has released a new cosmeceutical line, AlumierMD. According to the company, the new range can be used on Fitzpatrick skin types I-IV and includes cleansers, moisturisers, serums and exfoliators for both in-clinic and home use, chemical peels, eye creams, and a neck and décolleté cream. Marketing manager at Alumier Labs UK, Samantha Summerfield, said, “We are beyond excited to be launching AlumierMD into the market. This is a next-generation offering into the aesthetic skincare arena – we have created a product line that’s core is clean science – using only what is necessary for advanced results for a multitude of skin concerns. AlumierMD is results-driven; if it doesn’t work, we don’t use it.”

Alumier Labs UK says it has incorporated many key ingredients to create the desired effects in the products, including hinokitiol, L-ascorbic acid, sea whip, oyster phoenix mushroom, oligopeptide-10, encapsulated salicylic acid, encapsulated retinol, glutathione and gluconolactone, as well as Matrixyl Synthe’6 and Haloxyl formulations. The product range will be officially released on September 13.

Awards

Business

Finalists announced for the Aesthetics Awards 2016

After months of deliberation, the finalists for the Aesthetics Awards 2016 have been announced. The Park Plaza Westminster Bridge Hotel will play host to the much-anticipated awards ceremony on December 3, which celebrates the very best in medical aesthetics.

Commended and Highly Commended finalists will be recognised in more than 20 categories at the event, as well as the Winners, who will receive a trophy on stage in front of colleagues and peers. The evening will commence with a drinks reception, followed by a formal sit-down three-course meal and entertainment from British stand-up comedian Hal Cruttenden. The awards ceremony will then begin, recognising the highest standards in achievement, clinical expertise and product innovation. Guests will then celebrate the evening by enjoying music and dancing late into the night.

See pages 36-40 of this month’s journal for the full list of finalists.

To book your ticket or to vote, visit www.aestheticsawards.com

Healthxchange provides new Obagi Prescribing Consultation Service Pharmaceutical supplier Healthxchange Pharmacy has launched the Obagi Prescribing Consultation Service to help clinics that may not have the resources or time to prescribe the products themselves. Clinics can sign up to the service and market the Obagi Consult Day to their patients, which will allow patients to have a consultation with a nurse prescriber who can educate them about Obagi and prescribe them products. Nurse prescriber Jo Ward and pharmacist prescriber Mary Keltai are currently working with the service. Ward said, “Working with clinics helps build a nice relationship because these are the clinics that love Obagi but either don’t have a prescriber of their own and are seeking to bring one on-board, or they may be a business that is growing and may require extra prescribing services for Obagi Medical. We see this as extra support and educational service for our Obagi clinics.”

Healthxchange hopes that this service will help clinics market Obagi products, as well as allow them to save time and grow their profits through more prescriptions. “Obagi is the first skincare/ cosmeceutical company to introduce a Prescription Consultation Service, which demonstrates the unsurpassed support Obagi continues to provide for its clients,” said Donna Ofsofke, clinical educator of UK distributor, Healthxchange Pharmacy. She added, “Now all clients can grow profit without any cost.”

Reproduced from Aesthetics | Volume 3/Issue 10 - September 2016

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Laser

Syneron Candela releases PicoWay Resolve Laser Eraser Aesthetic device company Syneron Candela has launched a new holographic fractional laser for the PicoWay Resolve.

The PicoWay Resolve Laser Eraser aims to treat signs of ageing by stimulating the skin’s repair mechanism and encouraging collagen production. The Resolve’s two fractional wavelengths, 532 nm and 1064 nm, enables treatments of shallow and deep imperfections, treating skin texture, pigmentation, sun spots, fine lines and wrinkles. Syneron Candela claims that visible improvement can be seen after just one treatment but recommends that patients have one to three treatments, four weeks apart, for maximum benefit. According to the company, the treatment is also painless, requiring no anaesthetic and no downtime.

Jonathan Hunt, Syneron Candela’s regional manager, said, “Resolve uses picosecond pulses, which are equal to a trillionth of a second, which enables any target pigment in the dermis to be shattered into small enough pieces that can be removed safely by the body’s macrophage activity.” He continued, “Using the unique holographic lens in Resolve, the intensity of each spot on the skin has the same amount of energy, giving predictable and consistent results on all skin types every time.”

Aesthetics

Vital Statistics Last year, 4,205 rhinoplasty procedures were carried out on both men and women in the UK (The British Association of Aesthetic Plastic Surgeons, 2016)

90%

More than 90% of 15 to 17-year-old girls worldwide want to change at least one aspect of their physical appearance (Dove, 2016)

One in five women in the US use a facial cleansing brush device (Mintel, 2015)

Skin tightening

Schuco debut Plasma IQ The Plasma IQ device has been released in the UK by aesthetic distributor Schuco International. The Plasma IQ is a non-invasive device that aims to tighten the skin on the upper and lower eyelids, reduce fine lines around the eyes and the mouth, improve skin laxity and reduce the appearance of scars.

According to the company, plasma is generated through targeted microbeams to cause sublimation, shrinking the epidermis without the transfer of heat. Schuco claims that the device provides localised, targeted treatments with minimal downtime. “We are really excited to be introducing Plasma IQ to the UK and adding it to the Schuco product range,” said Sharon King, nurse prescriber and national clinical training and development manager at Schuco. added, “This product provides a safe, non-invasive alternative to traditional surgery with minimal downtime.”

Retinol

NeoStrata Retinol + NAG Complex launches Antiageing skincare company AestheticSource has added the NeoStrata Retinol + NAG Complex to its product portfolio. According to the company, the product aims to address fine lines, wrinkles, dark spots and sagging skin by delivering 0.5% of pure, stabilised retinol with 4% NeoGlucosamine, a NeoStrata non-acid exfoliator that aims to help build hyaluronic acid and activate enzymes. Lorna Bowes, director of AestheticSource, the distributor of NeoStrata in the UK, said, “I am very excited about the launch of NeoStrata Retinol + Nag Complex because it represents many years in research and development, giving practitioners and their patients a cosmetically appealing, easy to use, high potency retinol-based product at a cost effective price point.”

More than 1/3 of patients with plaque psoriasis suffer from the moderate-to-severe form (International Federation of Psoriasis Associations, 2016)

There are approximately 1,783,935 beauty videos on YouTube (Pixability 2015)

Dermatologic surgeons in the US performed nearly 10 million medically necessary and cosmetic procedures in 2015 (American Society for Dermatologic Surgery, 2016)

The prevalence of varicose veins is greater in women (55%) compared to men (45%) (Chicago Vein Institute, 2014)

Reproduced from Aesthetics | Volume 3/Issue 10 - September 2016

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News in Brief UK practitioners pay tribute to Brazilian plastic surgeon Mr Ivo Pitanguy Aesthetic practitioners in the UK have paid tribute to Brazilian plastic surgeon Ivo Pitanguy, who passed away aged 93 on August 6. It was reported that Mr Pitanguy had been suffering from kidney problems and died after his heart failed during a dialysis treatment. Chair of the BACN Sharon Bennett said, “RIP to a great plastic surgeon, who put Brazil on the world map. He trained and mentored hundreds of today’s finest plastic and cosmetic surgeons.”

Nimue Skin Technology releases Pro Age Foundation Skincare company Nimue Skin Technology has added the 3D Matrix Pro Age Foundation to its product range. The product is formulated with Ceramide 2 and PEG-10 Phytosterol, which aim to boost the repair mechanism of the skin, improve collagen production and keep the skin hydrated whilst providing 3D-appearing coverage. The Pro Age Foundation comes in four shades and also contains UBV protection.

Save Face and BBC expose ‘bogus’ nurse practising in Wales The BBC has released a report with the help of accreditation body Save Face to expose a ‘bogus’ aesthetic nurse in Wales, who has allegedly fabricated her qualifications and employment records.

According to the report, Vivienne Baker, from Porthcawl, claims to have administered botulinum toxin and other non-surgical cosmetic treatments to more than 10,000 patients in Wales. Following an investigation by the BBC Wales consumer TV programme X-Ray, it was revealed that Baker, who operates under the name ‘Vizzy Bizzy’, does not have a nursing qualification, has forged a prescribing certificate and fabricated an employment record since 2008.

Meder Beauty appoints new UK distributor Skincare company Meder Beauty International has appointed Strategy M Ltd as its sole distributor in the UK. Dr Tiina Orasmae-Meder, founder of Meder Beauty, said, “We are confident that our partnership will provide better service for all our customers, both business and private, by offering fast deliveries, special deals and additional services.

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Training

New dermal filler complications course launches in Coventry Consultant ophthalmic plastic reconstructive surgeon Mrs Sabrina Shah-Desai and aesthetic nurse prescriber Jackie Partridge will hold a dermal filler complications course on October 15 in Coventry. The ‘Anatomical Basis of Prevention and Management of Dermal Filler Complication Course’ will be a hands-on one-day course involving a fresh cadaver wet-lab, aiming to promote safe aesthetic practice amongst medical professionals. The course aims to give delegates an understanding of facial anatomical layers and intermediate and advanced safe filler injection techniques using different types of fillers. Delegates will practice anatomical surface marking, gain confidence in the prevention and management of common dermal filler complications, including the use of hyaluronidase, and be updated on current protocols for the management of vascular complications. The one-day course includes lunch and refreshments, handouts, fillers, hyaluronidase, a certificate of attendance and possible CPD accreditation, which has been applied for.

PDO threads

MedivaPharma launches PremiumLift PDO Threads UK pharmaceutical supplier MedivaPharma has added a range of polydioxanone threads to its product portfolio. PremiumLift PDO Threads come in a variety of needle gauges and lengths, and aim to treat a range of areas on the face and body for skin reinforcement, lip contouring, body contouring, face shape strengthening, collagen stimulation and skin tightening.

According to Krasotec AC, the manufacturers of the threads, the treatment process is smooth due to a silica gel coating, the patient’s pain and risk of side effects is reduced due to the smooth needle pipe, and the needle has a smooth surface.

Gary Wilson, commercial manager at MedivaPharma, said, “MedivaPharma is proud to launch PremiumLift PDO Threads and cannulas as a result of their recent partnership with Krasotec, a Swiss-based medical manufacturer. We are really excited to begin this new distribution arrangement and bring quality PDO threads to the UK and ensure our clients continue to receive a quality, customer-focused pharmacy service and wide range of aesthetic products.”

Skincare

Dr Levy Switzerland releases new makeup remover and skin cleanser Cosmeceutical brand Dr Levy Switzerland has launched the 3DEEP Cell Renewal Micro-Resurfacing Cleanser to its Intense Stem Cell line. According to creator Dr Phillip Levy, the product aims to act as both a makeup remover and skin cleanser, and its formula acts on three fronts. The ‘double micro-resurfacing’ action aims to treat dullness and fight pollution toxins locked in the skin’s superficial dead cells. The ‘antiageing cellular renewal’ action hopes to accelerate cell turnover and improve skin radiance, while also reducing the signs of ageing, and the ‘skin hydration and soothing’ action preserves the natural protective barrier, allowing the skin to retain its plumpness and elasticity.

Reproduced from Aesthetics | Volume 3/Issue 10 - September 2016

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Complaint management

BACN sign up to Hamilton Fraser Redress Scheme The Hamilton Fraser Cosmetic Redress Scheme (CRS) will now be offered to all members of the British Association of Cosmetic Nurses.

The CRS aims to resolve complaints made by consumers against traders in the cosmetic, aesthetic and beauty industry. “The BACN is pleased to support the newly announced Cosmetic Redress Scheme as a major new initiative to provide arbitration between members of the public and practitioners with regard to the service delivery of aesthetic procedures,” said CEO of the BACN Paul Burgess. He added, “BACN members place patient safety as one of their primary objectives and welcome all initiatives that enable any concerns over service delivery to be resolved quickly and to the satisfaction of all parties.” Sean Hooker, head of redress said, “The Cosmetic Redress Scheme is authorised by the Chartered Trading Standards Institute and designed to resolve complaints made by consumers against practitioners in the cosmetic industry.” He continued, “By joining, members will comply with their legal requirement to signpost their customers to an authorised redress scheme and also provide them with peace of mind that they can expect excellent customer service every step of the way. We are delighted to have the support of the British Association of Cosmetic Nurses and look forward to working closely with them to help improve complaint handling in the industry.”

The CRS is authorised by the Chartered Trading Standards, a body that represents trading standards professionals working in the UK. Melasma

Study suggests long-pulsed alexandrite laser is moderately effective in treating melasma A study published in Dermatologic Surgery has indicated that long-pulsed alexandrite laser with a fractional handpiece can produce moderately effective results in treating women with melasma. Researchers studied 48 Korean women with melasma, with a mean age 44.1 years, who were treated with two to four sessions of fractional, 755 nm long-pulsed alexandrite laser with two to three week intervals. Of the women, 27 had Fitzpatrick skin type 3, and 21 women had Fitzpatrick skin type 4. To treat the lesions, a 15mm spot size of the fractional handpiece was used with settings of 60-80 J/cm2, without a dynamic cooling device, and a 0.5-1 millisecond pulse width. Researchers noted that compared with baseline, there was a ‘significant decrease’ in the mean modified melasma area and severity index score, two months after final treatment. A reduction of 30.5% in the mean score was indicated. Patients with an epidermal type of melasma displayed significant improvement compared to those with the dermal type of melasma, in mean modified melasma and severity index scores. A 51% to 75% improvement was noted in 20 patients (41.7%), while 15 patients (31.3%) were suggested to show a 26% to 50% improvement using the quartile grading scale. Improvements were rated excellent by 10.4% of patients, while good-or-fair improvement was reported by 70.8% of patients.

“A fractional, long-pulsed 755 nm alexandrite laser was adapted for the treatment of melasma in patients with a Fitzpatrick skin type 3 or 4,” Lee et al said, “It is believed that long-pulsed alexandrite laser is effective and has few side effects in the treatment of melasma. However, as the outcome of monotherapy with the longpulsed alexandrite laser was not completely satisfactory for patients, and because the melasma subtype affected the efficacy of long-pulsed alexandrite laser, a combination with other modalities, such as topical agents and chemical peels, may be needed to optimise the management in unsatisfactory cases.”

60

Lee Garrett, Independent Nurse Prescriber What products and services does The Garrett Clinic offer?

The Garrett Clinic cares about what’s inside as well as outside.

We offer a full range of treatments including injectables, skincare, body contouring and laser treatments. Fixing the outside without the inside doesn’t work and doesn’t last – our customers need to feel, as well as see, improvement.

When you select a skin range what do you look for?

Whilst safety is of utmost importance, efficacy is also critical. I have to see a full range of evidence that indicates that the products we bring in will work for my patients, as well as fit into their lifestyle.

Why did you decide to use Obagi over other skincare brands?

We tried other brands but none seemed to offer the consistently positive results seen with Obagi Medical Products. Obagi has years of clinical evidence with many outstanding patient results, because there is an Obagi product for everyone and compliance is often easily achieved. It’s also about the support around the product that really makes it work for us, the marketing and clinical support we get from Obagi is fantastic.

What do Obagi products enable you to offer your patients that you couldn’t before?

Clinical research counts for a lot – you simply can’t put patients at risk, or risk our reputation running a treatment that doesn’t work. We need to have confidence in what we’re offering.

We also need the marketing backup that Obagi provides – the service, support, and consultancy they offer to up-skill us.

What have you planned for The Garrett Clinic’s future?

We have a good family of treatments and products the customers are following, and they all synergise together. We’ll now expand our team and find practitioners to grow with the clinic that have the same mindset as us.

This column is written and supported by

Reproduced from Aesthetics | Volume 3/Issue 10 - September 2016

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NITHYA launch, London Aesthetic practitioners were invited to the UK launch of NITHYA at the Royal Society of Medicine on July 26. Hosted by aesthetic supplier Vida Aesthetics, the event included a presentation and a live demonstration from Italian aesthetic practitioner Dr Giovanni Merone.

Dr Merone explained that the class III medical device is a heterologous type I collagen powder, which when mixed with Water for Injection and administered through intradermal infiltration, aims to restore existing collagen and stimulate the production of new collagen to promote natural regeneration.

He said that the product should be used in two to four treatments, depending on the patient’s skin condition, and results of increased skin density and elasticity are visible after seven to 14 days. Dr Merone also outlined how NITHYA has been successful in wound healing and scar treatment, and detailed how the product can be used in combination with other treatments such as CO2 laser, thread lifting, fillers and botulinum toxin. According to clinical research presented, there have been no complications or adverse reactions to NITHYA and no histological damage is evident. Attendee Dr Mohammed Ahmad, who has been using NITHYA in his clinic at 10 Harley Street, said, “I feel that NITHYA fills a gap for patients who don’t want anything too invasive as it offers a softer approach and more subtle rejuvenation. I’ve started using it with successful results and have been very satisfied. The studies that have been presented today have been interesting, however I believe the best evidence you have is the research you do yourself, and is gathered through patient feedback.”

Eddy Emilio, director of Vida Aesthetics, said of the evening, “It went extremely well. People were very engaged and asked lots of questions, which was great. NITHYA is the first of its kind and is very unique – there’s nothing else like it at the moment. We believe it will take the market by a storm.”

Retinyl Retinoate Youth Activating Cream launch, London Global skincare brand Medik8 revealed its new antiageing product to aesthetic professionals and members of the press in London on August 10. The breakfast event for the launch of Retinyl Retinoate (r-Retinoate) Youth Activating Cream, was held at the Sky Gardens on Fenchurch Street, and included a presentation from Medik8 founder Elliot Isaacs, who explained the science behind the product.

He explained that r-Retinoate is it is a hybrid vitamin A compound made with a condensing reaction of retinol and retinoic acid and

Aesthetics Journal

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PicoWay Resolve Laser Eraser launch, London The new holographic laser handpiece for the PicoWay Resolve was presented by Syneron Candela at a breakfast and live demonstration event in London on August 2.

Attendees of the event watched a presentation

by Syneron Candela’s regional manager Jonathan Hunt, at the Pulse Light Clinic, Percy Street, where he explained the science behind the Laser Eraser and the indications for use, which includes pigmentation, wrinkles, fine lines, acne and acne scarring. After the presentation, attendees were escorted to the treatment room to watch a live demonstration of the laser. According to Syneron Candela, treatments tend to take between 25 and 30 minutes, with one to three treatments recommended four weeks apart to feel the maximum benefit. Hunt said, “I was very excited to be involved in the breakfast event at Pulse Light Clinic for the UK launch of new PicoWay Resolve, the new treatment for pigmentation, skin rejuvenation and skin toning. The event was attended by some of the most prestigious journalists in our industry, and they were very impressed by the innovative technology.”

Femilift training day, London Aesthetic laser supplier ABC Lasers ran a training workshop for the Femilift device at Courthouse Clinics, Wimpole Street, on July 29.

Aesthetic practitioners who attended the event were taught about the laser by Albert Best, leader of the ABC Lasers surgical team. Best educated the practitioners about the techniques and benefits of the Femilift C02 treatment. He gave a full tutorial of how the treatment aims to reduce urinary stress incontinence, tighten the vaginal canal, improve sexual sensation, improve vaginal mucosal lubrication and help women feel more youthful. Each practitioner then saw three model patients and gave each a full Femilift treatment after an initial consultation and procedure consent and examination. Dr Kathryn Taylor-Barnes, who attended the training event, said, “All the models were pleasantly surprised that the procedure was quick (only 15 minutes) and the only degree of discomfort for them was towards the end of the treatment, described as 3/10 intensity and a ‘warm feeling’.” claimed that it delivers the full benefits of the retinol ingredient without the irritation.

Issacs then went on to show a range of clinical studies that support the effects of the product. After his talk, attendees were served breakfast and were invited to ask questions about the product. "After eight years of work from multiple scientist groups from all around the world, it feels tremendously exciting to finally be able to talk publicly about the technology inside r-Retinoate Youth Activating Cream,” said Isaacs. “We were blown away by the positive reaction at the stunning Sky Gardens venue. We simply cannot wait until October 2016 when this technology becomes available to our professional clinic stockists," he added.

Reproduced from Aesthetics | Volume 3/Issue 10 - September 2016

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Filming Aesthetic Procedures: good marketing or unethical?

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Using visual social media in practice

“Social media is a strong and powerful form of communication that we now use it not just with patients, but with the public in general,” says aesthetic practitioner and surgeon Miss Sherina Balaratnam, who uses Twitter, Facebook, Instagram and Pinterest to share content with her followers.

Balaratnam explains that while she does film Snapchat and Instagram are becoming ever more Miss her consultation style and skincare treatments, popular in the cosmetic surgery and aesthetic she does not share photographs and videos of injectable procedures, because there is limited specialty, with photographs and videos being control over who can view them. “As a medical used to showcase procedures and the results of professional, I need to act and behave ethically and responsibly on my videos as they are a form of treatment. Aesthetics asks practitioners, how communication between my patients and I, and we ethical is this? And, is doing so an effective shouldn’t convey the wrong messages,” she says. Mr marketing tool?

Olivier Branford, a plastic surgeon based at the Royal Marsden in London, who is an avid user of Twitter Social media has quickly become a key marketing platform with 67,000 followers as of August 2016, agrees. He does not film for many businesses in recent years, allowing companies to any of his surgical procedures for social media, as he believes, “Any communicate instantly with an engaged and varied audience.1 operation should be entirely focused on the safety and quality of the For the cosmetic surgery and non-surgical aesthetic specialties, care for that patient. There should be no distractions for the surgeon clinics can use social media to update and educate their patients or the surgical team in achieving this.” on new trends and treatments within their sector; which, as well as Mr Branford also serves on the Social Media Task Force at the being useful to current patients, can attract new patients too.

American Society of Plastic Surgeons (ASPS) and says social media is However, recent reports in the international press have highlighted here to stay. “If you don’t exist in the digital world then it is difficult to cases of plastic surgeons marketing their services to the extreme; achieve impact,” he says, adding, “Visual social media is very popular with photographs and videos of unconscious patients on the and results in much greater engagement.” Mr Branford also notes, operating table – having fat removed, their breasts augmented or however, that there is a very fine, sometimes blurred, line between buttocks lifted – being shared on photography-based social media education and self-promotion. He argues, “Those values that govern platforms such as Snapchat and Instagram.2,3,4 The short clips and our everyday practice, such as an emphasis on quality, safety and graphic images have led many people to question the morality of education, should also be applied to social media.” sharing such content on social media, asking, is it ethical and within patients’ best interests to market cosmetic surgery and aesthetic Safety and education procedures in this way?

For practitioners using Snapchat, it has been argued that the limited time that the clips are available for restricts the viewers’ The growth of social media marketing opportunity to learn from the content that is being shared. Miss In January this year, the Search Engine Journal reported that, globally, Balaratnam says, “The platform doesn’t allow the viewer to read 1.7 billion people have active social media accounts, with this number about how the treatment works, contraindications, side effects and set to rise by 14.2% in 2018.5 Of 2,800 marketers surveyed by the complications that could potentially occur.”

Social Media Examiner in 2014, 92% said that their social media efforts Aesthetic nurse practitioner Claudia McGloin, who uses Blogger, have generated more exposure for their businesses, while 80% Facebook and Twitter to engage with patients, says she would claimed that they had increased traffic to their websites as a result of consider filming procedures in a tasteful manner for social media in social media marketing.1 Instagram and Snapchat are among the the future, “In some videos and photographs I’ve seen, practitioners top ten social media platforms, with 400 million and 200 million aren’t wearing gloves, which is not only unprofessional, but unsafe.” monthly active users reported in January 2016, respectively.5 Both She adds, in cases of non-surgical treatments being shared on social platforms use photographs and videos to communicate and share media, some practitioners do not appear to be practising in a clinical content among users, with Instagram allowing users to upload setting, claiming that some are wearing jewellery, have their nails permanent content to their profile, and Snapchat being used to painted and/or are not dressed appropriately. “This does not set the share up to ten-seconds of photographs or video clips that can right look for medicine,” says McGloin, noting, “Practitioners could be viewed for 24 hours.6 Recently, Instagram has introduced a be putting patients at risk of infection, as well as suggesting to their similar feature that allows users to upload short clips that are only potentially large audience that this type of setting is acceptable for available for 24 hours.7 medical aesthetic procedures.”

The value of visual content is high; in 2016 it was reported that content with relevant images gets 94% more views than content Content without, and 51.9% of marketing professionals worldwide name video The graphic nature of some of the videos and photographs that as the type of content with the best return on investment.8 have been circulating on social media is one of the main concerns So, while it is apparent that producing image-based content for social highlighted by the practitioners interviewed. Miss Balaratnam suggests media marketing is beneficial, is it ethical for aesthetic practitioners to there are three types of viewers; practitioners and healthcare be utilising it to share videos and photographs of procedures? professionals who are looking to further their education, potential

Reproduced from Aesthetics | Volume 3/Issue 10 - September 2016

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patients who are genuinely interested in a procedure, and a third group, who Miss Balaratnam calls ‘the gawkers’. She says, “These are individuals who like watching the gory content of medical procedures and could be young and impressionable.” In regards to non-surgical procedures, McGloin says one of her pet hates is being able to see blood in the videos or photographs. “This isn’t tasteful and may scare viewers, so make sure you wipe it away if you are going to share images of procedures,” she advises. Mr Branford adds, “Surgery should never be trivialised or reinvented as voyeurism.”

Audience While Instagram and Snapchat, as well as other social media sites such as Facebook and Twitter, do allow users to reach many people, there is limited control over who can view content. Both platforms can be made private, with an option for the user to approve followers,9,10 however many businesses tend not to use this function as it can make you less accessible to the people you do want to target.

Practitioners interviewed for this article therefore argue that professionals should seriously consider their audience when sharing photographs and videos on social media. Miss Balaratnam says, “We can ethically choose not to treat a certain age group, but we are unable to control who’s looking at our social media pages. We may think it’s likely to be a 45-year-old woman who is genuinely looking for a procedure, but it could be a young adolescent” She continues, “I am seeing a rise in the number of younger girls requesting lip fillers whilst showing me graphic videos of lip filler treatments on their mobile phones, asking if I can offer the same procedure and results. And these results are often over-enhanced. What they don’t recognise is that the procedure may have been performed by a non-medical person, in unsafe conditions, or may not be the most appropriate treatment for them based on their facial assessment. It is unfortunate, because despite assessing and educating them, there is nothing I can do to stop young girls being influenced by what they see on social media.”

Mr Branford is also concerned about the age of viewers that social media can reach. He says, “The Instagram and Snapchat social demographic is a young one, including teenagers and young children, with half being in the 18 to 24-year-old age group.”1 Mr Branford says that this is not an appropriate audience to be targeting, arguing, “We should be reinforcing positive body image and never encouraging young people to have aesthetic procedures.” He adds, “Any surgeon that uses social media to promote their business with disregard for its effects on a developing adolescent generation should have a very long, hard look at their ethical code. Anything that is posted online can be viewed and saved by anyone. We should never encourage patients to make themselves vulnerable or do something that they might regret, even many years later.”

Consent “If it’s not documented, it’s not happened,” says McGloin, who emphasises the importance of practitioners seeking written consent if they do choose to share patient videos and photographs on social media. “The patient could still turn around and say, ‘Well, I didn’t know you were going to put it on Instagram, I thought it was only going to be a three-second video on Snapchat’,” she notes, adding, “If you’ve got everything written down and counter-signed then you can protect yourself from complaints.”

Miss Balaratnam highlights that it is also important for practitioners to explain to patients exactly what they are signing consent for. She suggests that practitioners should verbally explain and make clear on written consent forms whether their photographs and videos are

Aesthetics

“Surgery should never be trivialised or reinvented as voyeurism” Mr Olivier Branford

being used for internal clinic training, external teaching at meetings and conferences, or whether they are going to be used on websites and social media. If so, practitioners need to detail which social media platforms they will be shared on and how often they will be shared.

Guidelines In light of the growth of social media, the General Medical Council (GMC), the Nursing and Midwifery Council (NMC), and the General Dental Council (GDC) all have guidelines on its appropriate usage.

The GMC and GDC both state that the standard expected of doctors and dental professionals does not change because they are communicating through social media rather than face-to-face or through other traditional media,11,12 while the NMC emphasises that nurses should not post anything on social media that may be viewed as discriminatory, does not recognise individual choice or does not preserve the dignity of those receiving care.13 Moving forward, Mr Branford has co-authored an article, along with Dr David Song, the president of the ASPS, and Dr Rod Rohrich, editorin-chief of Plastic and Reconstructive Surgery (PRS), on the appropriate use of social media. He explains that the article, #PlasticSurgery, which will be published in PRS in December 2016, was created on the evidence-based desire for public education and engagement on social media, without self-promotion. Mr Branford explains that the authors hope the article will reinforce the value of a strong, personal ethical code for all surgeons. He concludes, “A high-quality practice will always be successful. One that has a questionable moral code will, eventually, by the democratic nature of social media, fall on its own sword. We should always focus on education and quality.”

REFERENCES 1. Michael A. Stelzner, 2014 Social Media Marketing Industry Report, US: Social Media Examiner, (2014) <https://www.socialmediaexaminer.com/SocialMediaMarketingIndustryReport2014.pdf> 2. Brittany Vonow, Selfie Surgeon: Fury as Ukraine plastic surgeon poses for SELFIES with naked patients unconscious on the operating table after boob jobs and shares the intrusive photos on social media (UK: The Sun, 2016) < https://www.thesun.co.uk/news/1428347/fury-as-ukraineplastic-surgeon-poses-for-selfies-with-naked-patients-unconscious-on-the-operating-table-afterboob-jobs-and-shares-the-intrusive-photos-on-social-media/?CMP=spklr-_-Editorial-_-TWITTER-_TheSunNewspaper-_-20160712-_-News-_-514469188> 3. Kara O-Neill, Dr Miami thrills viewers with gory live cosmetic surgery videos – from bum implants to boob jobs (UK: Mirror, 2016) <http://www.mirror.co.uk/news/world-news/dr-miami-thrills-viewersgory-8030520> 4. Margaret Abrams, Meet the Plastic Surgeon Who Broadcasts Procedures on Snapchat (US: Observer, 2016) < http://observer.com/2016/06/meet-the-plastic-surgeon-who-broadcastsprocedures-on-snapchat/> 5. The Growth of Social Media v3.0 [Infographic] (US: Search Engine Journal, 2016) https://www. searchenginejournal.com/growth-social-media-v-3-0-infographic/155115/ 6. Snapchat Support (US: Snapchat, 2016) <https://support.snapchat.com/en-US/article/post-story> 7. Introducing Instagram Stories (US: Instagram, 2016) <http://blog.instagram.com/ post/148348940287/160802-stories> 8. Jesse Mawhinney, 37 Visual Content Marketing Statistics You Should Know in 2016 (US: Hubspot, 2016) <http://blog.hubspot.com/marketing/visual-content-marketing-strategy#sm.00002ycnkyc85d6 f11w7iazc0j3r6 > 9. Privacy Policy (US: Instagram, 2016) <https://www.instagram.com/about/legal/privacy/> 10. Privacy Settings (US: Snapchat, 2016) <https://support.snapchat.com/en-US/ca/device-settings> 11. Doctors’ use of social media (UK: General Medical Council, 2013) <http://www.gmc-uk.org/guidance/ ethical_guidance/21186.asp> 12. Guidance on using social media (UK: General Dental Council, 2016) <http://www.gdc-uk.org/ Dentalprofessionals/Standards/Documents/Guidance%20on%20using%20social%20media.pdf> 13. Social Media Guidance (UK: Nursing and Midwifery Council, 2016) <https://www.nmc.org.uk/ standards/guidance/social-media-guidance/read-social-networking-guidance-online/>

Reproduced from Aesthetics | Volume 3/Issue 10 - September 2016

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Before

After

Before and after imagery: all patients have had their Ultherapy® treatment line counts tailored to their individual needs by their practitioner. These line counts may differ from those recommended in the Instructions For Use.

*stimulates new collagen and elastin which can reverse the signs of ageing References: 1. Sasaki GH & Tevez A. JCDSA. 2012; 2: 108-116 2. Ulthera System Instructions for Use, 1001393IFU Rev H 3. Lee HS, et al. Dermatol Surg. 2011;1-8 4. Data on File: ULT-DOF-008 – Ultherapy Mechanism of Action White Paper 5. Brobst RW, et al. Facial Plast Surg Clin N Am. 2014;22:191-202 6. ULT-DOF-003 Ultherapy Treatment Duration. Merz - July 2015 7. Alam M, et al. J Am Acad Dermatol. 2010;62:262-269 8. http://www.accessdata.fda.gov/cdrh_docs/pdf13/k134032.pdf Accessed May 2016 9. CE Certificate 3808396CE01, DEKRA April 2012 Adverse incidents must be reported. Reporting forms & information can be found at www.mhra.gov.uk/yellowcard. Adverse incidents must also be reported to Merz Pharma UK Ltd by email to ukdrugsafety@merz.com or on +44 (0) 333 200 4143

www.ultherapy.co.uk

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Augmenting the Face Three practitioners assess the face of a hypothetical patient and share their individual approaches to treating and augmenting the area

Frontal and side views of 39-year-old Patient A. Fitzpatrick skin type either II or III, depending on how the patient tans. Images courtesy of Canfield and Surface Imaging.

Dr Askari Townshend, aesthetic doctor “The things that jumped out for me was her brow position and her chin” “My philosophy is that I always describe myself as your kind of ‘bread and butter’ man. So I do, I hope, the simple things well,” explains Dr Askari Townshend. In every patient assessment, he looks at skin colour and texture, lines and wrinkles, facial volume and any other striking concerns. “The things that jumped out for me with this lady was her brow position and her chin,” he says.

Whilst assessing Patient A’s facial skin colour, Dr Townshend notes, “Her skin’s fairly even – there’s some slight dyschromia as you’d expect, so I would start with skincare that would even-out this colouration.” He explains that the type of skincare he would recommend to this patient would depend on her budget, “We would think about using vitamin A products, retinols, going up to prescription strength tretinoin.” Dr Townshend says that for vitamin A, he would suggest that Patient A uses either NeoStrata Skin Active Retinol + NAG Complex, Medik8 6TR or 10TR or ZO Skin Health Retamax.

Dr Townshend would also treat Patient A with a gentle chemical peel, “I would do a medium depth trichloroacetic acid (TCA) peel 20% or 25% from Enerpeel, which would help this patient with her brown spots and uneven texture and will add some luminosity to the skin.” However, Dr Townshend notes that this would require up to 10 days downtime, which many patients cannot afford. He says that, if necessary, “We could try and offer a compromise; we have some pretty gentle peels that mean that you don’t have to suffer any downtime, but you have to keep coming back for more of them.” Dr Townshend also looks at addressing fine lines and wrinkles using botulinum toxin (BoNT-A), with Botox being his product of choice. He notes that it is difficult to judge where injections are needed with static images, but explains that her low brow really stands out to him, “I suspect it’s from skin laxity, and over the years the skin over the forehead has had some solar elastosis, so we can potentially use some BoNT-A around the superior fibres of orbicularis oculi – this muscle is a muscle that pulls the eyebrow down

so if we weaken it Treatment options and product list we hope that the frontalis muscle • Skincare brands: NeoStrata, takes over and will Medik8 or Zo Skin Health help pull them back • Chemical peel: Enerpeel TCA up,”1,2 Dr Townshend peel might also consider • BoNT-A: Botox injecting BoNT-A • Filler: Juvéderm in the depressor • Devices: 3JUVE angularis oris (DAO) radiofrequency to lift the corners of the mouth, because, “They are looking a bit sad,” he says. However, the treatment would depend on how strong her DAO was, “If she didn’t have a very strong muscle, I would actually do this with filler – I think this would be my approach unless her muscle said otherwise.”

When addressing facial volume, Dr Townshend would use a dermal filler to augment Patient A’s forehead and chin. The Juvéderm filler range are usually his go-to products. “Patient A seems to have a flat frontal bone and forehead, but it might just be that she’s always had quite low brows because of the curvature of her bone,” says Dr Townshend, adding that, to correct this, “We can put filler into her forehead above the eyebrows to see if we can lift those brows up.” He says he would use a cannula here rather than a needle because, “I will know that I’m probably not in the right space if there is any resistance or difficulty, so I can come out and start again.”

Dr Townshend suggests that the chin is likely to be a problem area for this lady, explaining that, “She has quite a bulbous chin, and so you can imagine that she may have quite an active muscle, but at the same time this chin is sitting really far back, and I suspect what she needs is her chin built up a little.”

Finally, Dr Townshend says he would offer Patient A a course of radiofrequency treatments using his 3JUVE system for skin tightening, “That’s going to help with her droopy eyebrows and her chin as well – it’s something that could be an ongoing treatment for her.”

Reproduced from Aesthetics | Volume 3/Issue 10 - September 2016

NOW APPROVED FOR

UPPER FACIAL LINES The first and only aesthetic neurotoxin approved for combination treatment of Upper Facial Lines including: • Horizontal Forehead Lines • Crow’s Feet Lines • Glabellar Frown Lines

CONFIDENCE IN MY CHOICE

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

Bocouture® (incobotulinumtoxinA) 50 units Prescribing Information M-BOC-UK-0007 Please refer to the Summary of Product Characteristics (SmPC) before prescribing. Presentation: 50 units of Botulinum toxin type A (150 kD), free from complexing proteins as a powder for solution for injection. Indications: Temporary improvement in the appearance of moderate to severe upper facial lines (glabellar frown lines, crow’s feet lines, horizontal forehead lines) in adults below 65 years when the severity of these lines has an important psychological impact for the patient. Dosage and administration: Unit doses recommended for Bocouture are not interchangeable with those for other preparations of Botulinum toxin. Reconstitute with 0.9% sodium chloride. Horizontal Forehead Lines: Intramuscular injection, the recommended total dose range is 10 to 20 units, a total injection volume of 0.25 ml (10 units) to 0.5 ml (20 units) is injected into the frontalis muscle in five horizontally aligned injection sites at least 2 cm above the orbital rim. An injection volume of 0.05 ml (2 units), 0.075 ml (3 units) or 0.1 ml (4 units) is applied per injection point, respectively. Glabellar Frown Lines: Intramuscular injection (50 units/1.25 ml). Total recommended standard dose is 20units. 0.1ml (4units) into 5 injection sites (2 injections in each corrugator muscle and 1 injection in the procerus muscle). May be increased to up to 30 units. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. Crow’s Feet lines: Intramuscular injection (50units/1.25mL). Total recommended standard dosing is 12 units per side (overall total dose: 24 units); 0.1mL (4 units) injected bilaterally into each of the 3 injection sites. Injections too close to the Zygomaticus major muscle should be avoided to prevent lip ptosis. Not recommended for use in patients over 65 years or under 18 years. Contraindications: Hypersensitivity to the active substance or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, Lambert-Eaton syndrome).

Infection or inflammation at the proposed injection site. Special warnings and precautions: It should be taken into consideration that horizontal forehead lines may not only be dynamic, but may also result from the loss of dermal elasticity (e.g. associated with aging or photodamage). In this case, patients may not respond to Botulinum toxin products. Should not be injected into a blood vessel. Not recommended for patients with a history of dysphagia

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

Frequency of adverse reactions by indication is defined as follows: very common (≥ 1/10); common (≥ 1/100, < 1/10); uncommon (≥ 1/1000, < 1/100); rare (≥ 1/10,000, < 1/1000); very rare (< 1/10,000). Upper Facial Lines: Very common: Headache.

Common: Hypoaesthesia, injection site haematoma, application site pain, eyelid ptosis, dry eye, facial asymmetry, sensation of heaviness, nausea. Glabellar Frown Lines: Common: Headache, Muscle disorders (elevation of eyebrow). Crow’s Feet Lines: Common: Eyelid oedema, dry eye, injection site haematoma.

For a full list of adverse reactions, please consult the SmPC. Overdose May result in pronounced neuromuscular paralysis distant from the injection site. Symptoms are not immediately apparent post-injection. Bocouture® may only be used by physicians with suitable qualifications and proven experience in the application of Botulinum toxin. Legal Category: POM. List Price 50 U/vial £72.00 Product Licence Number: PL 29978/0002 Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer Landstraße 100,60318 Frankfurt/Main, Germany.

Date of Preparation: July 2016. Further information available from: Merz Pharma UK Ltd., 260 Centennial Park, Elstree Hill South, Elstree, Hertfordshire WD6 3SR.Tel: +44 (0) 333 200 4143

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

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

1. Bocouture® 50U Summary of Product Characteristics (SPC).

April 2016. Available from: https:/www.medicines.org.uk/emc/ medicine/23251 2. Carruthers A et al. Multicentre, Randomized, Phase III Study of a Single Dose of IncobotulinumtoxinA, Free from Complexing proteins, in the Treatment of Glabellar Frown Lines. Dermatol Surg. 2013:1-8 3. Prager W, et al. Comparison of Two Botulinum Toxin Type A Preparations for Treating Crow’s Feet: a Split-Face, DoubleBlind, Proof-of-Concept Study. Dermatol Surg. 2010 Dec; 36 Suppl 4:2155-60 4. Kerscher M, et al. Efficacy and Safety of IncobotulinumtoxinA in the Treatment of Upper Facial Lines: Results From a Randomised, Double-Blind, Placebo-Controlled, Phase III study. Dermatol Surg 2015;41:1149-1157 5. BOC-DOF-012 Bocouture® Convenient to Use, August 2015 BOCOUTURE® is a registered trademark of Merz Pharma GmbH & Co, KGaA. BOC/78/JUL/2016/LD

Date of preparation July 2016

PURIFIED1• EFFECTIVE2, 3,4 • CONVENIENT5

Botulinum toxin type A free from complexing proteins

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Dr Stefanie Williams, dermatologist “Overall the square facial shape looks more masculine than feminine” Dr Stefanie Williams says that every new aesthetic patient at her clinic will undergo a comprehensive 90-minute assessment. She explains, “During this time, we start with a Visia digital imaging scan to measure skin surface parameters such as pore size, pigmentation, invisible sun damage, skin texture and wrinkling. We will then analyse skin physiology parameters with our Courage + Khazaka device including skin hydration, sebum production, epidermal barrier function, skin surface pH and skin elasticity.” Patient A’s full medical history and her areas of concern will also be noted and Dr Williams will analyse the face both lying down and sitting up, taking into account facial volume and contours, lines and winkles (both resting and in motion), as well as skin surface changes. In her assessment of Patient A, Dr Williams says that, “Overall the face looks a little ‘angry’ and ‘tired’ with small eyes, low eyebrows, deep tear troughs, glabella frown lines and downward facing corners of the mouth. It also looks quite round/square, lacking contour with submental fat, loss of jaw line definition, lack of cheekbone contours and possibly masseter hypertrophy, but I would need to examine the patient in person to be sure about the latter. The square facial shape also makes the face look less feminine.”

In addition, Dr Williams also notices enlarged pores, mild irregular pigmentation, superficial but sharp-edged nasolabial lines, and mild marionette lines, as well as some asymmetry to the face, such as in the eyebrow position. She says that there is also scope to improve the contour of the bridge of the nose. However Dr Williams explains that, “I would discuss with the patient that the main problem is the ‘angry look’, and masculine facial contours. I would suggest that we should start to improve the first impression, making her look ‘friendlier’ and more feminine – more attractive rather than younger looking.”

To improve the ‘angry look’ Dr Williams says, “I would lift Patient A’s eyebrows, open her eyes and ease her frown lines with BoNT-A (in this case Bocouture), as well as ease her brow asymmetries with BoNT-A. I would inject into specific points of the orbicularis occuli, the procerus and corrugator for this, plus add a little HA filler to lift the eyebrows. To soften asymmetries I might use slightly different BoNT-A dosages left and right.” Dr Williams would avoid treating the forehead with BoNT-A as she believes this could make her eyebrows heavier. She notes that if nonsurgical treatments are not effective for the eye area, she might refer Patient A for an upper blepharoplasty.

To lift the corners of the mouth, Dr Williams would treat the DAO with BoNT-A. Alternatively, a HA filler (such as Belotero Intense) in the marionette lines, she says, will also achieve this. Dr Williams would also inject a HA skin booster for the tear troughs, “A few drops of Restylane Vital Light along the depression would improve the dark under-eye circles and improve skin quality here.” For the nasolabial lines, Dr Williams explains she would treat Patient A with a blanching technique using Belotero Soft. This is a technique that she says works particularly well in superficial, sharply edged-in lines. Filler is injected very superficially – strictly intradermal – so much so that a tiny wheal is raised, which temporarily blanches the

Aesthetics

skin. As Dr Williams notes, the appearance Treatment options and brand list of a feminine face is usually more heart• Skincare brands: NeoStrata, shaped than that of Skinceuticals, Medik8, Avene, a male. In order to Jan Marini, plus prescription enhance the patient’s tretinoin feminine features • BoNT-A: Bocouture and improve facial • Filler: Belotero, Juvéderm contours, she would • HA skin booster: Restylane firstly use fat-dissolving Vital light injections under the • Fat dissolving: Aqualyx chin and along the • PRP: Tropocells system jawline using Aqualyx, which aims to liquefy the fat cell and release the eliminated lipids through the lymphatic system, destroying it permanently in the area.3 Dr Williams recommends that Patient A is likely to need two to three sessions in four-week intervals and she would suggest a winter procedure, so that Patient A can hide the swelling with a scarf, which can last approximately a week.

“Once the fat is reduced, I would then send Patient A to one of my colleagues to have an Ulthera lower face lift, which I think works well in combination with Aqualyx, but the fat should be dissolved first so the lower face is less heavy and easier to lift,” says Dr Williams. She notes that this patient might suffer from masseter hypertrophy; if this were true upon a clinical examination, it could be treated with BoNT-A to further slim the lower face.

To create a more feminine, heart-shaped face, Dr Williams says she would subtly augment the cheeks, “A combination of reducing heaviness in the lower face while adding contour to the cheeks is ideal; I would therefore inject a lifting HA filler into the lateral cheeks, such as Juvéderm Voluma or Belotero Volume, to recreate a more sculptured cheekbone appearance and add contour to the face.” Dr Williams says that if Patient A wishes, all her dermal filler and BoNT-A treatments could be performed in one session.

In addition to these corrective procedures, Dr Williams is very passionate about educating every patient on the importance of regular regenerative procedures to slow down the ageing process on a cellular level. She says, “I feel that no patient should have only corrective procedures without boosting skin regeneration.

My suggestion for this lady would be a course of platelet-richplasma (PRP) needling to start off with, as this would also nicely improve her enlarged pores at the same time.” Patient A is likely to require three sessions in six-week intervals and the patient can expect 24-48 hours of erythema, according to Dr Williams.

She says that all of her patients leave her clinic with a tailored, written skincare regime, and, for Patient A, she would include a vitamin C-containing antioxidant serum and an SPF 30-50 moisturiser for the morning. “For the evening, I would give Patient A an arbutin/kojic acid-containing anti-pigment serum, prescription tretinoin twice each week, and a peptide-containing moisturiser,” she explains. Dr Williams believes that treating any patient should ideally involve an ongoing effort with gradual improvements over time; “I explain to my patients that this is the start of a journey, not a one-off event. Bit by bit, we work on the identified issues and regenerative procedures should be done in regular intervals.”

Reproduced from Aesthetics | Volume 3/Issue 10 - September 2016

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Mr Dalvi Humzah, consultant plastic, reconstructive and aesthetic surgeon “Her lower face is the main concern in terms of facial balance” “Firstly, I would ask Patient A what her areas of concern are, then I would analyse the full face, showing her how she can get an overall improvement,” explains Mr Dalvi Humzah. Whilst assessing these images, Mr Humzah notes that, “Her main issue is that she has heavy features; her lower-third and nose are the main concerns, the tear troughs are really striking and you can open those eyes up by just lifting the brows – those are the main things that really stand out for me.” To address the brow non-surgically, Mr Humzah would inject BoNT-A, either Azzalure or Bocouture, “Near the lateral tail of the eyebrow to stop the orbicularis oculi muscle from working, allowing the frontalis to lift the brow up.”1,2 He would inject filler in the forehead, probably Belotero Volume, to help the brow lift and to also add curvature and contour to the forehead. “I would also talk to her about a potential brow lift procedure such as an Endotine TransBleph brow lift to fix it in a more permanent position.”

Around Patient A’s eyes, Mr Humzah notes that, “The main problem is the tear trough deformity on the lower eye lid,” which he says he would address with Belotero Balance filler, although if Patient A wanted, “She would be a good candidate for the transconjunctival blepharoplasty, where you do the procedure through an incision on the inner part of the inside of the eye rather than on the outside.” In her mid-face, Mr Humzah notes a dip in the lower part of Patient A’s nose, which he says might not be a concern for her. However, he maintains that using Belotero or Radiesse fillers could hide this contour defect or a surgical rhinoplasty procedure could straighten the nose, refine the tip and bring it slightly forward to reduce the width of the alar. He says, “I would offer Patient A fillers as a first-line, just to change that little contour defect, but if she wanted an overall change then surgery would be the best option.” Mr Humzah would also slightly augment the cheeks, but would not consider an implant here, “Between 0.5ml and 1ml of filler would give her more curvature just below the tear trough area to give it a bit more of a rounded curvature, as it’s a bit flaccid at the moment.”

Mr Humzah comments that, “Patient A’s lower face is the main concern in terms of facial balance.” He explains, “If you look at her whole chin and jawline area, it lacks any sort of any prominent jawline effects – she’s got a bit of platysma smoothening there and you can’t see the jawline contour.” Mr Humzah’s treatment method would be to, “Offer her a little bit of liposuction around the neck and jawline, just to enhance and clarify the jaw contour, and then look at perhaps putting some filler in the base of her chin just to bring the chin and the lower part of her face down and increase the width.” In the lower third of the face he would use Radiesse, because, according to Mr Humzah, “It’s very good for jaw contouring.” Mr Humzah also says he would converse with the patient about lifestyle and diet as he thinks that she is carrying a little bit of extra weight around this area. For Patient A, Mr Humzah might also consider skin

Aesthetics

tightening to help improve the jawline Treatment options and product list and submental fat, “I would use • Skincare brands: Image radiofrequency or Skincare or NeoStrata Ultherapy – that • Chemical peel: Obagi Medical, works really well on Skintech or Neostrata the lower third for • BoNT-A: Azzalure or Bocouture tightening the skin, • Filler: Belotero or Radiesse so she might get • Devices: Pellevé radiofrequency some improvement or Ultherapy machine for that.” He says • Surgical considerations: he would use the Endotine TransBleph brow lift, Pellevé device for transconjunctival blepharoplasty, radiofrequency or the rhinoplasty Ultherapy machine.

• Liposuction To improve Patient A’s overall skin clarity and brightness, after a careful skin analysis, Mr Humzah’s treatment method would also include skincare and chemical peels, recommending a glycolic cleanser and vitamin C moisturiser from either Image Skincare or NeoStrata, “That’s a protocol I recommend – good cleansing, good moisturising, and sun protection.” His peel of choice would depend on his consultation with the patient, but he would recommend ones from Obagi Medical, Skintech or Neostrata, “We also use those in combination depending on what the patient needs – this needs to be done with a very careful skin analysis which you cannot really do on a photograph.”

Mr Humzah concludes, “Each of these treatments should be done in a staged manner, because, if you do too much in one go it’s difficult to get a good result and it’s going to be quite expensive for the patient. What you offer will really depend on the patient’s budget, however advising them to always maintain a good skincare regime and a healthy diet and lifestyle is always beneficial for ageing skin.”

Mr Humzah would inject BoNT-A, either Azzalure or Bocouture, “Near the lateral tail of the eyebrow to stop the orbicularis oculi muscle from working, allowing the frontalis to lift the brow up”

REFERENCES 1. Abrahams PH, Hutchings RT, Marks SC, Color Atlas of Human Anatomy, (2003), 2. Norton NS, Netter’s Head and Neck Anatomy for Dentistry, (2011).

3. What is Aqualyx? (2014) <http://www.aqualyx.co.uk/product>

Reproduced from Aesthetics | Volume 3/Issue 10 - September 2016

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1

Other cells also present in the epidermis, which are part of the barrier function of the stratum corneum include:15 • Melanocytes – which secrete melanin and provide a barrier against UV radiation • Merkel cells – which provide a sensory role and detect light touch and sensation • Langerhan cells – which are dendritic cells that initiate an immune response when there is any injury to the skin

Treating the Epidermis Dr Ahsan Ullah details the function of the epidermal barrier and explains how cosmetic treatments can affect this ‘Beauty is only skin deep’ – a phrase which originated and evolved from the works of British poet Sir Thomas Overbury in 1613 – “All the carnall beauty of my wife, is but skin deep.”1 Indeed he was correct to a point, but the question arises, how deep? The study of dermatology has revealed complex but vital functions of the skin, which can be classified into three main categories of protection, regulation and sensation2 and are achieved through the layers of the skin; the epidermis, the dermis and the hypodermis/ subcutaneous fat. In this report we will focus on the epidermal layer and its barrier functions.

Stratum spinosum As the keratinocytes undergo mitosis, they travel upwards and form the stratum spinosum consisting of mainly squamous cells. This is the thickest layer of the epidermis and provides strength and flexibility as the keratinocytes become flatter and more condensed. A process known as keratinisation begins in this layer.14,16 Stratum granulosum Cell differentiating continues and the keratinocytes get further compressed and flattened to form a three-to-five cell layer of the epidermis. These granular cells contain keratohyalin, which appears under a light microscope as dark granules and contains two proteins called profilaggrin and involucrin, which play an essential part in the barrier function of the epidermis. The profilaggrin aids keratin aggregation in the stratum corneum and involucrin, whose role is to aid formation of the cell envelope that protects the keratin in the stratum corneum. Lamellar granules, also present, contain lipids and glycoproteins, which help act as an adhesive in the stratum corneum layer.5 Stratum lucidum This is a thick three-to-five layer of hyperdense keratinocytes forming an extra barrier against external stressors to the skin, especially seen on the palms and soles.

Layers of the epidermis

The epidermis The epidermal layer comprises four main layers: the stratum basale, stratum spinosum, stratum granulosum and stratum corneum; and it also has a fifth layer (if we include the stratum lucidum found in areas such as the palms and soles). These layers mainly consist of keratinocytes, which produce the protein keratin, and it is the maturation process of the keratin, which is seen across the layers of the epidermis.3 To discuss the role further, we explore the deepest layer of the epidermis – the basal cell layer.

Basal cell layer (stratum basale) Keratinocytes populate the majority of the single, often cuboidal to columnar, layer of basal cells, by up to 95%,4 and provide a highly organised structure. They contain intracellular proteins called tonofilaments in each individual keratinocyte, which form part of the cytoskeleton. These structures are interconnected by intercellular desmosomes and are also attached to the basal lamina via hemidesmosomes. This is important in delivering the strength and stability of the epidermis, preventing the epidermal layer from shedding off completely and subsequently providing the basis of the barrier function of the epidermis. It is this layer that is targeted by some aesthetic procedures, which we will discuss later.15

Stratum corneum Stratum lucidum Stratum granulosum

Stratum spinosum

Stratum basale Dermis

Stratum corneum This is the outermost layer of the epidermis and contains closely flat-packed dead cells rich in keratin across approximately 15-20 layers. As mentioned before, lamellar granules from the stratum granulosum layer help ‘cement’ the cells together in the stratum corneum, providing a semi-impermeable layer that is a major part of the physical skin barrier. The cells in the stratum corneum are considered ‘dead’ and hence this is the layer that flakes off.5 As we age this layer becomes more dense and does not flake off as easily, leaving the appearance of dull skin. Subsequently the lower layers

Reproduced from Aesthetics | Volume 3/Issue 10 - September 2016

CPD Epidermal Barrier

@aestheticsgroup Cells of the epidermis

Dead keratinocyte

Stratum corneum

Lamellar granules

Granular cell layer

Langerhans cell

Keratinocyte Spinous layer Melanin Melanocyte Merkel cell

Basal lamina

Basal layer

within the epidermis slow down as the top layer of keratinocytes from the stratum corneum have not yet shed, and this cycle slows down the skin regeneration programme and results in ageing of the skin.5 There are many different aesthetic procedures which help improve the skin by controlled damage of the epithelium and removal of the stratum corneum helps brighten up the appearance of dull old-looking skin.

Aesthetic techniques disrupting the epidermal barrier function The process of keratinisation from the basal layer to the stratum corneum usually takes about four weeks, however it can be as long as 75 days depending upon the age of the patient and the quality of the skin.6 With progressive age and environmental factors, the process of keratinisation slows down as the skin is less efficient in the desquamation process, resulting in a build-up of dead cells and reduced skin renewal.6 This often leads to dull, thicker, less toned and poor quality skin. It is the process of improving the desquamation process that medical aesthetic practitioners aim to achieve. This is provided through various aesthetic techniques that enable the disruption of the epidermal barrier function of the skin, including chemical skin peels, microneedling and microdermabrasion.

A study conducted by Okano et al, investigated the effects of an AHA (glycolic acid) on the skin and revealed accelerated collagen synthesis occurs through keratinocyte degradation

Aesthetics Journal

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Chemical skin peels Chemical skin peeling, also known as chemical resurfacing or chemexfoliation, is a process by which various chemical agents are applied topically to the skin to promote a disruption of the skin barrier function, resulting in cutaneous exfoliation and subsequent cellular rejuvenation.7 This process allows the keratinised epidermal layers to shed off, or ‘peel’ and promote the epidermis to ‘repair’ itself by starting the keratinisation process again at the basal cell layer. This action is primarily based on the skin’s ability to repair itself after damage, and this type of controlled trauma to the skin allows regeneration of newer cells, resulting in a healthier epidermis.9 There are three main types of chemical peels: superficial, medium and deep.8 For the purpose of this report we will focus on the superficial chemical peels, which act on the epidermis.

Alpha hydroxy acids Alpha hydroxy acids, also known as AHAs, are hydrophilic/watersoluble, and are some of the first used chemical peels derived from natural substances such as fruits (malic), nuts (mandelic) and milk (lactic).6 These substances pass into the stratum corneum and cause destabilisation of the desmosomes, which results in desquamation.9 The outcome is a compromised epidermal barrier which starts shedding or ‘peeling’, and consequently triggering cell regeneration. These types of peels are recommended for patients with thickened, sun-damaged skin.10 A study conducted by Okano et al, investigated the effects of an AHA (glycolic acid) on the skin and revealed accelerated collagen synthesis occurs through keratinocyte degradation.11 As the degradation takes place, the epidermal barrier is compromised as it is expected to regenerate faster than it is naturally expected to do, and hence causes shedding of the skin and subsequent damage to the epidermal barrier, often referred to as the ‘peel’ or ‘peeling process’.11 This speeds up the keratinisation process resulting in a more youthful appearance to the skin, as older cells are able to shed revealing the younger and fresher cells.11 This cosmetic enhancement allows brighter and plumper looking skin giving a youthful appearance.

It also has other advantageous effects, such as depigmentation treatments, however they affect the deeper layers.

Beta hydroxy acids These acid peels, also known as BHA, are lipophilic/fat-soluble and hence penetrate the epidermal barrier to dissolve sebum and help exfoliation of the epidermal layer. Salicylic acid peels are an example of BHA, and are recommended in patients with oily, acne-prone skin.10

Jessner peels Jessner peels, named after the famous American-German dermatologist Dr Max Jessner, use a combination of the alpha and beta hydroxy acids at a lower dose to help achieve an overall chemical exfoliation of the epidermal layer and even deeper, to allow maximum generalised peeling.19 These peels achieve an overall aesthetic improvement to the skin but are obviously not as strong as their independent peels. It is thought that Jessner peels are able to achieve desmosomal destruction as well as dissolve sebum, causing the epidermal barrier function to be compromised and thus resulting in the ‘peeling effect’ of the skin.20 Microneedling Collagen induction therapy (CIT) or microneedling, has been around for many hundreds of years, but only recently over the past

Reproduced from Aesthetics | Volume 3/Issue 10 - September 2016

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CPD Epidermal Barrier

Summary

The process of keratinisation from the basal layer to the stratum corneum usually takes about four weeks, however it can be as long as 75 days depending upon the age of the patient and the quality of the skin

few decades has it found its niche in the aesthetic market. This process involves the use of microneedles, which penetrate the epidermal stratum corneum barrier and cause micro-trauma to the localised tissues. This in turn causes the tissues to activate due to the direct trauma and release growth factors, which stimulate the collagen and elastin in the papillary dermis.12 In my experience, this technique also allows it to form as a delivery service for useful topical cosmeceutical agents or treatments, such as vitamin A and C, which can result in a higher uptake as the epidermal barrier has been penetrated, increasing cellular absorption at a deeper layer, resulting in neocollagenesis and neovascularisation.21 As the skin heals it becomes tighter and stronger.21 There are a variety of needle lengths that can be used to rejuvenate the skin for aesthetic results; finer lines are usually treated with smaller needles, disrupting the epidermal skin barrier, and deeper acne scars are usually treated with longer needles, penetrating the dermal layers.

Microdermabrasion This is a procedure which uses a mechanical medium, such as exfoliating crystals or diamond flakes, which cause damage to the epidermal layer, allowing it to cause superficial damage by mechanical force, damaging the desmosomes and hemidesmosomes.13 This process damages the epidermal barrier function, and the resulting suction from the microdermabrasion device causes lifting of the ‘dead skin’ from the stratum corneum revealing cleaner, brighter looking skin. This aesthetic procedure is minimally invasive and can achieve excellent aesthetic results if used on the correct patient.18 This technique is excellent for those with older aged or sun damaged skin where the stratum corneum doesn’t shed off adequately and thus prevents the upward migration of keratinocytes from the stratum basale. The aim of this procedure is to indirectly increase the keratinisation process, allowing fresher smoother looking skin to surface.

In this article, the pathophysiology of the epidermal barrier function, the different layers involved, and the functions of each of those layers has been explained. How three different techniques, chemical peels, microneedling and microdermabrasion, can affect the epidermal barrier function to achieve aesthetically pleasing results has been explored. Chemical peels chemically damage the layers of the epidermis, causing deeper chemical burns to the cells involved in the stratum basale causing instability in the epidermal layers resulting in the skin ‘peeling off’. Microneedling, where the deployment of skincare products can reach lower into the epidermal layers and even into the dermis, provides increased efficacy of skincare products as well as resulting in neocollagenesis and neovascularisation of the deeper layers improving overall strength of the skin. Microdermabrasion physically exfoliates the epidermal layer resulting in erythema of the skin, but can achieve the exfoliation effects at a fraction of the price when compared to other procedures.

Dr Ahsan Ullah is the medical director at My Skin Clinic.

He specialises in facial rejuvenation for women, male facial masculinisation alongside antiageing treatments.

He is a member of the BCAM and AAAM and has recently launched My Skin Clinic Training Academy, educating other practitioners in the field of aesthetic medicine.

REFERENCES: 1. All Poetrym, A Wife by Sir Thomas Overbury, (2015), <http://www.allpoetry.com/A-wife> 2. Kumar, P, ‘Kumar and Clark’s Clinical Medicine 8e,’ Saunders Ltd, 8(2012), pg.1271.

3. Ardern-Jones, MR, ‘Dermatology: An Illustrated Colour Text 4e,’ Churchill Livingstone, 4(2007), Pg.2.

4. McGrath, JA, Eady, RA, Pope, FM, Rook’s Textbook of Dermatology 7(2004), Blackwell Publishing. pp.3.1–3.6.

5. Marks JG, ‘Lookingbill and Marks’ Principles of Dermatology’, 5(2006).

6. The International Dermal Institute, Skin Exfoliation 101, (2015), <http://dermalinstitute.com/uk/ library/28_article_Skin_Exfoliation_101.htm> 7. BEDIN, B, ‘Pathophysiology of Chemical Peels,’ PRIME Journal (2015), <https://www.prime-journal. com/pathophysiology-of-chemical-peels/> 8. Goldsmith, LA, Katz, SI, et al, ‘Fitzpatrick’s Dermatology in General Medicine’, McGraw-Hill Medical Publishing, (2012).

9. Small R, A Practical Guide to Chemical Peels, Microdermabrasion & Topical Products, (2012).

10. Brannon,H, ‘How Beta Hydroxy Acid Combats Aging Skin and Wrinkles,’ About Health, <http:// dermatology.about.com/cs/skincareproducts/a/bha.htm> 11. Kornhauser, A, Coelho, SG & Hearing VJ, Applications of hydroxy acids: classification, mechanisms, and photoactivity, (2015). <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3047947/> 12. Doddaballapur, S, Microneedling with Dermaroller, J Cutan Aesthet Surg, (2015) <http://www.ncbi.nlm. nih.gov/pmc/articles/PMC2918341/> 13. Richard Usatine, 2011. ‘Microdermabrasion,’ Dermatologic and Cosmetic Procedures in Office Practice. Elsevier Saunders (2012).

14. Shetty, S & Gokul, S, ‘Keratinization and its Disorders,’ Oman Med J, (2012), <http://www.ncbi.nlm.nih. gov/pmc/articles/PMC3472583/> 15. Cells: The Living Units (2015) <http://classes.midlandstech.edu/carterp/Courses/bio210/chap03/ lecture1.htm> 16. Solanas G & Aznar Benitah S, ‘Regenerating the skin: a task for the heterogeneous stem cell pool and surrounding niche,’ Nature Reviews Molecular Cell Biology, Nature Publishing Group (2013) < http://www.nature.com/nrm/journal/v14/n11/abs/nrm3675.html?message-global=remove> 17. BestofbothworldsAZ, Retin-A: The Truth About Tretinoin, <http://bestofbothworldsaz.com/2010/10/18/ the-truth-about-tretinoin-retin-a/> 18. Coustan, D, Professional Microdermabrasion, HowStuffWorks, (2015) <http://health.howstuffworks. com/skin-care/beauty/skin-treatments/microdermabrasion2.htm> 19. Rinzler, CA, The Encyclopedia of Cosmetic and Plastic Surgery, (2010).

20. Rendon, MI, Berson, D.S., Cohen, et al., ‘Evidence and considerations in the application of chemical peels in skin disorders and aesthetic resurfacing’, J Clin Aesthet Dermatol, 7(2010).

21. Ganceviciene, R, Liakou, AI, Theodoridis, et al., ‘Skin anti-aging strategies’, Dermatoendocrinol, 23(2012).

Reproduced from Aesthetics | Volume 3/Issue 10 - September 2016

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LPT for Hair Loss Consultant trichologist Sally-Ann Tarver discusses the science behind laser phototherapy Millions of individuals around the world suffer from hair loss (alopecia) for various reasons. Genetics often plays an important role but other factors such as hormonal imbalances, stress, nutrition and numerous underlying medical conditions can also greatly contribute to hair loss. Alopecia can cause severe emotional distress, depression, social phobia and anxiety.1 A UK study indicates that approximately 40% of women suffering from hair loss claim to have had marital problems, while 63% have reported career-related issues as well.1 Common hair loss solutions today include FDA-approved medications such as minoxidil (which can be used by both men and women) and finasteride, a prescription drug that is only intended for men. Although widely used in the treatment of hair loss, both also have a small risk of side effects.2,3 Technologically-advanced natural solutions to hair loss that have limited side effects are rapidly gaining popularity amongst hair loss experts and medical practices. In particular, laser phototherapy (LPT) for hair loss is currently used to effectively treat androgenetic alopecia (hereditary baldness) at a cellular level.4,5 What is laser phototherapy?

The first case of using light to treat a medical condition (lupus vulgaris) dates back to 1903 with the work of Dr Niels Ryberg-Finsen, a Danish physician and scientist who won the Nobel Prize in Physiology or Medicine for his pioneering work on the treatment of disease with concentrated light radiation.6 It was not until 1965 that the first study on LPT was published by Hungarian physician, Dr Endre Mester. While irradiating shaven mice with ruby laser light, he realised that the fur of the exposed mice was growing back more quickly than the control group of the experiment.7 LPT for hair loss is actually a branch of low-level laser therapy (LLLT), also called cold laser therapy. It involves treating human tissue with low-powered (or ‘cold’) lasers to trigger the absorption of low-density energies that are much lower than energies produced by hot lasers. Studies have indicated that LPT has therapeutic effects on human tissue and cells.8 The mechanism of LPT has been thoroughly researched.

Evidence suggests that LPT targets cells

and positively alters their metabolism with an increase of: 10 1. Adenosine triphosphate (ATP) production 2. Protein synthesis that boosts cell replication and migration 3. Growth factors and inflammatory mediators 4. Tissue oxygenation 5. Nitric oxide (NO) release, which augments blood flow with its vasodilation properties Ironically, the invention of laser hair removal eventually led to the introduction of LPT for hair loss. This occurred due to paradoxical hypertrichosis, whereby several patients would experience hair growth around areas being treated for hair removal due to light reflecting off the target area at low energies.9,10

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nutrients to hair follicles. Feelings of scalp tightening have also been reported – also due to increased blood flow. All of these side effects are temporary and improve on their own as patients adjust to renewed blood flow.12 It must be noted here that advanced hair loss patients (Norwood VI and above in males, Ludwig III in females13) may not be candidates for laser phototherapy. However, combining LPT with hair transplantation has been shown to be extremely effective for reasons that shall be examined later.

Past LPT clinical studies and current results Clinical studies on successfully treating androgenetic alopecia with LPT are numerous. Overall LPT for both men and women is decidedly safe and effective10 and on average patients experience a decrease in the number of vellus hairs, and an increase in the number of terminal hairs with an increase in shaft diameter.5 Positive changes in the texture and quality of hair have also been reported.6 In a 2013 study,14 40 subjects diagnosed with androgenetic alopecia were enrolled in a 24-week randomised doubleblind sham device-controlled experiment.

Subjects received 18-minute LPT treatments every day with a sham device or helmet-type home-use device, emitting wavelengths ranging from 630 nm to 660 nm. Progress was monitored using a phototrichogram and global assessment. The LPT group showed a significant increased mean hair diameter and considerably greater hair density in comparison with the sham device group.

Another study conducted in 2014 reports a 35% to 39% hair growth increase in males diagnosed with androgenetic alopecia receiving 25-minute, 655 nm wavelength LPT treatments every other day for a period of 16 weeks.7 More recent reviews9,10 of LPT conducted in 2016 conclude that hair count and hair density can be significantly improved in both males

How does laser phototherapy influence hair loss?

In essence, LPT provides energy to hair follicles in the form of laser light. The use of coherent light ensures that the base of hair follicles, buried 3-5mm under the scalp, can be reached and subsequently treated. This involves the stimulation of epidermal stem cells in hair follicle bulges by irradiating the engine of hair cells – organelles – known as mitochondria with energy, which permits them to convert this light energy into chemical energy. This chemical energy becomes available for hair cells to use and grow into healthy, terminal hair.10 The above process defines photobiostimulation or simply biostimulation. Human cells can be stimulated by energy, which triggers therapeutic effects for healing. Since LPT also reportedly shifts hair follicles into the growing anagen phase,11 which optimises the Before After natural hair growth cycle, individuals can also use LPT devices as effective hair loss prevention tools. Side effects are rare and minimal with LPT; a minority of patients can experience headaches, sometimes accompanied by scalp sensitivity. This is due Figure 1: 62-year-old female patient presenting with FPHL Savin scale stage 3. Treated with LPT with the Theradome LH80 PRO home-use helmet four to an augmentation of times a week for eighteen months. Hair was reportedly visibly thicker and blood flow to the scalp, more manageable with improved hair-shaft diameter and quality. Images which carries additional courtesy of Sally-Ann Tarver.

Reproduced from Aesthetics | Volume 3/Issue 10 - September 2016

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@aestheticsgroup Before treatment

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Aesthetics Journal

Eight months after

Figure 2: 27-year-old male patient with male pattern baldness Norwood scale 5. Treated with finasteride for four weeks prior to LPT with the Theradome LH80 PRO home-use helmet four to five times a week for an initial six months. Marked improvement was noted at the patient’s five-month review and a further moderate improvement at the eight-month review. Images courtesy of Sally-Ann Tarver.

and females undergoing LPT treatment, along with increased hair thickness and tensile strength, leading to high patient satisfaction.

called energy density or fluence, and is calculated by multiplying the power density of an LPT device by its treatment time. LPT is specifically governed by the Arndt-Schultz law, which dictates how much energy dosage should be administered during treatment (Figure 3). Therapeutic effects can be seen with a dose as low as 0.01 J/cm2; however, doses higher than 10 J/cm2 can inhibit repair and actually cause damage.17 In the case of LPT for hair loss, energy doses should range between 6-10 J/cm2 to achieve the adequate stimulation of hair follicles.

How should LPT for hair loss be administered?

It is important here to mention a few factors that determine whether or not LPT for hair loss will be successful. First, it is crucial that the base of hair follicles are treated since this is where epidermal stem cells are forming. For this reason, the use of lightemitting diodes (LEDs) is not effective for hair restoration. LED lightwaves propagate incoherently and aren’t powerful enough to transverse the scalp. A study published in 1996 to compare the effect on skin blood flow found that coherent laser light increased vasodilation by 54% whereas the noncoherent LED monochromatic light did not.15 Secondly, an optimal dose of energy must be deposited at the base of hair follicles. A good analogy would be treating an ailment with a specific dose of medicine: a precise number of milligrams, for instance, must be prescribed to a patient in order to address their problem effectively. In the case of LPT for hair loss, energy dosage is the amount of energy in joules (J) administered to a scalp area in centimetres squared (cm2) – thus is measured in J/cm2.16 Energy dosage is also

Undergoing LPT with other hair loss therapies Another advantage of LPT is that it does not exclude the use of other common hair loss solutions such as minoxidil, finasteride and even newer, more experimental procedures such as platelet-rich plasma (PRP) injections.

In fact, numerous patients choose to undergo LPT in combination with another treatment under the guidance of a hair loss expert or medical practitioner.

Additionally, hair transplantation patients can maximise the outcome of their surgery by integrating LPT in their treatment plan. Hair transplantation can come with several side effects – including infection, inflammation, scarring, facial oedema, swelling and the necrosis of transplanted

Biological Effects

Stimulating & Positive Effects

Therapeutic Window: Energy doses between 0.01 and 10 J/cm2 are therapeutic. Doses higher than 10 J/cm2 are inhibitory.

Dose in J/cm2 0.1

1

10

100

Inhibitory & Negative Effects

Figure 3: Arndt-Schultz law for energy dosage and hair growth

Aesthetics aestheticsjournal.com

grafts and surrounding hair.18 Some studies suggest that the practice of combining LPT with hair restoration surgery is rapidly expanding.19 Due to the release of nitric oxide and an increase of blood flow to hair follicles, LPT can produce stronger grafts before a procedure and reduce the extent of subsequent hair necrosis. LPT can also decrease swelling, redness and inflammation after a hair transplant.20,21 Thus the use of a convenient, effective, at-home LPT device is recommended for patients planning to undergo hair restoration surgery.

The future of LPT for hair loss The anti-inflammatory properties of LPT and its proven abilities to augment hair shaft diameter, decrease vellus hair count and increase terminal hair count make it a very promising viable option for treating hair loss due to other causes, such as scalp conditions and various types of alopecia other than androgenetic alopecia. Many alopecia areata patients, for instance, have undergone LPT to treat their condition and have reported significant improvement.

Theories suggest that LPT could be efficacious at treating alopecia areata by stimulating hair growth in bald patches typical of the autoimmune condition.22 For instance, a study conducted in 200623 suggests that resistant patches of alopecia areata could be effectively treated at a high success rate with 904 nm pulsed laser light. Since LPT promotes hair regrowth in most hair loss patients,5,24 treating chemotherapy-induced alopecia with LPT is also promising; added to this is an encouraging animal study that reports superior and accelerated hair regrowth in rats given chemotherapy agents while undergoing LPT.25 By optimising the natural hair growth cycle and strengthening hair follicles, LPT has the potential to reverse or prevent traction alopecia. This type of alopecia is becoming a large concern amongst women who wear hair extensions26 and engage in potentially destructive hairstyling habits such as tight braiding or hair weaving.27 The future of LPT is indeed very promising. Today, convenient, affordable clinic and at-home LPT devices are available to individuals wishing to boost their current hair loss therapy or opt for an effective, alternative solution to topical hair loss lotions and medications. With further clinical studies, it should only be a matter of time before LPT is recognised as a standard form of treatment for many types of alopecia.

Reproduced from Aesthetics | Volume 3/Issue 10 - September 2016

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Sally-Ann Tarver is a trichologist with 20 years’ experience in hair loss diagnosis and treatment. She established Cotswold Trichology in 1998 and also practised in Harley Street, London. Tarver is a past president (2008-2010) and fellow of The Trichological Society and a Member of The Institute of Trichologists.

REFERENCES 1. Nigel Hunt et al, ‘The Psychosocial Impact of Alopecia’, British Medical Journal, Volume 20 (2007) <http://www.academia.edu/189491/The_psychosocial_impact_of_alopecia> (p. 363) .

1. RL Rietschel et al, ‘Safety and efficacy of topical Minoxidil in the management of Androgenetic Alopecia’, Journal of the American Academy of Dermatology (1987) <http://www.ncbi.nlm.nih. gov/pubmed/3549802> 1. L. Lui et al ‘ Effect of 5α-Reductase inhibitors on Sexual Function: A Meta-Analysis and Systematic Review of Randomized Controlled Trials’, Journal of Sexual Medicine Epub ahead of print (2016) <http://www.ncbi.nlm.nih.gov/pubmed/3549802> 2. Joaquim Jimenez et al, ‘Efficacy and Safety of a Low-Level Laser Device in the Treatment of Male and Female Pattern Hair Loss: A Multicenter, Randomized, Sham Device-Controlled, Double-Blind Study’, American Journal of Clinical Dermatology, Volume 15 (2014) <https://dash. harvard.edu/bitstream/handle/1/12152951/3986893.pdf?sequence=1> (pp. 115-127).

3. Raymond Lanzafame et al, ‘The Growth of Human Scalp Hair in Females Using Visible Red Light Laser and LED Sources’, Lasers in Surgery and Medicine, Volume 46 (2014) <http://www. ncbi.nlm.nih.gov/pmc/articles/PMC4265291/> (pp.601-607).

4. Jan Tunér and Lars Hode, The New Laser Therapy Handbook (Gragensberg, Sweden: Prima Books AB, 2010), preface.

5. Endre Mester and et al, ‘The Effect of Laser Beams on the Growth of Hair in Mice’, Radiobiologia, Radiotherapia (Berl), Volume 9 (1968) <http://www.ncbi.nlm.nih.gov/ pubmed/5732466> (pp.621-626].

6. Jan Tunér and Lars Hode, The New Laser Therapy Handbook (Gragensberg, Sweden: Prima Books AB, 2010), p.10.

7. Gerardo Moreno-Arias et al, ‘Paradoxical Effect After IPL Photoepilation’, Dermatologic Surgery, Volume 28 (2002) <http://onlinelibrary.wiley.com/doi/10.1046/j.15244725.2002.02101.x/full> (pp.1013-1016).

8. Pinar Avci et al, ‘Low-Level Laser (Light) Therapy (LLLT) for Treatment of Hair Loss’, Lasers in Surgery and Medicine, Volume 46 (2014) <http://onlinelibrary.wiley.com/doi/10.1002/lsm.22170/ full> [accessed 7 July 2016] (p. 144–151).

9. Mina Zarei et al, ‘Low Level Laser Therapy And Hair Regrowth: An Evidence-Based Review’, Lasers in Medical Science, Volume 31 (2016) <http://link.springer.com/ article/10.1007%2Fs10103-015-1818-2> (pp.363-371).

10. G. Mrinal and V. Mysore, ‘Classifications of Patterned Hair Loss: A Review’, Journal of

Aesthetics Cutaneous Aesthetic Surgery (2016) <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4812885/> 11. H.Kim et al, ‘Low level light therapy for androgenetic alopecia: a 24 week, randomized, double-blind, sham device controlled multicenter trial.’ American Society for Dermatologic Surgery (2013) http://www.ncbi.nlm.nih.gov/pubmed/23551662 12. P.J Pöntinen et al ‘Comparative effects of exposure to different light sources (HeNe laser, InGaAl diode laser, a specific type of noncoherent LED) on skin blood flow for the head.’

Acupunture and Electro-therapeutics research (1996) p. 105-118 http://www.ncbi.nlm.nih.gov/ pubmed/8914685 13. Jan Tunér and Lars Hode, The New Laser Therapy Handbook (Gragensberg, Sweden: Prima Books AB, 2010), p.78.

14. Jan Tunér and Lars Hode, The New Laser Therapy Handbook (Gragensberg, Sweden: Prima Books AB, 2010), p.514.

15. Walter P Unger and others, ‘Hair Transplanting: An Important but Often Forgotten Treatment for Female Pattern Hair Loss’, Journal of the American Academy of Dermatology, Volume 49 (2003) < http://www.ncbi.nlm.nih.gov/pubmed/14576664> (pp.853-860).

16. Marc Avram and others, ‘Contemporary Hair Transplantation”, Dermatological Surgery, Volume 35 (2009) < http://www.ncbi.nlm.nih.gov/pubmed/19674037> (pp.1705-1719).

17. Rajendrasingh J Rajput, ‘Controversy: Is There A Role For Adjuvants in the Management of Male Pattern Hair Loss?’ Journal Of Cutaneous And Aesthetic Surgery, Volume 3 (2010) <http:// europepmc.org/articles/PMC2956962> (pp.82-86).

18. Paul T Rose, ‘The Latest Innovations in Hair Transplantation’, Facial Plastic Surgery, Volume 27 (2011) < http://www.ncbi.nlm.nih.gov/pubmed/21792780> (pp.366-377).

19. Jan Tunér and Lars Hode, The New Laser Therapy Handbook (Gragensberg, Sweden: Prima Books AB, 2010), pp.239-240.

20. Makram Waiza et al, ‘Use of the Pulsed Infrared Diode Laser (904 nm) in the Treatment of Alopecia Areata’, Journal of Cosmetic and Laser Therapy, Volume 8 (2006) <http://www.ncbi. nlm.nih.gov/pubmed/16581682> (pp.27-30).

21. Raymond Lanzafame et al, ‘The Growth of Human Scalp Hair Mediated by Visible Red Light Laser and LED Sources in Males’, Lasers in Surgery and Medicine, Volume 45 (2014) < http://www.ncbi.nlm.nih.gov/pubmed/24078483> [accessed 8 July 2016] (p. 487-495).

22. Tongyu Cao Wikramanayake and others, ‘Low-Level Laser Treatment Accelerated Hair Regrowth in a Rat Model of Chemotherapy-Induced Alopecia (CIA)’ Lasers in Medical Science, Volume 28 (2013) < http://www.ncbi.nlm.nih.gov/pubmed/22696077> (pp.701-706.)

23. A. Yang and et al, ‘Hair Extensions: A Concerning Cause of Hair Disorders’, British Journal of Dermatology, Volume 160 (2009) <http://onlinelibrary.wiley.com/doi/10.1111/j.13652133.2008.08924.x/abstract> (pp.207-209).

24. Alessandra Haskin et al, ‘All Hairstyles Are Not Created Equal: What the Dermatologist Needs to Know About Black Hairstyling Practices and the Risk of Traction Alopecia (TA)’, Journal of the American Academy of Dermatology, Epub ahead of print (2016) <http://www.ncbi.nlm.nih. gov/pubmed/27114262>

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Filler suitability

As detailed in my previous article, the clinical outcomes for lip augmentation are defined by the patient’s unique anatomy, injection technique and the type and amount of filler used.

I have discussed why it is vital to consider the relevant anatomy for lip augmentation and how careful considerations must be made when selecting patients. This article will look at some of the different types of fillers that can be used to treat the perioral area and will explain the techniques for enhancement.

When selecting a suitable filler for the lips, the following factors must be taken into consideration: • Longevity: it is important to advise the patient how long a product is expected to last for, and explain that this is not guaranteed in order to successfully manage their expectations • Crosslinking technology: relates to longevity and propensity to swell • Cost: patient needs to be aware of financial commitment • Company support: specific product knowledge and training/marketing is essential • Reversibility: ensures a safety net incase of vascular accident or other filler-associated complications; you should have an emergency kit including hyaluronidase on site • Strong clinical study evidence: ensures a safe, evidence-based choice • Previous patient experience of product: if a patient has had good clinical results with a certain product and is happy with it, do not use something else as they may be unhappy with the new product

Product and instrument selection

Cannula or needle?

When performing lip rejuvenation, reversible hyaluronic acid fillers pre-filled with lidocaine are the product of choice for most practitioners. Some of the brands of fillers available and suitable for lip augmentation, which I have used, are detailed below.

In my opinon, the decision to use a cannula or a needle depends on the part of the lip that is being treated. As needles are thinner, I believe they are best used to define the vermillion border, recreate the philtral columns, lift the oral commissure, volumise the lip in the sub vermillion area, efface oral rhytids and create lateral protrusions in the lower lip.

In my experience, cannulas are best used in patients with thin lips where product needs to be placed behind the muscle; the rationale behind this decision is based on the position of the labial arteries, which usually reside behind the muscle. The use of a 25g cannula will help to reduce the risk of intravascular accident in this highly perfused area. I have found that placement of filler behind the muscle gives a forward projection, helping to evert the lip.

Lip Augmentation In the second of his two-part article, Dr Lee Walker provides technique advice for treating the perioral area

Juvéderm VOLBELLA Juvéderm VOLBELLA is a soft product, designed for subtle lip enhancement. It incorporates short and long chain hyaluronic acid to enhance the crosslinking without increasing stiffness.

This makes it a good filler choice for those patients seeking a subtle look with a softer feel. The manufacturer claims that results last 12 months.1 Belotero Intense Belotero Intense is a thicker yet elastic product that can still be injected through a small gauge needle. I have used this product in patients requesting ‘fuller’ more voluptuous lips. The manufacturer claims that results last six to nine months.2 Emervel Lips Emervel Lips is formulated to enhance, define or augment the lip body and border. The product is designed to be altered via a combination of factors, including the levels of crosslinking and particle sizes, which aim to have a maximum effect in the different layers of tissue into which they are injected. In my experience, this can be suitable for those patients who want a ‘fuller’ appearance without looking too big. The manufacturer claims that results last six to nine months.3 Teosyal RHA Resilient hyaluronic acid (RHA) is a dynamic gel with high strength and stretch capacity.

Teosyal RHA comes in 1,2,3 and 4 according to its simplicity, but for lips, I recommend using RHA 2 and RHA 3. According to the manufacturer, RHA 2 should be used in patients wanting a ‘natural’ appearance as it has less viscosity and firmness than RHA 3, whilst those demanding ‘fuller’ or ‘pouty’ lips are better treated with RHA 3. The manufacturer claims that results last approximately 12 months.4

Lip augmentation techniques There is no single technique that fits every lip, and each practitioner will have his or her own approach to treatment. Below are the factors of which I follow when it comes to lip augmentation: Visually assess the lip in 3D: i.e. the lateral and frontal view. This will give an idea of projection required. For an attractive lip, the upper lip should project around 2mm further than the lower lip.5

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Assess the smile: if the patient has a ‘gummy’ smile and the lip disappears upon smiling then consider botulinum toxin injections to soften the action of the lip elevators. I have found that for best results, it should be a deep injection, 1cm lateral to the lateral alar of the nose. If the patient has an active depressor anguli oris, contributing to a downturned mouth, also consider treating this muscle with botulinum toxin to prevent a downward pull of muscle on the corners of the mouth.

Determine the amount of filler: agree with the patient the amount of filler that will be used. It is important to not over or underfill the lip (amount is case dependent). For example, overfilling the upper lip can create a ‘duck lip’ appearance, which is usually not regarded as aesthetically appealing. I do not use more than 1ml per visit to prevent overcorrection and reduce the risk of vascular compression.

Enhancement or restoration: ask if the patient is seeking enhancement or restoration – this usually depends on the patient’s age – to ensure that you understand their expectations of treatment.

Age appropriateness: ensure that the lips are ‘age appropriate’. I advise not to try to create the lips of a 25 year old on a 60-year-old patient.

In patients showing signs of ageing: treat the perioral complex and not just the lip. To do this, use filler to turn up the corners of the mouth at the oral commissure, to treat oral rhytids and to restore volume in the cutaneous lip and chin area. Botulinum toxin in the mentalis and depressor angular oris can be used to reduce hyperkinetic activity of mouth depressors.

Consider the vermillion border: consider using low viscosity filler when treating the vermillion border. This Figure 1: Lips before and after using low can create a very sharp and viscosity filler well-defined demarcation by creating maximum light reflection without distorting the delicate lip architecture (Figure 1).

Figure 2: Lips before and after using Teosyal RHA 3

Consider single lip treatment: only treat the upper lip as a single unit if there is significant volume discrepancy with the lower lip (Figure 2).

Cupid’s bow: I do not recommend injecting the No filler here Cupid’s bow with filler. I instead recommend injecting the Glogau-Klein point in the vermillion border. In my experience, injection directly Figure 3: Recommended injection points into the Cupid’s bow may lead to a flattening of this delicate and desirable feature (Figure 3).

Retrograde flow

Glogau-Klein points

Retrograde flow

Cannula use: use cannulas to place filler behind the muscle in thin, older lips as, in my experience, placement in this area acts as further dentoalveolar support to the inverted lip. When it comes to cannula use, I find it is best to first volumise and then shape, which can take 3-4ml to achieve adequate support, which I would perform over multiple visits. The patient must understand the progressive nature of restoring thin, aged lips and that treatment may take as long as 12-18 months. When it comes to size, I use a 25g cannula for lip treatment.

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I have found that any gauge smaller than this has the potential to ‘skewer’ larger vessels.

Everting upper lip: if the goal of treatment is to evert the upper lip, treat the vermillion border and the area 2mm below it (subvermillion).

In my experience, an amount of 0.4ml in total usually suffices but this can be patient dependent.

Treating ‘lipstick bleeds’: treat by injecting the vermillion border with a ‘firmer’ filler. This approach can be very effective and usually has the added Figure 4: Before and after treating the vermillion border to correct ‘lipstick bleeds’ benefit of everting the lip and defining the Cupid’s bow (Figure 4).

Increasing pout: if the patient requests a more defined pout, I first mark out the boundary of the pout. This usually equates to the line drawn from the Figure 5: Example of drawn lines used to increase a ‘pout’ external nares. Filler is then placed inside the lines to accentuate the pout. Centrelines are also drawn to ensure symmetry (Figure 5).

Vermillion border treatment: when treating the vermillion border from its lateral aspect, the needle must be placed superficially. The superior labial artery runs along the vermilion border of the upper lip to the facial sagittal midline at a depth of 3mm.5 Philtral column injection: injection of the philtral columns must also be superficial due to the position of the columellar vessels.

Summary It is important that practitioners equip themselves with the appropriate anatomical knowledge, as well as a familiarity of the products and techniques available to achieve optimum treatment goals. Remember to appropriately assess the patient and consider the treatment limitations as well as the patient’s existing lip architecture for best results.

This article is the second of two on lip augmentation by Dr Lee Walker. His previous article was published in the August issue of Aesthetics, and detailed patient selection and the relevant anatomy to consider for lip augmentation. To read Dr Walker’s first article, visit www.aestheticsjournal.com Dr Lee Walker is a former cosmetic dental surgeon with more than 14 years’ experience in non-surgical facial aesthetics. He is clinical director at B City Clinics in Liverpool. Dr Walker regularly presents and lectures at conferences and aesthetic training events, and in 2014 founded the Northern Aesthetics Practitioners’ Group.

REFERENCES 1. Allergan, Juvéderm VOLBELLA, (2013) <http://www.allergan.com.au/Products/Documents/ juvederm_volbella_ifu.pdf> 2. Consulting Room, Belotero Product Summary, (2016) <http://www.consultingroom.com/Treatment/ Belotero> 3. Consulting Room, Emervel Product Summary, (2016) <http://www.consultingroom.com/Treatment/ Emervel> 4. Consulting Room, Teosyal Product Summary, (2016) <http://www.consultingroom.com/Treatment/ Teosyal> 5. Penna V, Stark B, ‘Classification of the aging lips: A foundation for an integrated approach to perioral rejuventation,’ Aesth Plast Surg, 39(2015), pp.1-7.

6. Lee SH, ‘Topographic anatomy of the superior labial artery for dermal filler injection,’ Plast Reconstr Surg, 135(2015) pp.445-50.

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THE FINALISTS ARE ANNOUNCED After months of discussion and careful consideration, Aesthetics is delighted to announce the finalists for the 2016 Awards. This yearâ&#x20AC;&#x2122;s entries proved tougher than ever to choose from, as the standard of applications was of exceptional quality, making the competition to get to the finalist stage especially difficult. See the full list of finalists in 23 categories revealed here in the journal and visit the Aesthetics Awards website to vote today.

The voting and judging process is open from September 1 and will close on October 30, with winners announced at the Aesthetics Awards ceremony on December 3 at the Park Plaza Westminster Bridge Hotel, London. Also honoured on the night will be the Commended and Highly Commended finalists, with the Winners invited to the stage to be presented with their trophies in front of more than 600 members of the medical aesthetics profession.

Tickets can be booked on the Aesthetics Awards website www.aestheticsawards.com

The judging panel An esteemed panel of more than 50 judges will consider all entries, with five assigned to each category. These groups have been chosen specifically for their knowledge and expertise in that area, as well as to ensure conflicts of interest are avoided in the judging process. The full list of judges can be found on the Aesthetics Awards website.

H AV E YO U R S AY !

You can now vote for your winners on the Aesthetics Awards website.

Login to www.aestheticsawards.com to view all the finalists and cast your votes today.

Select categories will be decided upon by reader votes and a judging panel, while others will be decided by judges alone. Please see details under each category for clarification. Voting and judging will close on October 30 and there will be no opportunity to vote after this point. Voting is IP address monitored and each individual can only vote once. Multiple votes under the same name will also be discounted from the final total. Multiple voting from within organisations will be monitored.

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THE FINALISTS Cosmeceutical Range/Product of the Year

Equipment Supplier of the Year

Winner decided by: reader votes and judging panel

Winner decided by: reader votes and judging panel

Elizabeth Arden PRO (Skinbrands) Epionce® (Episciences Europe) Heliocare® (AesthetiCare) Medik8 (Medik8) NeoStrata® Skincare Range (AestheticSource Ltd) Obagi® Medical (Healthxchange Pharmacy) SkinCeuticals® Range (SkinCeuticals) SWISSCODE PURE (Pure Swiss Aesthetics)

3D-lipo Ltd Fusion GT Healthxchange Pharmacy Lynton Lasers Ltd Naturastudios Ltd Syneron Candela

Distributor of the Year Winner decided by: reader votes and judging panel

The Sterimedix Award for Injectable Product of the Year

Winner decided by: reader votes and judging panel

Aqualyx® (Healthxchange Pharmacy) Neauvia Organic (Schuco International) Nithya (Vida Aesthetics Ltd) Profhilo® (HA DERMA/ IBSA) TEOSYAL® RHA (Teoxane UK) Xela Rederm® (Hyalual)

Treatment of the Year Winner decided by: reader votes and judging panel

3D-lipo (3D-lipo Ltd) Dermalux LED (Aesthetic Technology Ltd) Dermapen™ (NaturaStudios Ltd) EndyMed 3DEEP (AesthetiCare) The Perfect Peel® (Medica Forte) Plexr® (Fusion GT) Soprano ICE (ABC Lasers) ULTRAcel (Healthxchange Pharmacy)

AestheticSource Ltd Church Pharmacy Eden Aesthetics Distribution Ltd Healthxchange Pharmacy Med-fx Medical Aesthetic Group NeoPharma UK Ltd Wigmore Medical Ltd

Best Customer Service by a Manufacturer, Supplier or Distributor Winner decided by: reader votes and judging panel

AestheticSource Ltd Church Pharmacy Cynosure Fusion GT Healthxchange Pharmacy Lynton Lasers Ltd

The Healthxchange Academy Award for Sales Representative of the Year

Winner decided by: reader votes and judging panel

Best Treatment Partner Winner decided by: reader votes and judging panel

Dermalux™ LED (Aesthetic Technology Ltd) CRYSTALSMOOTH® (MACOM Medical) Obagi® Medical (Healthxchange Pharmacy) Observ Skin Analysis (Observ Ltd) Skinade® (Bottled Science Ltd) SkinCeuticals® CE Ferulic Acid (SkinCeuticals) SWISSCODE (Pure Swiss Aesthetics) UVLrx™ Treatment System (UVLrx)

Bill Lewis (Teoxane UK) Caroline Gwilliam (AestheticSource Ltd) Kerrie Smythe (Wigmore Medical Ltd) Sarah-Jayne Tipper (Pure Swiss Aesthetics) Simon Ringer (Naturastudios Ltd) Toni Warren-Smith (Healthxchange Pharmacy)

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The Hamilton Fraser Award for Association/Industry Body of the Year

The Wigmore Medical Award for Best Clinic North England

Winner decided by: reader votes and judging panel

Winner decided by: judging panel

British Association of Cosmetic Nurses (BACN) British College of Aesthetic Medicine (BCAM) Society of Mesotherapy of the United Kingdom (SoMUK) The Association of PDO Threads UK (APDOT)

Air Aesthetics Clinic Diane Nivern Clinic Ltd Good Skin Days Ltd Harrogate Aesthetics Internal Beauty Clinic Outline Clinic Ltd Skinqure Clinic SkinViva

duction Fat Re

The 3D-lipo Award for Best New Clinic UK & Ireland

ing

Skin Tighten

Cellulite

A Powerful Three Dimensional Alternative to Liposuction

The Lynton Lasers Award for Best Clinic South England

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

Winner decided by: judging panel Why choose 3D-lipo?

ASKINOLOGY Botastic Aesthetics Ltd Dr Nestor’s Medical Cosmetic Centre Eudelo RejuvaMed Skin Clinic Skin Philosophy Cavitation

Cavitation is a natural phenomenon based on low frequency

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

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

Complete start up and support package available from under £400 per month

advantages of this technology are high treatment efficacy, no pain as less energy is required, shorter treatment services and variable

3D Dermology

Combines pulsed variable vacuum and skin rolling for the effective treatment of cellulite.

What the experts say...

‘As a Clinician I need to know that the treatments we offer are safe, effective, scientifically based and fit in with our ethos of holistic care for our clients.

Before

Winner decided by: judging panel

depths of penetration.

After

3D-Lipo has delivered this to us’ Dr Mohamed Dewji – GP & Medical Director LasaDerm Ltd (Milton Keynes)

For further information or a demonstration call: 01788 550 440

www.3d-lipo.com www.3d-skintech.com

Best Clinic Scotland Winner decided by: judging panel

Age Refined Clinetix Rejuvenation dermalclinic® Frances Turner Traill Skin Clinic La Belle Forme Temple Medical

Absolute Aesthetics Changes Clinic of Excellence Cosmex Clinic health + aesthetics Purity Bridge Radiance MediSpa S-Thetics Medical Aesthetic Clinic The Skin to Love Clinic

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The Med-fx Award for Best Clinic London

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The AestheticSource Award for Best Clinic Group UK and Ireland (3 clinics or more)

Winner decided by: judging panel

Dr Leah Cosmetic Skin Clinics Health & Aesthetic Clinic Juvea Aesthetics London Professional Aesthetics Ltd Medicetics PHI Clinic Dr SW Clinics Viva Skin Clinics

Winner decided by: judging panel

EF MEDISPA Harley Health Village La Belle Forme Group Premier Laser & Skin The Laser and Skin Clinic

The Swisscode Award for Best Clinic Group UK and Ireland (10 clinics or more)

Best Clinic Wales Winner decided by: judging panel

Cellite Clinic Limited Skinfinity Specialist Skin Clinic The Cardiff Clinic The Grove Skin Clinic

The SkinCeuticals Award for Best Clinic Ireland

Winner decided by: judging panel

Courthouse Clinics National Slimming & Cosmetic Clinics sk:n Group The Private Clinic

The Alumier Labs UK Award for Clinic Reception Team of the Year Winner decided by: judging panel

Ailesbury Clinic ClearSkin Clinic CosmeticDoctor Dundrum Skin and Laser Clinic Elite Aesthetic Clinic The DermaClinic

Winner decided by: judging panel

ASKINOLOGY FAB Clinic La Belle Forme Outline Clinic Ltd Radiance Medispa Smileworks S-Thetics Medical Aesthetic Clinic Temple Medical

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The Enhance Insurance Award for Training Initiative of the Year

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The Dermalux Award for Medical Aesthetic Practitioner of the Year

Enhance Insurance

|

Advice

|

Support

Winner decided by: judging panel

Winner decided by: judging panel

Allergan Medical Institute Aesthetic Complication Training Cosmetic Courses Dr Kate Goldie, Advanced Training and Masterclass Dalvi Humzah Aesthetic Clinical Training Courses Harley Academy Healthxchange Academy Inspired Cosmetic Training MATA RA Academy

Dr Raj Acquilla Dr Nestor Demosthenous Dr Katherine Goldie Dr Maria Gonzalez Mr Dalvi Humzah Dr Beatriz Molina Dr Tapan Patel Dr Simon Ravichandran Mr Taimur Shoaib Dr Johanna Ward

The Institute Hyalual Award for Aesthetic Nurse Practitioner of the Year

The Barry Knapp Award for Product Innovation of the Year, supported by Oxygenetix

Winner decided by: judging panel Winner decided by: judging panel

Anna Baker Rosie Cooper Anna Gunning Sharon King Michelle McLean Jackie Partridge Luisa Scott Frances Turner Traill

earFold® (Allergan Ltd) Estechoc (Medical Aesthetic Group) DEKA Moveo Technology (Globe AMT) PicoWay Resolve™ (Syneron Candela) Profhilo (HA DERMA/IBSA) Radara (Innoture) SculpSure (Cynosure) THE INViSIBLE NEEDLE (TSK Laboratory Europe)

The Schuco International Award for Special Achievement

This award recognises the outstanding achievements and significant contribution to the profession and industry by an individual with a distinguished career in medical aesthetics.

There will be no finalists for this category and the Winner will be announced at the Aesthetics Awards ceremony.

B O O K N OW!

Don’t miss your chance to attend the most prestigious awards event in medical aesthetics.

Individual ticket: £250 plus VAT Table of 10: £2,350 plus VAT Visit www.aestheticsawards.com to book your tickets today For further information about the Aesthetics Awards or for any support with voting or booking call 0203 096 1228 or email support@aestheticsawards.com

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Spotlight On: Juvapen Aesthetics explores the research and efficacy behind the new botulinum toxin injection system According to the American Society of Plastic Surgeons, 6.7 million botulinum toxin injections were administered in 2015, topping the list for most performed minimally-invasive cosmetic procedures in the US that year.1 And while there are no statistics that tell us exactly how many botulinum toxin (BoNT-A) procedures were performed in the same year in the UK, anecdotal reports from practitioners suggest that the wrinkle-relaxing treatment is one of the most requested and performed procedures amongst patients. A steady hand that offers gentle and accurate administration is arguably the most necessary requirement for any practitioner offering an injectable treatment; ensuring that the correct dosage, which produces the best results, is administered, and bruising is avoided at best or kept to a minimum at worst. To further support this, the Juvapen has been developed by Switzerland-based company JUVAPLUS, which specialises in the design and production of wireless motorised devices. According to the company, Juvapen was designed to offer practitioners improved accuracy, with more steady administration compared to manual injection, and reduced side effects for patients.2

Studies Two studies have been conducted to assess the efficacy of the Juvapen; namely, New Clinical Analysis and Device for Botox Injections by Dr Bertossi et al, to be published in the Journal of Craniofacial Surgery later this year,3 and Study to Assess the Accuracy and Precision of JuvaPen by Dr Joanna Bou Saab, published in March 2016. The first aims to provide a guide to improve the precision of injection and evaluate the different levels of pain during injection, while the second aims to demonstrate the enhanced accuracy and precision of the Juvapen injection system, as compared to a manual syringe injection for the delivery of BoNT-A.4 New Clinical Analysis and Device for Botox Injections Method The first study analysed the results of 50 patients, of which 25 were injected with the use of the Juvapen, while the remaining 25

patients were treated with a standard manual procedure. Pain was evaluated using a Visual Analogue Scale (VAS), whereby patients were asked to indicate their pain level by marking it one to 10 on a horizontal line, with 10 being the highest level of pain.

Patients were then injected in five points on the glabella, three points in each periorbital area and eight points in the brow. The average amount of units used was 20 units of BoNT-A on the glabella, 24 units of BoNT-A for the periorbital area and 16 units of BoNT-A for the brow. Pictures of the patients were taken on frontal and profile view in static and dynamic positions, before the injections were administered. The VAS analysis was conducted immediately after the procedure to gauge the patients’ experience of pain.

Clinical examination was conducted and photographs were taken at four, seven, 15 and 30 days after the procedures.

Results The mean level of pain registered by the VAS immediately after the procedure was three for the first group, who were treated with the Juvapen, and eight for the second group, who were treated manually. Of the 50 patients treated in total, 98% reported that they were happy with the results following the study. The authors conclude that the Juvapen allows for an accurate injection, standardised by a device that can modulate different parameters, which can guarantee less painful injection.

Study to Assess the Accuracy and Precision of JuvaPen Method In the second study, Dr Joanna Bou Saab used distilled water, dispensed using either a manual method with a 1ml syringe or by using the Juvapen, to assess the accuracy and precision of results that can be achieved with the device. Results were measured on a diamond scale; based on the fact that 1ml distilled water is equal to 1g.5 Five different syringes and five different Juvapen devices were used and, for each, five different volumes (0.0125ml, 0.020 ml, 0.025ml, 050ml and 0.100ml) were measured. For each volume, five recordings were taken.

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According to the study, the accuracy refers to the difference between the dispensed volume and the tested volume and, as such, an accurate device will give less measurement error. The error of each device was calculated using the following formula: E = Vm – Vo (Error = mean volume of the five recordings – the nominal volume tested) The error is then reported as a percentage based on: %E = 100 x E/Vo As with the first study, the precision of the injection relates to the reproducibility of the measures to give the same results under unchanged conditions. According to Dr Bou Saab, the less variable the results are, the more precise the system is. Precision was calculated as the standard deviation to reflect the variability of the reported results using the following formula: %Variability = 100 x S/Vm (Percentage variability = 100 x standard deviation / mean volume of five recordings) Results Results of the study indicated that the percentage of error using Juvapen was less than 2%, whereas manual results varied from 5% to more than 30%. According to the author, this was significantly observed at low volumes (0.0125ml, 0.020ml and 0.0250ml), which suggests there is an enhanced accuracy of Juvapen dispensing the correct volume, even with a small difference of 0.0005ml. Dr Bou Saab suggests that the accuracy of the Juvapen allows the practitioner to trust the dispensed volume and concentrate on targeting the proper areas. She concludes, “In procedures that require repetitive injections in near-by areas of the skin, the doctor can be confident that the amount injected is similar, leading to more reproducible and uniform results.”

Discussion A select number of practitioners have been trialling the Juvapen on patients in clinic.

Dr Kate Goldie, who runs Medics Direct training for aesthetic professionals, has been utilising the device when training delegates in the administration of BoNT-A. She explains that, in her experience, many newcomers want to look at the tip of the

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needle and the plunger at the same time when injecting, to allow them to observe how much toxin they are administering and where it is going. Trying to do both, however, can affect their concentration and, ultimately, the accuracy and precision of results. “With the Juvapen, practitioners can just focus on the tip of the needle, especially when working in areas around the eye,” says Dr Goldie.

Dr Sabine Zenker, founder of the dermatology clinic DrZenkerDermatology and the cosmetic institute DrZenkerCosmetics in Munich, Germany, has also trialled a range of different injection systems for BoNT-A administration. She was impressed with the Juvapen studies’ results, its handling and the patients’ acceptance of the device. Dr Zenker says, “No matter how experienced a practitioner is, we don’t always inject what we think, meaning, we don’t dose exactly with the conventional equipment for BoNT-A injections that we have used for years now. This may not matter for one single injection, but it does matter overall as we need to create the

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utmost natural results and no frozen faces.

Additionally, we have to be able to achieve reproducible results – I can’t afford to have a good result one day and a bad result three months later.”

Dr Goldie notes that it was also positive to see the results that suggest the Juvapen can accurately inject micro-doses of toxin.

“The smaller the dose, the harder it is to be accurate,” she explains, adding, “The study indicated quite a significant difference between manual and machine injection accuracy; which, again, is particularly important when injecting in the periorbital area.” Both practitioners agree that patients have reported less pain with the Juvapen, however Dr Goldie does note that, in general, the faster you inject toxin, the more painful it is. “So for people who put it in quite fast manually, the Juvapen is certainly going to decrease the pain,” she explains, adding, “But for people who already put it in very smoothly, evenly and slowly, it may not change. You also still get the nick of the needle of course, which doesn’t go away.”

Dr Zenker adds, “Patients in my clinic appreciate the new technology because

INTRODUCING JUVAPEN TOXIN INJECTOR

the injections are – first of all – far less painful. And the aesthetic result is very appealing and natural. They come back asking for ‘that machine’. Patients tell you the truth about injections and, so far, feedback has been positive – that’s why I go for it.” To conclude, Dr Zenker emphasises, “Botulinum toxin is a prescription medicine – I am a medical doctor – so why on earth would we not be accurate when injecting it? In my opinion, anything that can further support the accuracy and precision of injections is of benefit to aesthetic practitioners.”

REFERENCES 1. Heather Gates, American Society of Plastic Surgeons Releases Report Showing Shift in Procedures, ASPS, (2016) <http:// www.plasticsurgery.org/news/2016/new-statistics-reflect-thechanging-face-of-plastic-surgery.html> 2. MDMS, Toxin Made Simple (2016) <http://toxinmadesimple.com> 3. Bertossi D et al, New Clinical Analysis and Device for Botox Injections, The Journal of Craniofacial Surgery, (2016).

4. Bou Saab J, Study to Assess the Accuracy and Precision of JuvaPen, Available on request from JUVAPLUS, (2016).

5. ConvertUnits, Convert milliliter to gram, ConvertUnits, (2016) <http://www.convertunits.com/from/milliliters/to/grams>

The future of injections is the Juvapen, because it is more precise, more efficient and therefore will deliver predictable results.

DR. LIPP Dermatologist

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Treating Vulvovaginal Atrophy Dr Suren Naidoo details common vulvovaginal concerns and explains how to treat atrophy with CO2 fractional laser Vulvovaginal atrophy (VVA) is a common symptom of the menopause. It is caused by depletion in oestrogen levels, associated with menopause. Prior to this time, the abundance of oestrogen thickens the vaginal epithelium and produces glycogen, which is essential for patients who are sexually active as it maintains an appropriate acidic environment.1 When oestrogen levels are depleted the vaginal mucosa becomes thinner, less elastic, drier and fragile. The lack of oestrogen also affects periurethral tissues resulting in stress incontinence. The subsequent effects of oestrogen depletion can have a significant impact on sexual function, quality of life and daily activities.1

Aetiology and clinical presentation Globally, approximately 15% of premenopausal women and 50% of postmenopausal women experience VVA-associated symptoms, however it is under-reported and the true prevalence is unknown.2 The clinical manifestations of VVA generally occur four to five years after the menopause, and 25-50% of postmenopausal women present with objective changes as well as individual symptoms.

Apart from the natural menopause, VVA may occur due to a surgically-induced menopause in women taking anti-oestrogen therapy following breast cancer and in some post-partum women.2 The declining levels of oestrogen associated with the menopause leads to morphological alterations of the epithelium of the vaginal mucosa.3 There is loss of mucosal elasticity, loss of rugal folds, which allows for distensibility, and the vagina becomes shorter and narrower. The thinning of the epithelium and loss of vaginal rugae generally occurs two to three years after the menopause.

The function of the epithelium of the vaginal mucosa is to protect the mucosa against mechanical friction during intercourse, while vaginal dryness is due to a reduction in blood flow and vaginal secretions. As such, women who are sexually active are likely to experience dyspareunia. The epithelium may become friable with petechiae and may ulcerate causing post-coital bleeding.3 The most common symptoms of VVA are vaginal dryness, itching and burning, dyspareunia, decreased genital stimulation and postcoital infections. Other symptoms include urinary tract symptoms, such as nocturia, dysuria, urinary urgency and urinary incontinence.3 The vagina is colonised with lactobacilli bacteria, which produces lactic acid and maintains an acid pH of 3.5-5, resulting in a hostile environment against pathogenic micro-organisms. Due to the lack of oestrogen in postmenopausal women, however, there is a decrease in lactobacilli and the pH can increase to 6-8, resulting in a growth of pathogens such as yeasts and bacteria, including

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staphylococci, coliforms and group B streptococci. As such, the vulvovaginal area becomes susceptible to infections causing pain, vaginal discharge and post-coital bleeding.3 If the patient presents with vaginal bleeding or discharge then appropriate investigations such as pelvic ultrasound, vaginal swabs and a midstream-urine test should be done to exclude more serious causes such as cervical, endometrial and vulval cancers.

The genital tract is particularly sensitive to the decline in oestrogen levels as women get older, which, as discussed, can significantly affect women’s sexual function and quality of life. While vasomotor symptoms of the menopause will gradually disappear with time, VVA symptoms are likely to become worse, which may encourage women to seek targeted therapy.

Treatment Until recently, the treatments available included vaginal oestrogen creams, hormone replacement therapy, vaginal lubricants and moisturisers. Now, however, women can choose to undergo CO2 fractional laser treatment, which aims to rejuvenate the vulvovaginal area and relieve VVA-associated symptoms. There are other devices on the market that use radiofrequency to treat the vulval area, however, with these treatments, the vaginal mucosa is not targeted.

Patient suitability5 • Patients who present with gynaecological changes due to a decrease in oestrogen • Patients with a history of breast cancer, thrombophlebitis, or other contraindications to oestrogen therapy • Patients with inadequate response to oestrogen therapy or decline of treatment results with oestrogen

Contraindications5 • Vaginal, cervical, or other lesions in the treatment area that have not been evaluated and diagnosed • Active vaginal or vulvar infection (herpes, candida, HPV, STDs) • Pregnant or within three months postpartum • Prolapse beyond hymen • History of radiation to vaginal/colorectal tissue • History of reconstructive pelvic surgery with ‘mesh kits’ • History of impaired wound healing • History of keloid formation • Known anticoagulation treatment or thromboembolic condition Mechanism of action Fractional technology involves the laser emitting a beam of light that creates a pattern of small ablative wounds, without damaging the surrounding tissue, which aims to stimulate tissue regeneration.4 In my clinic, I use the SmartXide2 Mona Lisa Touch to treat VVA. The initial part of the laser pulse comprises high peak power for rapid ablation of the vaginal mucosa (both epithelium and lamina propria), which is characterised by low water content. The second part of the pulse is extended to create the thermal effect around the edge of ablation, stimulating the synthesis of new collagen and the components of the ground substance of the matrix.5 The ‘injury’ triggers a complex and coordinated series of events that includes:

Reproduced from Aesthetics | Volume 3/Issue 10 - September 2016

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• Chemotaxis – the migration of cells in response to the thermal energy from the laser • Phagocytosis – the process in which cells remove pathogens and debris • Neocollagenesis – the stimulus of new collagen formation The fractional laser pulse causes thermal damage to the atrophic vaginal walls, resulting in the process described above to restore the vaginal mucosa with new cells rich in water and fibroblasts.5 In addition, angiogenesis, epithelialisation, and the production of new glycosaminoglycans (GAGs) and proteoglycans are vital to the wound-healing process and important in the revascularisation of the vaginal epithelium. The wound caused by the laser energy results in new tissue, comprising extracellular matrix and collagen, which forms the structure for a new network of blood vessels to replace the damaged ones.5 The assessment of histological examinations following CO2 laser treatment indicates that:6 • The mucosa is well nourished with extended three-dimensional papillae rich in blood vessels • The glycogen of the epithelial cells is clearly visible and is present in a larger amount as compared with the initial condition • The extracellular matrix (collagen fibres and ground substance) has increased with numerous fibroblasts that can be identified after treatment Pre-treatment discussion As with any aesthetic procedure, the practitioner should provide the patient with a thorough consultation, detailing exactly what the patient may experience during treatment. Key points to be aware of during CO2 fractional laser treatment are: • Slight discomfort may be noted during insertion of the vaginal probe • Treatment near the introitus feels ‘tingly’ with increased sensation • May hear a slight ‘sizzle’ or ‘buzzing’ sound during the pulse phase, especially when treating at the introital level • The buzzing sound may be more evident as the probe is withdrawn closer to the vaginal opening • Some report of introitus feeling ‘irritated’ after treatment • Minor spotting lasting one to two days (brown, pink or bright red) • Reports of ‘watery discharge’ occurring two to three days after treatment a normal and an expected effect caused by the thermal damage to the dry vaginal epithelium and wound repair taking place, as described above

Pre-treatment protocol Prior to treatment the practitioner should:5 • Use dilators to determine canal diameter size to optimise comfort for the patient • Test vaginal pH • Ensure that the patient has avoided sexual intercourse and all vaginal creams and lubricants 24-48 hours prior to procedure • Check progress of VVA before each subsequent treatment and after final treatment using pH sticks It is also important to be aware that some patients may require a series of pre-treatment dilatation based on the treating practitioner’s assessment. Patients most in need of this are those who have had severe vaginal atrophy and patients who have undergone a surgically-induced menopause.

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treatments spaced six weeks apart (approximately 40-50 days).5 At the follow-up appointment, practitioners should discuss the patient’s satisfaction with results and determine if follow-up treatments are required. Treatment time with a CO2 laser is usually brief, lasting approximately five minutes. Gentle manipulation of the labia minora and vulvar tissue is of utmost importance as to avoid causing discomfort for the patient. The insertion of a non-lubricated, gloved finger in the introitus with gentle downward pressure on posterior fourchette can help prior to the insertion of the probe. Depending on the patient’s pain threshold, lidocaine gel or EMLA cream may be applied to vulvar/perineal tissue for five minutes prior to procedure, however it is important that the practitioner gently wipes all gel or cream off before insertion of probe.7 If lubricated gloves are used, ensure that any residue is thoroughly wiped off before treatment. Ensuring all residues are removed is important with the use of a fractional CO2 laser, as they are water dependent and gels will absorb the light, potentially making the treatment outcome unsatisfactory. Following treatment patients should refrain from vaginal sexual activity for 48 hours and can resume other normal activity as tolerated immediately after procedure.5

Potential side effects and complications Patients may have slight reddening and light swelling immediately after a session, which will usually resolve after a few days. This may be due to the insertion and removal of the vaginal probe so practitioners should be careful to reduce the energy at the introitus to avoid causing damage. Rarely, slight blood leakage may occur but this should resolve without any treatment over 24 hours. In those patients with low immune deficiency from whatever cause the immune response to the inflammation caused by the treatment will be more evident than normal causing inguinal lymphadenopathy, these patients should be informed about this and given reassurance that it is harmless.

Conclusion CO2 fractional laser treatment for VVA is a simple and safe, time efficient procedure that requires no/minimal anaesthesia. With little side effects and downtime, the treatment has revolutionised the lives of thousands of women worldwide, enabling them to have an improved quality of life and sexual function.

Dr Suren Naidoo has been in general practice since 1973 and has a vast amount of experience in medical emergencies and routine medicine. He has special interests in dermatology and since 2004 has worked as an aesthetic practitioner at the BMI Cavell Hospital in Enfield. Dr Naidoo is an associate member of the British College of Aesthetic Medicine and the British Medical Laser Association.

REFERENCES 1. Atrophic Vaginitis (US: Patient, 2016) <http://patient.info/doctor/atrophic-vaginitis> 2. Nappi, R E., Impact of vulvovaginal atrophy on sexual health and quality of life at postmenopause’, Climacteric, 17(1) (2014), pp.3-9.

3. Sturdee DW, Panay N et al., ‘Recommendations for the Management of Postmenopausal Vaginal Atrophy’, International Menopause Society, (2010).

4. Smartxide2 V2LR (US: MonaLisa Touch, 2016) <http://www.monalisatouch.com/smartxide2-v2lr/> 5. Ronconi and M. Galli., ‘Mona Lisa Touch: The Latest Frontiers in the treatment of Vaginal Atrophy’, (2012).

6. Midwood K, Williams L, Schwarzbuer J, ‘Tissue repair and the dynamics if extracellular matrix’, The International Journal of Biochemistry & Cell Biology, 36 (6) (2004), pp.1031-1037.

7. Further reading 8. Kingsberg SA, ‘Vulvar and vaginal atrophy in postmenopausal women’, J Sex Med, 10(7) (2013), pp.1790-9.

9. Parham P, ‘The Immune System’, Garland Science.

Treatment considerations For optimum results VVA patients should undergo a series of three

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Henna characteristics

Managing Henna Tattoo Complications Dr Anjali Mahto and Dr Derrick Phillips discuss the risks of black henna tattoos and explain how to best manage complications Recent years have seen a rise in the popularity of temporary tattoos, which is likely to have been driven by a change in societal views, with tattoos in general being more widely accepted. Daily bombardment with images of tattoo-laden celebrities has also helped elevate tattoo culture to the precipice of ‘modern cool’. It was reported in 2015 that almost 19% of the UK population has a tattoo.1 This increasing fascination with body art has translated to an increase in the consumption of temporary tattoos.

On the surface this seems a benign, inconsequential trend, providing consumers with coveted body art without any of the guilt or longevity associated with permanent tattoos. However, related with this trend has been a rise in adverse reactions to these products,2 particularly those purchased during holidays, funfairs or festivals abroad.2 These tattoos are often marketed as ‘black henna temporary tattoos’ and sold by artisans. This so-called ‘black henna’ may contain irritant dyes such as paraphenylenediamine (PPD), in concentrations which may lead to blistering, painful skin burns and scarring, putting the long-term integrity of the user’s skin at risk. A survey conducted by the British Skin Foundation in 2015 suggested that 40% of dermatologists (244 respondents) had seen skin reactions to temporary black henna tattoos.2 Although many patients with black henna temporary tattoo complications may be treated through the NHS, long-term complications do arise and it is important for aesthetic practitioners to be aware of the causes before determining the best treatment methods, and to ensure that they are equipped to educate their patients. This article therefore hopes to provide a comprehensive overview of black henna temporary tattoos, highlighting the possible adverse reactions and detailing management in both the acute setting and treatment of long-term sequelae.

Henna is a naturally-occurring pigment derived from the leaves of Lawsonia inermis, a small tree native to northern Africa, southern Asia and northern Australasia. The active ingredient lawsone is liberated from the leaves through a drying process, before further processing to produce henna paste. When applied, henna paste concentrates in the epidermis of the skin and stains orange when removed. After two to three days it darkens to a reddish brown colour, and it is in this form that henna has been used to create body art since antiquity.

Black henna, on the other hand, is a synthetic pigment derived by mixing chemicals and unlisted dyes with naturally-occurring henna. Its constituent chemicals are chosen to produce a dark, quick-drying ink that leaves a finish similar to that of a permanent tattoo. One agent that is often added to black henna to enhance the colour and expedite drying time is PPD.3 Paraphenylenediamine PPD is a diamine compound, an aromatic hydrocarbon with two amino groups attached. It is used in the textile industries for the production of synthetic polymers, latex chemicals, cosmetic dyes and pigments.2 Historically PPD was a key constituent of many cosmetic products. In the 1930s the practice of tinting eyebrows and eyelashes with PPD-infused dyes was commonplace. Following reports of blistering reactions and blindness associated with numerous tinting products, the US federal government created a legislative framework to govern the cosmetics industry; this was in the form of the Food, Drug and Cosmetics Act of 1938 (now known as the Food and Drug Administration).5 The first act was to remove ‘Lash Lure’ (eyelash and eyebrow dye) off the market.5,6 Through patch testing and product interrogation, a causal link between PPD and allergic contact dermatitis was established. It is now known that PPD is a potent stimulator of T-lymphocytes.3,7 Once activated by antigen, these cells release inflammatory cytokines and activate other lymphocyte subsets resulting in a delayed type IV hypersensitivity reaction. As a result, its use in the cosmetic industry has come under significant restriction. In the US, the FDA does not permit the use of PPD at any concentration in skin products.3,8 Its use however, is permitted in hair dyes. The European Union (EU) also enforces a complete ban on the use of PPD in skin products. In addition, EU countries restrict PPD concentrations in hair dyes to less than 2%.9

A survey conducted by the British Skin Foundation in 2015 suggested that 40% of dermatologists (244 respondents) had seen skin reactions to temporary black henna tattoos

Reproduced from Aesthetics | Volume 3/Issue 10 - September 2016

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The potency of PPD as an allergen is a function of its concentration and the duration of direct exposure. Previous allergen studies have indicated that patch testing 0.01% PPD for 15 minutes elicited no reaction. Increasing this to 1% for 15 minutes caused a reaction rate in 37.5% of subjects. Use of 1% for 120 minutes increased the reaction rate to 69% of subjects.3,10 Black henna tattoos have been found to have PPD concentrations as high as 15-30%; furthermore the ink is often left in contact with skin for several days.3,10

Black henna complications Cutaneous reactions to black henna are usually T-lymphocytes mediated type IV hypersensitivity reactions. These reactions are traditionally delayed, occurring up to 10 days after exposure.3 Previous sensitisation, however, may hasten the onset of symptoms.3 Initial manifestation of this reaction may be in the form of an intractable itch or burning associated with an erythematous eczematous rash in the pattern of the tattoo. This can progress to blistering, weeping and significant oedema with an attendant risk of supra-infection.3,11 In rare cases, anaphylaxis has been reported.3,12 Severe reactions can lead to significant scarring with keloid formation in at-risk skin types.11 In addition, many patients develop post-inflammatory hypopigmentation after resolution of the reaction. Long-term immune sequelae are particularly problematic.3,11 Once patients have been sensitised, they are at risk of developing more extensive allergic reactions, including anaphylaxis, if subsequently exposed to PPD. The widespread use of PPD in hair and textile dyes means that sensitised patients may develop allergic contact dermatitis to natural rubber latex, azo dyes, thiurams, para-aminosalicylic acid and benzocaine.3,13,14,15 Patient education and patch testing are therefore an integral part of longterm management.

Treatment In the acute phase, treatment is focused on switching off the inflammatory process and symptom control. Topical corticosteroids are the mainstay, with potency chosen according to the site of the lesion. For widespread reactions systemic (oral and intravenous) steroids may be considered. Antihistamines and simple analgesia may help the itch and burning. Any weeping lesions should be swabbed and sent for microscopy, culture and sensitivity testing.

Acutely, treatment is similar to that for other cases of allergic contact dermatitis. In the event of anaphylaxis, intramuscular adrenaline must be given in addition to the above, with mandatory hospitalisation for observation (in case of biphasic disease).

Once the acute phase has settled, scarring can complicate the recovery phase. Scarring tends to be hypertrophic in nature with excess collagen deposition leaving a raised unsightly mark at the site of the temporary tattoo. Darker skin types (Fitzpatrick type V and VI) are at risk of keloid scar formation.11 Treatment of post-inflammatory scars poses a significant challenge. There are numerous approaches, which may be taken with varying degrees of success.

Conservative treatments Conservative treatments include the use of occlusive dressings (silicone gel sheets, non-silicone occlusive sheets and cordran tape) and compression. The anti-keloid effects of occlusion are thought to derive from a combination of occlusion and hydration. Previous studies have indicated moderate improvement in 37.5% of patients treated with silicone occlusive sheeting worn with pressure 24 hours a day for 12 months.16 Another study of patients treated with semi-permeable,

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semi-occlusive, non-silicone based dressings for eight weeks reported flattening of scars in 60% of the cohort with a 90% satisfaction rate in the treatment group.16,17 Compression therapy involves the use of pressure to flatten scars. It is thought that engaged mechanoreceptors activate cellular apoptosis and also inhibit proliferation of fibroblasts.16 Injections Intralesional corticosteroid injections are the mainstay of treatment and reduce scar formation by down-regulating the synthesis of collagen, glycosaminoglycan, inflammatory mediators and fibroblast proliferation.16 The most commonly used agent is the medium strength steroid, triamcinolone acetonide. Patients must be warned of the complications of repeated intralesional corticosteroid injections including atrophy, telangiectasia and local changes in pigmentation.16 Invasive treatments More invasive treatments include cryotherapy and surgical excision.

Cryotherapy affects the microvasculature, inducing apoptosis through intracellular crystal formation and anoxia. One to three freeze-thaw cycles lasting 10-30 seconds each are recommended for the desired effect.16,18 Treatment can be painful which may be a limiting factor with large treatment areas. As with intralesional corticosteroids, cryotherapy can also cause changes to local pigmentation.16 In addition to the aforementioned techniques, scar tissue may also be surgically excised with wounds carefully closed under minimal tension.16 This may produce a more cosmetically-appealing scar, however the outcome is operator dependent and there is a risk of new keloid formation in the revised scar in those with darker skin types.16 Laser Finally, non-ablative and ablative laser techniques have also been used to treat hypertrophic and keloid scars with varying degrees of success. In a study treating 21 keloid scars with the Erbium: Yttrium aluminium garnet laser (Er:YAG), there was a 51% reduction in elevation.16,19 Similarly, a case series of 22 hypertrophic and keloid scars treated with the Neodymium: Yttrium, aluminium, garnet laser (Nd:YAG) indicated a persistent flattening of scars in 22.7% of cases, 12 months after treatment.16,20 The above techniques may be implemented with varying degrees of success depending on the nature of the scars.

For the best cosmetic outcome a combination of the above treatments is likely to be required. Each case must be assessed on an individual basis with consideration of Fitzpatrick skin type, scar location, scar size and local expertise taken into account. Surgical excision and scar revision for instance may be favoured in Fitzpatrick I-III while intralesional steroid injection may be first-line for darker pigmented skin (IV-V) due to attendant risk of keloid scar formation.

Post-inflammatory hypopigmentation Post-inflammatory hypopigmentation is both a complication of black henna temporary tattoos and the treatment of scar sequelae. There are few effective treatments and in many cases pigmentation may improve with time. Camouflage makeup may be used as an interim measure.

Conclusion Black henna temporary tattoos can represent a significant public health risk. The adulteration of naturally occurring henna with unlisted dyes including the banned compound PPD,3 puts the user at risk of developing allergic contact dermatitis and longer

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term sequelae. Acute reactions are characterised by painful/itchy erythema, blistering and weeping with the added risk of suprainfection.3,11 This can lead to scarring and pigmentation changes, which may be difficult to treat. As practitioners, it is important that we are aware of the causes of such reactions and scars, and how to best manage the complications. More worryingly patients may become sensitised to PPD and other constituents with the risk of developing more severe reactions (including anaphylaxis) when challenged with these allergens in the future (e.g. hair dye).3,2,13,14 Prevention is always better than cure and as healthcare professionals it is our duty to ensure that our patients are adequately informed and educated about the risks associated with black henna tattoos. This is particularly pertinent as the source of this danger may be friendly, unassuming, itinerant artisans who are themselves unaware of the hazardous nature of their products.

Dr Anjali Mahto is a medical and cosmetic dermatologist at The Cadogan Clinic in London. She has an interest in acne, rosacea, injectable and laser therapies. She is a member of the British Cosmetic Dermatology Group and a spokesperson for the British Skin Foundation.

Dr Derrick Phillips graduated from UCL Medical School in 2011, and, since then, has exercised a keen interest in dermatology. He completed four months of dermatology as a junior doctor, during which he was awarded the St John’s Dermatology Prize, and has presented dermatological cases at international and national conferences.

Aesthetics REFERENCES 1. William Jordan, Myth busted: people do Not regret getting tattoos later in life, YouGov, (2015)<http:// www.yougov.co.uk/news/2015/07/14/myth-busted -people-do-not-regret-their-tattoos/> 2. Zosia Kmietowicz, “Black henna” tattoos can cause blistering and scarring, doctors warn, British Journal of Medicine, 351(2015).

3. Sonnen G, ‘Type IV Hypersensitivity reaction to a temporary tattoo’, Baylor University Medical Centre Proceedings, 20(2007), pp.36-38.

4. Wolf R, et el., ‘Cutaneous reactions to temporary tattoos’, Dermatology online Journal, 9(2003) <http:// escholarship.org/uc/item/5dd6616d>b 5. US Food and Drug Administration, ‘FDA History-Part 2: The 1938 food, drugs and cosmetics act’ FDA (2012), <http://www.fda.gov/AboutFDA/WhatWeDo/History/Origin/ucm054826.htm> 6. Jacob SE, Goldenberg A, ‘A look at paraphenylenediamine’,The Dermatologist, 22(2014) <http://www. the-dermatologist.com/content/look-para-phenylenediamine> 7. Sieben S, et el., ‘T Cell responses to Paraphenylenediamine and to its metabolites mono- and diacetyl-para-phenylenediamine’, International Archives of Allergy and Immunology, 124(2001), pp.356-358.

8. The Food and Drug Administration, ‘Temporary tattoos, Henna/Mendhi, and “Black Henna”: Fact Sheet,’ FDA, (2015) <http://www.fda.gov/Cosmetics/ProductsIngredients/Products/ucm108569.htm> 9. The European Commission, ‘Commision Regulation (EU) No 344/2013’, Official Journal of The European Union (2013).

10. Gawkrodger DJ, English JS, ‘How safe is patch testing to PPD?’, British Journal of Dermatology, 154(2006), pp.1025-1027.

11. Dyall-Smith D, ‘Black henna tattoo reactions’, DermNet NZ, (2006) <http://www.dermnet.nz.org/ reactions/black-henna-tattoo.html> 12. Onder M, et al., ‘Temporary henna tattoo reactions in children’, International journal of Dermatology, 40(2001), pp.577-579.

13. Onder, M, ‘Temporary holiday tattoos may cause lifelong allergic contact dermatitis when henna is mixed with PPD, Journal of Cosmetic Dermatology, 2(2004), pp.126-130.

14. Sosted H, et al., ‘Severe allergic hair dye reactions in 8 children’, Journal of Contact Dermatitis, 54(2006), pp.87-91.

15. Martin JA, Hughes TM, Stone NM, ‘Black henna tattoos: an occult source of natural rubber latex allergy?’, Journal of Contact Dermatitis, 52(2005), pp.145-146.

16. Berman B, et al., ‘Keloid and hypertrophic scar treatment and management’, Medscape (2016) <http:// www.emedicine.medscape.com/article/1057599-treatment#d9> 17. Eaglestein WH, ‘Occlusive dressings’, Journal of Dermatological Surgery and Oncology,19(1993), pp.716-720.

18. Har-Shai Y, ‘Intralesional cryosurgery enhances the involution of recalcitrant auricular keloids: a new clinical approach supported by experimental studies,’ Journal of wound repair and regeneration, 14(2006), pp.18-27.

19. Wagner JA, Paasch U, Bodendorf MO, et al., ‘Treatment of keloids and hypertrophic scars with the triple-mode Er:YAG laser: A pilot study’, Journal of Medical laser application, 26(2011), pp.5-10.

20. Apfelberg DB, et al., ‘Preliminary report on the use of Neodymium-YAG laser in plastic surgery’, Lasers in Surgery and Medicine, 7(1987), pp.189-198.

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Reproduced from Aesthetics | Volume 3/Issue 10 - September 2016

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cardiovascular and other health risks.6 These patients benefit much more from global weight reduction initially, followed by tightening of loose skin and contouring. When selecting patients, it is important to thoroughly discuss their motivations for treatment and gain an appreciation of their social and psychological wellbeing during the consultation.

Types of treatments

An Introduction to Fat Reduction Aesthetic practitioner Dr Tatiana Lapa and trainee ENT Surgeon Mr Rishi Mandavia provide a comprehensive overview of the different types of noninvasive fat reduction treatments Public awareness of health problems associated with obesity, combined with popular trends towards achieving physical beauty, has given rise to a demand for fat reduction and body contouring treatments that are effective, safe, affordable and have minimal downtime. Liposuction has been indicated in many studies to be very effective, however, it carries a relatively high risk of complications and side effects1 with reports of long-term and even fatal difficulties due to complications during and after treatment.2 Non-surgical aesthetic procedures offer a lower-cost and safer alternative with a shorter recovery time. It is therefore not surprising that demand for these treatments has grown by more than 500% since 1997 and that they account for 80% of total cosmetic procedures in the US.3

Non-invasive fat reduction Non-invasive fat reduction therapies are often classified as either ablative (cooling, heating, adipocyte disruption or dissolution) or non-ablative (lipolytic stimulation or ultrastructural modification). The ablative treatments cause adipocytes to shed triglycerides and result in apoptosis, necrosis or reduced cell size. Non-ablative therapies leave adipocytes intact.4 The most commonly used non-invasive treatments for fat reduction include: cryolipolysis, low level laser therapy (LLLT), radiofrequency (RF), high-intensity focused ultrasound (HIFU) and injection lipolysis.

Patient selection In general, three types of patients undergo body contouring procedures: • Patients wanting to treat focal adiposity in problem areas such as the abdomen, thighs, or hips • Patients with skin laxity of the face, neck, or arms wanting to tighten skin and deeper layers • Patients requiring treatment that combines both fat reduction and skin tightening5 These treatments are most ideal for non-obese (body mass index of less than 30) patients seeking modest localised fat reduction. With a BMI of more than 30, patients often have visceral fat, which increases

Cryolipolysis Cryolipolysis is growing in popularity and works by controlled cooling causing adipocyte apoptosis. One cryolipolysis device, CoolSculpting, has been approved by the Food and Drug Administration (FDA) for the treatment of the flanks, abdominal area and thigh fat.4 The devices for cryolipolysis usually contain a cupshaped applicator that is applied to the treatment area causing tissue to be drawn into the handpiece under vacuum. Each area is treated for approximately 45 minutes and then massaged to quicken recovery. Results are generally seen within three days of treatment with full effects visible at three to four weeks.7 The number of treatment cycles is dependent on the treatment area and patient: the flanks typically require one treatment, whilst abdomen and thighs often require two or more. Treatments should be spaced eight weeks apart to allow sufficient recovery time between procedures.8 High-intensity focused ultrasound This modality uses high frequency focal acoustic energy to raise the temperature around adipose tissue and produce coagulative necrosis.9 HIFU has a focal point depth of 1.3cm and therefore patients need adipose tissue depth of at least 1cm beyond the focal point. The HIFU LipoSonix device has been approved by the FDA for the reduction of waist circumference.10 The procedure typically involves placing the HIFU device two or three times on the treatment area, each time taking 15 to 20 minutes, for a total treatment time of 45 minutes to one hour. The clinical response is usually evident within two weeks and complete within three months. A study by Jewell et al supports mean reductions in waist circumference ranging from of 4.2-4.7cm, 12 weeks after the procedure.8

Radiofrequency Radiofrequency causes thermal injury to targeted tissue layers using electrical energy.11 Monopolar and multipolar forms are available for fat reduction. In monopolar radiofrequency devices, energy is passed from a single electrode into the tissues and directed to a return pad in another area of the body. In multipolar radiofrequency, two or more electrodes within the same handpiece are positioned at different points on the skin so that the waves pass between them to create a heating effect.12 Radiofrequency devices have traditionally been used for tightening of the skin and targeting wrinkles but are also used for fat and cellulite reduction.5 Targeted body sites include the abdomen, thighs, buttocks, extremities and face.4 Reductions in fat volume are typically seen three to eight weeks after treatment, with up to 3cm reductions in waist circumference following 10 treatments.13 Radiofrequency can present challenges in terms of pain management. Topical anaesthetics that numb the epidermis are not recommended as they may aggravate pain, whilst local anaesthetics may interfere with delivery of radiofrequency waves.14 Oral analgesics are the generally recommended agents for pain management.8

Reproduced from Aesthetics | Volume 3/Issue 10 - September 2016

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Dosage and Administration: Should be applied to the affected area twice daily, at least eight hours apart. Application should be limited to the face and under the chin. Maximal applied doses used safely in clinical trials were up to 30 grams per month. Improvement in the condition may be noticed within eight weeks and continued treatment may result in further improvement and is necessary to maintain beneficial effects.

Discontinue if no beneficial effects are noticed within four months of commencing therapy. Patients may need to continue to use hair removal methods (e.g. shaving or plucking) in conjunction with Vaniqa. Application of Vaniqa should be no sooner than 5 minutes after use of other hair removal method, as increased stinging or burning may occur. A thin layer of the cream should be applied to clean and dry affected areas. The cream should be rubbed in thoroughly. The medicinal product should be applied such that no visual residual product remains on the treated areas after rub-in. Hands should be washed after applying this medicinal product.

For maximal efficacy, the treated area should not be cleansed within four hours of application. Cosmetics (including sunscreens) can be applied over the treated areas, but no sooner than five minutes after application.

The condition should improve within eight weeks of starting treatment.

Paediatric populations: The safety and efficacy of Vaniqa in children 0-18 years has not been established. Hepatic/renal impairment: caution should be used when prescribing Vaniqa. Consult SmPC for further information. Contraindications, Warnings, etc: Contraindications: Hypersensitivity to eflornithine or to any of the excipients. Warnings & Precautions: Excessive hair growth can result from serious underlying disorders (e.g. polycystic ovary syndrome, androgen secreting neoplasm) or certain active substances (e.g. cyclosporin, glucocorticoids, minoxidil, phenobarbitone, phenytoin, combined oestrogen-androgen hormone replacement therapy). These factors should be considered in the overall medical treatment of patients who might be prescribed Vaniqa. For cutaneous use only. Contact with eyes or mucous membranes (e.g. nose or mouth) should be avoided. Transient stinging may occur if applied to abraded or broken skin. If skin irritation or intolerance develops, the frequency of application should be reduced temporarily to once a day. If irritation continues, treatment should be discontinued and the physician consulted. Contains cetostearyl alcohol and stearyl alcohol which may cause local skin reactions (e.g. contact dermatitis) as well as methyl parahydroxybenzoate and propylparahydroxy-benzoate which may cause allergic reactions (possibly delayed). Interactions: No interaction studies have been performed. Pregnancy and lactation: Women should not use Vaniqa whilst pregnant or breastfeeding. Ability to drive and use machines: Vaniqa has no or negligible effects on

UKEFL3585b Date of preparation: August 2016.

the ability to drive and use machines. Adverse Effects: These are ranked under heading of frequency using the following convention: very common (≥1/10); common (≥1/100 to <1/10); uncommon (≥1/1,000 to <1/100); rare (≥1/10,000 to <1/1,000); very rare (<1/10,000). Very common: acne. Common: pseudofolliculitis barbae, alopecia, stinging skin, burning skin, dry skin, pruritus, erythema, tingling skin, irritated skin, rash, folliculitis. Uncommon: bleeding skin, furunculosis. Rare: rosacea, skin neoplasm, skin cysts, vesiculobullous rash. Consult SmPC in relation to other adverse effects. Legal Category: POM. Marketing Authorisation Number(s): EU/1/01/173/003. NHS Cost: (excluding VAT). Tube containing 60g – £56.87. Marketing Authorisation Holder: Almirall, S.A. Ronda General Mitre, 151 08022 Barcelona, Spain.

Further information is available from: Almirall Limited, 1 The Square, Stockley Park, Uxbridge, Middlesex, UB11 1TD, UK. Tel: (0) 207 160 2500.

Fax: (0) 208 7563 888. Email: almirall@professionalinformation.co.uk.

Date of Revision: 10/2015. Item code: UKEFL3336

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

Adverse events should also be reported to Almirall Ltd.

For more information please go to: www.medicines.org.uk/emc/medicine/21243

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Low level laser therapy LLLT utilises non-thermal ablation of adipocytes for focal adiposity and skin tightening. It can be used for the abdomen, thighs, flank and neck, requiring up to eight sessions for optimal effect. Laser light is applied to areas with excess fatty tissue for five to 10 minutes per region with total procedure time of approximately 30 minutes.15 It takes up to three weeks to see the final results.7 A trial by Jackson el al16 demonstrated a reduction of 2.6cm in waist circumference following LLLT over a two-week treatment period.

Injection lipolysis Injection lipolysis is used for focal adiposity and skin tightening around the face, abdomen, hips, thighs and flanks.7 Prior to the procedure, topical or injectable local anaesthetic is applied, and an injection consisting of phosphatidylcholine with deoxycholic acid is then delivered using a 4-6mm needle.17 Three to 15 treatment sessions are usually required, with optimal effect seen at four to six weeks.

The addition of a ‘detergent’ such as deoxycholic acid, causes fat cell destruction. This aims to prevent fat cells from refilling over time and reduces the number of treatments required. The mechanism of action for the treatment is not fully understood.

Complications and side effects Non-invasive fat reduction therapies are generally very safe, with most patients reporting only mild and transient adverse effects. The most commonly reported side effects are mild discomfort, erythema and oedema, with the majority of patients having little downtime. A decrease in sensation in the treatment area for up to eight weeks is reported in around two-thirds of patients treated with cryolipolysis18 and rarely with injection lipolysis, due to direct nerve injury.19 Paradoxical adipose hyperplasia (PAH) is also a rare complication of cryolipolysis; typically appearing two months post-treatment with an incidence of one in 20,000 treated patients.20 Rare adverse events following radiofrequency treatment include scars, burns, purpura, oedema, hyperpigmentation and blisters.20 LLLT treatments are generally thought to have the fewest and most mild complications with several studies reporting no adverse effects at all.1,20,21,22,23

Clinical effectiveness A number of studies support the effectiveness of these therapies for reducing subcutaneous fat tissue, with a degree of efficacy dependent on body-site.8,11,14,24 Owing to the heterogeneity of studies, it is difficult to compare efficacy between modalities. Nevertheless, there are reports of high patient satisfaction for these procedures: LLLT carries patient satisfaction rates as high as 80%;25 studies on cryolipolysis report patient satisfaction at 73%100%;1 while RF and HIFU studies identify patient satisfaction at 97% and 85% respectively.26,27 A study by Reeds et al indicated that patients receiving phosphatidylcholine and deoxycholate injections on subcutaneous fat were highly satisfied with the treatment protocol.28 Conclusion There is increasing patient demand for non-invasive fat reduction and body contouring treatments, which offer a quicker, low-cost and safer alternative to liposuction. Appropriate patient selection and thorough pre-procedural assessment is essential in order to select the optimal treatment strategy for the patient and achieve the best outcomes.

All discussed therapies have a good safety profile, but nevertheless, practitioners should undergo appropriate training and be aware of potential complications and subsequent management options. Future

Aesthetics

studies should use standardised, agreed outcome measures so that results between modalities can be more accurately compared.

Dr Tatiana Lapa is the medical director of The Studio Clinic on Harley Street. She is a qualified doctor and an experienced aesthetic practitioner with a background in surgery, dermatology and general practice. Dr Lapa has a keen interest in research and has conducted trials in specialist centres in Brazil and London, and has published and presented her academic work internationally.

Mr Rishi Mandavia is a trainee ENT, head and neck surgeon and NICE scholar with academic interests in ENT health policy research. Mandavia is also a NICE specialist advisor in its guidelines and quality development programmes and has published more than 20 peerreviewed studies and book chapters.

REFERENCES 1. Kennedy et al, Non-Invasive Subcutaneous Fat Reduction: a Review, Journal of the European Academy of Dermatology and Venereology, (2015) <http://www.ncbi.nlm.nih.gov/pubmed/25664493> 2. Serge Mordon and Eric Plot, Laser Lipolysis Versus Traditional Liposuction for Fat Removal, Expert Review of Medical Devices 6, no. 6 (2009): 677–88, doi:10.1586/erd.09.50.

3. American Society for Aesthetic Plastic Surgery, Cosmetic Surgery National Data Bank Statistics, ASAPS (2014) < http://www.surgery.org/media/statistics> 4. Nils Krueger et al, Cryolipolysis for Noninvasive Body Contouring: Clinical Efficacy and Patient Satisfaction, Clinical, Cosmetic and Investigational Dermatology 7 (2014): 201–5.

5. Mark L Jewell, Nowell J Solish, and Charles S Desilets, Noninvasive Body Sculpting Technologies with an Emphasis on High-Intensity Focused Ultrasound. Aesthetic Plastic Surgery 35, no. 5 (2011): 901–12, doi:10.1007/s00266-011-9700-5.

6. Dr Axe, Visceral Fat: What It Is and Why It’s So Dangerous, Dr Axe, (2016) <https://draxe.com/visceral-fat/> 7. Dieter Manstein et al, Selective Cryolysis: a Novel Method of Non-Invasive Fat Removal,” Lasers in Surgery and Medicine 40, no. 9 (2008): 595–604, doi:10.1002/lsm.20719.

8. Jewell, Solish, and Desilets, Noninvasive body sculpting technologies with an emphasis on highintensity focused ultrasound, (2011) Aesthetic Plastic Surgery,<http://www.ncbi.nlm.nih.gov/ pubmed/21461627> 9. Afschin Fatemi and Michael A C Kane, High-Intensity Focused Ultrasound Effectively Reduces Waist Circumference by Ablating Adipose Tissue from the Abdomen and Flanks: a Retrospective Case Series, Aesthetic Plastic Surgery 34, no. 5 (2010): 577–82 10. Shiv Gaglani, LipoSonix Ultrasound System Approved by FDA, medGadget, (2011), <http://www. medgadget.com/2011/09/liposonix-ultrasound-system-approved-by-fda.html> 11. Ernesto Gadsden et al, “Evaluation of a Novel High-Intensity Focused Ultrasound Device for Ablating Subcutaneous Adipose Tissue for Noninvasive Body Contouring: Safety Studies in Human Volunteers, Aesthetic Surgery Journal / the American Society for Aesthetic Plastic Surgery 31, no. 4 (2011): 401–10.

12. M Lapidoth and S Halachmi, Basic Radiofrequency: Physics and Safety and application to Aesthetic Medicine, Radiofrequency in Cosmetic Dermatology, (2015) Germany; Karger 13. Weiss, Noninvasive radio frequency for skin tightening and body contouring, Semin Cutan Med Surg 32, no 1 (2013): 9-17.

14. Christine C Dierickx, The Role of Deep Heating for Noninvasive Skin Rejuvenation, Lasers in Surgery and Medicine 38, no. 9 (2006): 799–807.

15. Mary K Caruso-Davis et al, Efficacy of Low-Level Laser Therapy for Body Contouring and Spot Fat Reduction, Obesity Surgery 21, no. 6 (2011): pp.722–29.

16. Jackson et al, Low-Level Laser Therapy as a Non-Invasive Approach for Body Contouring: a Randomized, Controlled Study, Lasers in Surgery and Medicine, (2009) <http://www.ncbi.nlm.nih.gov/ pubmed/20014253> 17. Chiara Milanese et al, Effect of Low-Intensity, Low-Frequency Ultrasound Treatment on Anthropometry, Subcutaneous Adipose Tissue, and Body Composition of Young Normal Weight Females, Journal of Cosmetic Dermatology 13, no. 3 (2014): 202–7 18. Sydney R Coleman et al, Clinical Efficacy of Noninvasive Cryolipolysis and its Effects on Peripheral Nerves, Aesthetic Plastic Surgery 33, no. 4 (2009): 482–88 19. Vanaman, Fabi, and Carruthers, “Complications in the Cosmetic Dermatology Patient: a Review and Our Experience (Part 1), Dermatology Surgery, 20. Monique Vanaman, Sabrina Guillen Fabi and Jean Carruthers, Complications in the Cosmetic Dermatology Patient: a Review and Our Experience (Part 1), Dermatologic Surgery: Official Publication for American Society for Dermatologic Surgery et al. 42, no. 1 (2016): 1–11.

21. Caruso-Davis et al, Efficacy of Low-Level Laser Therapy for Body Contouring and Spot Fat Reduction, Obesity Surgery, (2011) <http://www.ncbi.nlm.nih.gov/pubmed/20393809> 22. Nestor, Newburger, and Zarraga, Body Contouring Using 635-Nm Low Level Laser Therapy, Seminars in Cutaneous Medicine and Surgery, (2013) <http://www.ncbi.nlm.nih.gov/pubmed/24049928> 23. Mark S Nestor, Matthew B Zarraga, and Hyunhee Park, Effect of 635nm Low-Level Laser Therapy on Upper Arm Circumference Reduction: a Double-Blind, Randomized, Sham-Controlled Trial,”The Journal of Clinical and Aesthetic Dermatology 5, no. 2 (2012): pp.42-48.

24. Fatemi and Kane, High-Intensity Focused Ultrasound Effectively Reduces Waist Circumference by Ablating Adipose Tissue From the Abdomen and Flanks: a Retrospective Case Series,Aesthetic Plastic Surgery, (2010) <http://www.ncbi.nlm.nih.gov/pubmed/20383499> 25. Mark S Nestor, Jessica Newburger, and Matthew B Zarraga, Body Contouring using 635-nm Low Level Laser Therapy, Seminars in Cutaneous Medicine and Surgery 32, no. 1 (2013): 35–40.

26. Maurice A Adatto, Robyn M Adatto-Neilson, and Grietje Morren, Reduction in Adipose Tissue Volume Using a New High-Power Radiofrequency Technology Combined with Infrared Light and Mechanical Manipulation for Body Contouring, Lasers in Medical Science 29, no. 5 (2014): 1627–31.

27. Steven A Teitelbaum et al, Noninvasive Body Contouring by Focused Ultrasound: Safety and Efficacy of the Contour I Device in a Multicenter, Controlled, Clinical Study, Plastic and Reconstructive Surgery 120, no. 3 (2007): 779-89.

28. Reeds et al, Metabolic and Structural Effects of Phosphatidylcholine and Deoxycholate Injections on Subcutaneous Fat, Aesthetic Surgery Journal, (2013) <http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC3667691/>

Reproduced from Aesthetics | Volume 3/Issue 10 - September 2016

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Bioidentical Hormone Therapy Dr Marion Gluck details how bioidentical hormones can be used in aesthetic practice and the ways in which they can benefit patients For more than 20 years, I have successfully treated thousands of patients with hormonal imbalances such as premenstrual syndrome, perimenopause, menopause, fatigue, mood swings, acne and ageing skin using bioidentical hormone replacement therapy (BHRT). I have developed research and training to raise awareness of its efficacy and benefits; training many medical professionals.

I am passionate about making BHRT mainstream and available for everyone.

Because a woman produces less oestrogen as she ages, most commonly from her early 40s,1 the amount of collagen, which provides underlying support for her skin, drops. The result is a loss of firmness and elasticity; the skin around her mouth and eyes begin to sag and wrinkles deepen.2 I believe that one of the best ways to rejuvenate ageing skin is by replacing the declining production of oestrogen, progesterone and testosterone.

But like any treatment, I would advise practitioners to learn why it works, how to use it safely and to select the best possible training.

Hormone replacement therapy Replacing the missing oestrogen with hormone replacement therapy (HRT) would seem an essential component of any antiageing programme. However, the

Women’s Health Initiative trial in 2002, which tested HRT and a placebo on 162,000 post-menopausal women, highlighted a link between conventional HRT and an increased risk of cancer and heart disease. The trial took place over 10 years and included treating women with two non-bioidentical hormones; Premarin, which is an oestrogen derived from mare’s urine – known as conjugated equine oestrogen (CEE) – and a Provera which is a progestin named medroxyprogesterone acetate (MPA). The combination indicated an increase in the relative risk of heart disease by 26% and of cancer by 25%.3 Since then, some women have been wary of using HRT, and practitioners only tend to recommend it for the treatment of menopausal symptoms such as sweating, flushing, insomnia and mood swings, and for as short a time as possible.

Bioidentical hormones Bioidentical hormones have the same chemical and molecular structure as the naturally-occurring hormones produced in the body. As a result, they fit their hormone receptor sites wholly and their effects are more consistent with the normal biochemistry of the body.6 These hormones are derived from plant sources such as Mexican yams

Research Research in 2008 highlighted the difference between bioidentical progesterone and progestins found in HRT. The research suggests that progestins are associated with raised blood pressure, damage to the lining of blood vessels, breast cancer, increased inflammation and insulin resistance.7 The report concludes that the use of bioidentical progesterone ‘confers less or even no risk of breast cancer as compared to the use of synthetic progestins’. Research by Mohammed et al conducted last year also indicates that the cancer risk with progestins was not found with progesterone.8 Bioidentical oestrogen – most widely used in the form of estradiol – is also indicated to have a better safety profile compared to non-bioidentical CEE.10 Research published in the Journal of the American Osteopath Association indicates that it protects the heart, does not increase blood pressure and has limited evidence for an antidepressant effect and improved insulin sensitivity.9 This is in addition to its ability to increase the production of collagen and fibrin around the time of the menopause, hence improving the signs of ageing on the face.10

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and soy, and manufactured into micronised powder form.4 For a hormone to be considered ‘natural’ or ‘bioidentical’, its structure must replicate the exact structure of the hormones produced by the body, including the arrangement of carbon, oxygen and hydrogen atoms.5 A ‘synthetic’ hormone has slight structural differences to a hormone produced by the body, which means it can act differently and produce substantially different effects. Synthetic hormones have a different arrangement of carbon, oxygen and hydrogen atoms compared to naturally-occurring hormones in the body, and sometimes have additional atoms such as sodium or sulphur.6 Prescribing hormones The bioidentical hormones often prescribed are estradiol, estriol, progesterone, testosterone and dehydroepiandrosterone (DHEA). Firstly, the practitioner must check the levels of these hormones through a blood test. They must also look at a combination of symptoms, medical history, and lifestyle along with the blood results. Weight gain and mood swings, for example, are linked with increased sensitivity to oestrogen while trouble sleeping can indicate a progesterone deficiency.11,12 Acne, facial hair and greasy skin suggest an excess of testosterone.13 Most bioidentical hormones are delivered via transdermal cream, lozenge, capsule or pessary in prescription forms that are tailored to the patient.

Getting the balance right The very effectiveness of hormones means that they have to be prescribed individually and designed specifically for each patient.

Oestrogen given on its own has long been linked with an increased risk of cancer of the womb, which is why it needs to be balanced by bioidentical progesterone.11 Controlled studies and some observational studies have indicated that a combination of oestrogen and progestins increases the risk of breast cancer, while a recent study suggests the oestrogen/progesterone combinations do not raise the risk.14 With the possibility of adjusting dosages as required, side effects seldom occur.15 As well as the suggested reduced risk with BHRT, this approach is far more individualised. While HRT is prescribed in a standard dose without any testing to find out what a patient’s actual hormone levels are, BHRT practitioners are aware that oestrogen, testosterone and progesterone are not the only hormones that decline as we age and that the levels of each hormone can influence others,

Reproduced from Aesthetics | Volume 3/Issue 10 - September 2016

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which include DHEA and vitamin D. For example, increasing progesterone levels has been indicated to increase the level of free thyroxine;16 a supplement of DHEA has been suggested to raise progesterone levels;17 while one of the effects of hypothyroidism is to reduce testosterone levels because it down-regulates the first step in testosterone production.18

Estradiol (E2)

Estriol (E3)

O

OH

H

H

HO

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As well as a low libido, testosterone deficiency is linked with fatigue irritability and depression. Correcting it can improve memory and energy.24 Most of the research on hormones has been conducted on menopausal women, but even the normal monthly oestrogen fluctuations of younger women can cause changes in skin thickness, increasing the possibility that an oestrogen cream could benefit women of a lower age.15 If a patient is particularly sensitive to oestrogen; signs of which include breast tenderness, fluid retention and headaches,25 a progesterone cream may do just as well. A double blind trial including 40 peri or post-menopausal

Background of BHRT Bioidentical hormones have been around since the early 1930s and are now increasingly accessible and are what I feel is an important option in balancing hormones.

Estrone (E1)

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OH

H

H

H

HO

H

H

H

OH

H

HO

Figure 1: The three forms of hormone that make up oestrogen

The benefits of balanced hormones Oestrogen is actually a combination of three forms of the hormone – estriol, estrone and estradiol (Figure 1) – each of which can be used independently. Estriol has been indicated to have what is a very welcome cosmetic effect – improving the condition of skin scarred by chronic acne.19 Supplementing oestrogen can increase firmness and smooth wrinkles on the face, as well as provide some degree of protection against skin photoageing,20 improve sleep and maintain muscles.21 However, their benefits aren’t limited to making the skin more youthful. A study in the Journal of the American Pharmacists Association highlighted the beneficial effects on the brain of both oestrogen and progesterone by such routes as increasing blood flow, reducing inflammation and protecting brain cells, all of which show both emotional and health benefits.22 The impacts on some other areas affecting health, such as changes in weight, are more complicated. As oestrogen levels decline, women tend to put on more fat around the stomach; whereas, when these levels are increased to normal levels with BHRT, fat is more likely to be stored under the skin subcutaneously.15 Testosterone might be added to a prescription for someone suffering from low libido, as it has been linked with an improvement in wellbeing, mood and sexual function in menopausal women.23

women aged between 45 and 60 who applied a progesterone cream every night for 16 weeks noted improved elasticity, improved firmness and a reduction in wrinkle count.26 Conclusion Improving the external appearance using dermal fillers or botulinum toxin isn’t always enough. If practitioners really want to enhance a patient’s appearance, we need to change the way they think and feel, which is where hormones can help. BHRT can provide a powerful new tool that would fit easily into any aesthetic programme, offering improvements in energy, mood and physical appearance.

Disclosure: Dr Marion Gluck has developed and provides an introduction course in the UK on bioidentical hormones, aiming to provide practitioners with competency to treat common conditions such as premenstrual syndrome, acne, perimenopause and menopause using BHRT. Dr Marion Gluck trained as a medical doctor in Hamburg more than 30 years ago and has worked all over the world as a women’s health specialist.

Dr Gluck is passionate about the potential of bioidentical hormones to change the lives of people for the better and takes a leading role in teaching other practitioners.

REFERENCES 1. Women’s Health Concern, The menopause, WHC, (2015) <https://www.womens-health-concern.org/help-and-advice/ factsheets/menopause/> 2. Brincat MP, Estrogens and the skin, Climacteric, (2005) 8(2):110-23 3. Evan Simpson & Richard J Santen, Celebrating 75 years of oestradiol (T1–T20), Journal of Molecular Endocrinology V.55 (2015).

4. Harvard Health Publications, what are bioidentical hormones?

Harvard Medical School, (2015) <http://www.health.harvard. edu/womens-health/what-are-bioidentical-hormones> 5. Julia A Files, Marcia G Ko, Sandhya Pruthi, Bioidentical Hormone Therapy, Mayo Clinic Proceedings, (2011) 86 (7): 673-680.

6. Steven F Hotze & Kelly Griffin, Hormones, Health and Happiness: A Natural Medical Formula for Rediscovering Youth with Bioidentical Hormones (Second edition), (2013) 7. M L’hermite, T Simoncini, S Fuller, AR Genazzani, Could transdermal estradiol + progesterone be a safer postmenopausal HRT? A review, Maturitas, (2008) <http:// www.ncbi.nlm.nih.gov/pubmed/18775609> 8. H Mohammed et al, Progesterone receptor modulates ERα action in brest cancer, Nature (2015) <http://www.ncbi.nlm.nih. gov/pubmed/26153859> 9. E Conway , Bioidentical Hormones: An Evidence-Based Review for Primary Care Providers, The Journal of the American Osteopathic Association (V.111), (2011), 153-164.

10. L Rittié , S Kang , JJ Voorhees, GJ Fishe, Induction of Collagen by Estradiol. Difference Between Sun-Protected and Photodamaged Human Skin In Vivo, Archives of Dermatology Research, (2008) 144: 1129-1140.

11. C Barth et al, Sex hormones affect neurotransmitters and shape the adult female brain during hormonal transition periods. Frontiers in Neuroscience (2015).

12. Christina Boufis, Can’t sleep before you get your period?

Here’s why – and what you can do about it WebMDMagazine, (2011) <http://www.webmd.com/women/pms/features/whypms-gives-you-insomnia> 13. Jodi Godfrey Meisler, Toward Optimal Health: The Experts Discuss Facial Skin and Related Concerns in Women, MedScape, (2003) <http://www.medscape.com/ viewarticle/461568> 14. Carlo Campagnoli, Françoise Clavel-Chapelon, Rudolf Kaaks, Clementina Peris & Franco Berrino, Progestins and progesterone in hormone replacement therapy and the risk of breast cancer, Journal of Steroid Biochemistry & Molecular Biology, 96 (2005) 95–108.

15. D Moskowitz, A comprehensive review of the safety and efficacy of bioidentical hormones for the management of menopause and related health risks. Bioidentical hormones review. Alternative Medicine Review, 2006, 11 (3): 208-223 16. P. Sathi et al, Progesterone Therapy Increases Free Thyroxine Levels, Clinical Endocrinology (2013);79(2):pp.282-287.

17. A Weissman et al, Dehydroepiandrosterone supplementation increases baseline follicular phase progesterone levels, Gynecological Endocrinology, (2011), <http://www.ncbi.nlm.nih. gov/pubmed/21500990> 18. AW Meikle, The interrelationships between thyroid dysfunction and hypogonadism in men and boys, Tyroid, (2004) <http:// www.ncbi.nlm.nih.gov/pubmed/15142373> 19. Kathleen A. Head, Estriol: Safety and Efficacy, Alternative Medicine Review V.3, (1998) <http://www.anaturalhealingcenter. com/documents/Thorne/articles/Estriol.pdf> 20. Susan Stevenson & Julie Thornton, Effect of estrogens on skin aging and the potential role of SERMs, Journal of Clinical Interventions in Aging (2007) <http://www.ncbi.nlm.nih.gov/ pmc/articles/PMC2685269/> 21. Jade Teta, Female Hormones: Estrogen (oestrogen) & weight loss. ME Females, (2013) <http://www.metaboliceffect.com/ female-hormones-estrogen/> 22. J E Shepherd, Effects of estrogen on congnition mood, and degenerative brain diseases, Journal of the American Pharmacists Association, (2001) <http://www.ncbi.nlm.nih.gov/ pubmed/11297335> 23. R Goldstat, E Briganti, J Tran, R Wolfe & SR Davis, Transdermal testosterone therapy improves well-being, mood, and sexual function in premenopausal woman, Menopause, (2003) <http://www.ncbi.nlm.nih.gov/pubmed/145 01599> 24. SR Davis, Testosterone in Women the clinical Significance, The Lancet Diabetes & Endocrinology V.3, No. 12, pp.980–992.

25. Patrick Holford, The Optimum Nutrition Bible, (2004), pp.215219 26. G Holzer, E Riegler, H Hönigsmann, S Farokhina & JB Schmidt, Effects and side-effects of 2% progesterone cream on the skin of peri- and postmenopausal women: results from a double-blind, vehicle-controlled, randomized study, British Journal of Dermatology, (2005) <http://www.ncbi.nlm.nih.gov/ pubmed/16120154>

Reproduced from Aesthetics | Volume 3/Issue 10 - September 2016

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A Micro-Channelling Approach to Skin Rejuvenation

Aesthetic practitioner Dr Shirin Lakhani offers an exclusive preview into the results of her patient case study series using Radara

Introduction A key challenge I see with my patients is that they have become disillusioned with the exaggerated scientific claims of high-street skincare products, many of which claim clinical benefits but leave patients disappointed when the promised results fail to appear. In addition, there is a strong demand for non- or minimally-invasive skin rejuvenation treatments to tackle the early signs of ageing; paired with a need for effective at-home treatments to enhance or maintain what they receive in-clinic with an easy, painless, mode of action. Earlier this year I heard about a new skincare treatment called Radara, which employs a painless, quick and easy micro-channelling technology with a high-purity hyaluronic acid serum to treat periocular wrinkles. The treatment also has impressive clinical data outlining an average 35% reduction in lateral canthal lines within the four-week treatment period. Exploring new innovations in skin rejuvenation and medical-grade skincare products are central to my aesthetic clinic ethos; therefore I have undertaken an additional case study analysis to further demonstrate the results of Radara – the initial results of which are presented below.

How Radara works Unlike microneedling, which is associated with pain, erythema, oedema and significant downtime, Radara uses a patented micro-channelling technology to penetrate the stratum corneum. The unique, flexible periocular adhesive patches are coated with microscopic plastic projections less than 0.5mm long, which create more than two-thousand micro-channels within the skin, thus allowing deeper penetration of the topical HA serum to restore natural elasticity, hydration and support. The process takes just five minutes, with the recommended treatment course lasting four weeks. Existing independent clinical studies demonstrate an average reduction of 35% in lateral canthal lines, with the patches almost doubling the anti-wrinkle efficacy versus serum alone and no reported adverse effects. Additionally, treatment benefits were shown to continue for a further four weeks post treatment, in terms of wrinkle reduction and improvements in skin quality.

Methodology • Eight female and two male patients aged between 35 and 50, with concerns about lateral canthal lines and periocular skin degradation, were selected to participate.

• Eight patients were currently undergoing treatment with other aesthetic procedures, including botulinum toxin, dermal fillers, laser resurfacing or chemical peels, whilst two were naïve to any aesthetic treatments. Three of these eight did not receive botulinum Right-hand side before toxin to the lateral canthal lines prior to or during the trial.

• A treatment protocol of one daily treatment for an eight-week period using the Radara system (micro-channelling patches plus topical HA serum) with fortnightly review was used.

• Skin analysis was conducted at baseline and week four using Aram Huvis API 100 / wrinkle severity scale / physician and user visual assessment, plus digital photography.

Left-hand side before

Results 100% of patients reported that Radara was easy to use and there were no adverse effects. All patients had a visual improvement in lateral canthal lines at four weeks, according to physician analysis and digital photography. Two out of 10 patients did not feel they had a noticeable improvement at four weeks on self-assessment, but when inspecting 56

Aesthetics | September 2016

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their digital photographs, agreed that there had been an improvement. Using the API 100 skin analyser, it became apparent as early as two weeks that there was improvement in hydration and skin quality. All patients also had a reduction in their skin sensitivity – a measure of the reactivity to physical and chemical stimuli. It is thought that this was a result of skin thickening due to increased hydration.

Conclusions Radara is a promising and effective treatment option to offer across the spectrum of aesthetic patients. The results of this case study series demonstrate multiple treatment benefits, including reduced wrinkle severity, improved skin hydration and elasticity, as well as increased patient satisfaction. There were no adverse events and the regimen Before

After

Images indicate reduced vascularisation and improved skin texture after four weeks

was well tolerated by all patients, in line with previous data. This latest study underlines the versatility and opportunity for Radara as part of an aesthetic clinic offering. For experienced patients, it can be used as an effective maintenance regimen between clinic treatments – or for new patients looking for a skincare ‘step up’ it can bridge that gap between cosmeceuticals and procedures.

Radara One-Month Supply – Trade Price: £100 (RRP £240) For stockist enquiries, please contact Wigmore Medical on 020 7491 0150 www.wigmoremedical.com For further information, contact: info@radara.co.uk www.radara.co.uk | @radaraUK Right-hand side after

Left-hand side after

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A summary of the latest clinical studies Title: Hand rejuvenation: Combining dorsal veins foam sclerotherapy and calcium hydroxylapatite filler injections Authors: Lim A, Mulcahy A Published: Phlebology: The Journal of Venous Disease, June 2016 Keywords: Sclerotherapy, cosmetic results Abstract: The hands can reveal aging through surface pigmentary changes, loss of skin thickness and ectatic dorsal hand veins.

Techniques addressing these changes already exist but are not routinely combined for optimum results. The dorsal hand veins are treated with sclerotherapy (0.5% Sodium tetradecyl sulphate). This is then followed by subdermal injection of 0.75 mL-1.5 mL calcium hydroxylapatite (Radiesse, Merz) per hand, in conjunction with tumescent anaesthetic. The dorsal hands should be gently massaged for 2 min (per hand), twice a day for two days. If necessary, the procedure can be repeated after one month for further improvement. Calcium hydroxylapatite is safe and effective for hands and associated with high patient satisfaction. In suitable patients, the reduction in ectatic veins from sclerotherapy results in a longstanding improvement that complements volume restoration with fillers. Aging hands with ectatic dorsal hand veins and skin atrophy/wrinkling not fully responsive to filler correction alone can further improve with the combination of sclerotherapy and filler injections.

Title: Combination of microneedling and 10% trichloroacetic acid peels in the management of infraorbital dark circles Authors: Kontochristopoulos G, Kouris A, Platsidaki E, Markantoni V, Gerodimou M, Antoniou C Published: Journal of Cosmetic and Laser Therapy, October 2016 Keywords: Dark circles, TCA 10%, microneedling Abstract: The objective of this study was to evaluate the efficacy and safety of a combination of microneedling and 10% trichloroacetic acid (TCA) peels in the treatment of dark circles (DC). Thirteen female patients with mild to severe infraorbital DC, aged between 21 and 61 years, were included in the study.

They were treated with Automatic Microneedle Therapy SystemHandhold and topical application of 10% TCA solution to each infraorbital area for five minutes. Almost all patients showed significant aesthetic improvement. Both Physician and Patient Global Assessment rated a fair, good or excellent response in 92.3%. The procedure was well tolerated. Mild discomfort, transient erythema and oedema were quite common during or immediately after the procedure. The patients were followed up regularly every month for four months, and no recurrence was recorded. Microneedling and 10% TCA constitute an innovative combination treatment for DC with encouraging results and minor side effects.

Title: Efficacy and safety of fractional Q-switched 1064-nm neodymium-doped yttrium aluminum garnet laser in the treatment of melasma in Chinese patients Authors: Yue B, Yang Q, Xu J, Lu Z Published: Lasers in Medical Science, July 2016 Keywords: 1064-nm Nd:YAG laser, fractional laser, melasma Abstract: The objective of this study is to explore the clinical efficacy and safety of fractional-mode (Pixel) Q-switched Nd:YAG 1064-nm laser for treatment of melasma in Chinese patients. Twentyseven patients completed all the treatment sessions and the 12-week follow-up. All were treated using the fractional-mode Pixel QS Nd:YAG (1064 nm) laser for eight sessions at a 2-3-week interval. Two blinded assessors evaluated melasma area and severity index (MASI) scores before and 4 weeks after the final session. Melanin index (MI) and erythema index (EI) was measured before each treatment visit and after the final treatment. The degree of pigmentation and erythema was assessed using a tristimulus color analyzer. Wilcoxon signed-rank test was performed to evaluate clinical response. Mean MASI scores decreased from 12.84 ± 6.89 to 7.29 ± 4.15 after treatment (p = 0.000). 70% of patients got moderate to good improvements after all the treatment. Mean MI decreased significantly from 56.52 ± 23.35 to 32.75 ± 12.91 (p = 0.000). L value increased from 59.21 ± 2.22 before treatment to 61.60 ± 2.40 (p = 0.000) after therapy. The mean score of PGA was 3.76 ± 0.71, indicating a “moderate” clearance of the lesion.

In patients’ self-evaluations, 70% of the patients rated the result as “good” to “remarkable”. Partial recurrence was seen in 40% patients at the 3-month follow-up. No severe adverse events were observed during the study, and the treatment was well tolerated. The fractional mode (Pixel) QS Nd:YAG 1064-nm laser is an effective and safe treatment for melasma.

Title: Treatment of chronic daily headache with comorbid anxiety and depression using botulinum toxin A: a prospective pilot study Authors: Zhang H, Wei Y, Lian Y, Chen Y, Zheng Y Published: International Journal of Neuroscience, July 2016 Keywords: botulinum toxin A, chronic daily headache, psychiatric comorbidity Abstract: Psychiatric comorbidities, including depression and anxiety, are clinical entities associated with chronic daily headache (CDH). Botulinum toxin A (BTA) is an FDA-approved drug for the treatment of chronic migraine, a subtype form of CDH. This study aimed to investigate the potential efficacy and safety of BTA for controlling psychiatric symptoms in CDH patients. A prospective, open-label, pilot study (n = 30; 7 males, 23 females) was performed. A single low-dose of BTA (40-120 U) was injected into the pericranial muscle at multiple sites. Participants were evaluated before and 1, 4, 8, 12, 16, 20 and 24 weeks after BTA treatment.

Primary outcomes included: headache severity, determined by a visual analog scale; depression and anxiety severity, assessed via the Hamilton Depression and Anxiety Rating Scales (HAM-D and HAM-A, respectively); headache frequency per month and single headache episode duration. Headache severity was significantly ameliorated one week after treatment. Depression and anxiety symptoms were significantly reduced one month after treatment.

At month four, the headache incidence per month decreased from 28.83 ± 2.95 to 17.57 ± 11.30 d (p < 0.001), and the single headache duration decreased from 12.03 ± 9.47 to 6.63 ± 8.98 h (p < 0.001).

BTA treatment alleviated the severity and frequency of CDH, with improvements in depression and anxiety. These novel findings indicate that BTA may represent an effective and safe intervention to target psychiatric comorbidities in CDH.

Reproduced from Aesthetics | Volume 3/Issue 10 - September 2016

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Staying Professional Online Operations and marketing manager Victoria Vilas shares advice on maintaining an appropriate and professional profile on social media When you enter your name into a search engine, what results do you get? If your search returns link to your social media profiles, then others could see the same, and may be tempted to click through and browse your comments or photos. In an era where people make careers from their social media presence, promoting brands and products to the many strangers that follow their life in photos, videos and blogs, a public social media profile is virtually a statement that you don’t mind people looking, or that you want people to look, at the content you post.

If that’s not the case, and you don’t wish for strangers to scroll through your social media profiles, then choose your social media channels wisely, and pay attention to your privacy settings. If you’re happy for some, or all of your content to be on show, then remember that it may not be just your family and friends scrolling through your Instagram photos and reading your tweets, it could be your patients, your colleagues, your employer, or other industry professionals, too.

If you are a medical professional, inappropriate content or conduct on social media could give you a bad reputation, alienate potential patients, attract the wrong target audience, or undermine your status as a trustworthy, reputable clinician. If you’re an employee in the aesthetics industry, it could lose you your job, and hamper your efforts to find a new role.

Professionalism online Medical professional or business owner It may be called ‘social’ media, but interaction with strangers online should still stay professional if you want to keep up your good reputation. If you are a medical professional, and you present yourself as exactly that, you’re likely to get the respect you deserve. If you become too casual, or are involved in discussions of contentious topics, your audience may remember you more for your choice of holiday destination or political preferences than for your professional knowledge.

People who have never met you, but can see your public social media profiles, will build a picture of you from your online presence alone. They may not know that inperson you’re a skilled clinician with a calm, professional demeanour, instead they might just see you sharing memes and jokes and get an impression of your sense of humour.

If your audience is simply made up of family and friends, there’s obviously nothing wrong with that, but if it’s a public feed you also use to promote your clinical services, it may not do much to boost business.

For that reason, take care with what you say, and how you present yourself. You may have strong political opinions, but if you are a doctor and not a politician, your patients are coming to you for your cosmetic procedures, not for your insights on the government. Some who agree with you may not mind at all, but you risk alienating

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those who do not, so proceed with caution.

If you’re Ricky Gervais, you can probably get away with risqué jokes and opinions without it damaging your career. If you’re a surgeon, jokes may not make your future patients feel reassured. Stick to what you know and only share the most relevant and helpful information with prospective patients. Think about the clientele you are trying to attract, or the peers you want to engage with. If you run a high-end, well-respected clinic in an exclusive location, then posting links to sensationalist articles in ‘trashy’ magazines or tabloid newspapers is unlikely to garner interest from the elite, and won’t offer any academic insights for clinical professionals, or support your expertise. On the other hand, if you run a chain of high street laser clinics and offer straightforward, affordable treatments, you may give your customers the wrong impression if you only post links to medical journals or elitist publications.

Employee What is acceptable on social media differs to some extent depending on who you are and what you do. If you’re a professional model, then posting photos of yourself pouting and posing in lingerie may be promoting your line of work, but if you’re doing the same and you’re an aesthetician, it may not do much to boost your reputation as a dedicated professional, and it may be unacceptable to your employer. Wearing a skimpy bikini on the beach is hardly going to cause offense, but your employer may not be keen for employees to be seen like that by patients, so it may be wise to keep those for your private Facebook page. Whether you agree with them or not, there are conventions of society that deem certain language or behaviour as disrespectful or unacceptable in public and in the workplace. On social media it is sometimes possible for users to break those rules, but be wary, as the lack of regulation doesn’t make it all okay. Online profiles offer a degree of anonymity that gives some a façade to hide behind, and behave in a way they never would in public.

When wondering whether a comment you’re about to post publicly is acceptable, think about whether you would be happy saying it out loud in public, or whether you would show it to your boss, because it’s possible that your patients or your colleagues may see it too. Some types of behaviour may be unacceptable for your particular line of work, and some are simply unacceptable in any public place. Swearing, racism, and threatening language are

Reproduced from Aesthetics | Volume 3/Issue 10 - September 2016

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Intended use of social media platforms LinkedIn2

Facebook3

Twitter4

Mission statement

“To connect the world’s professionals to make them more productive and successful.”

“To give people the power to share and make the world more open and connected.”

“To give everyone the power to create and share ideas and information instantly, without barriers.”

Intended purpose

LinkedIn is for professional use only.

Though you can ‘connect’ with friends as well as colleagues and other industry professionals, the site is designed for business networking, not personal sharing.

Facebook profiles were designed for personal sharing; Facebook pages were designed mostly for marketing and professional promotion, with options for businesses, brands, products, and public or professional figures.

Twitter was designed to be a public forum; when you sign up your Tweets are public by default. If you would rather Tweet to an approved group of followers, you can make your feed private.

Privacy options

Choose whether your profile appears in search engines, and edit how much is displayed, choose who sees your public updates and who you connect with, block other users, and opt to hide your contact details.

Use Profile settings to control who can contact you, who sees your profile and posts, or posts you are tagged in, and control your visibility in search engines. Use Page settings to control who can see the page and posts, and limit who can post or comment.

‘Page Moderation’ allows you to block certain words from appearing in comments, mark posts as ‘spam’, and activate a profanity filter.

‘Protect’ your tweets and only ‘approved’ followers will see them.

You can choose to ‘block’ certain accounts from becoming followers or interacting with your Tweets.

Instagram5 “To capture and share the world’s moments.”

Instagram was designed as a visual newsfeed, with content selected and published by users. There is little definition between personal and professional profiles, but you can choose to make your photos private.

The app has strict moderation to remove nudity, violence and more.

Choose whether your posts are public or private; if made private, only approved followers will see them.

To stop specific users from liking or commenting on your posts, block them.

offensive both in and out of the workplace, so expect no employer to find that acceptable on social media.

Just remember that employers and recruiters do look at public social media profiles to check whether a person is acting professionally. When you apply for a job, a hiring manager or agency recruiter may perform a brief search to make sure your online presence appears reputable, and if there is any hint that you could act unprofessionally either in or out of the workplace, your application may end up at the bottom of the pile.

It’s also not unheard of for an employee to be reprimanded or even sacked for offensive remarks or other online content that the employer deems as unacceptable, so don’t be careless and think social media doesn’t matter. In her article for The British Medical Journal, ‘How much of a social media profile can doctors have?’, GP Dr Margaret McCartney discusses social media and the issue of maintaining a distinction between professional and personal lives.

Dr McCartney makes reference to a case in Nottingham where a nurse was sacked after she breached patient confidentiality with a post on Facebook, and a case where a Scottish junior doctor was suspended over online comments about senior doctors.1

much attention, unless it happens to be a particularly exceptional or amusing photo. On LinkedIn, as your cat photo is unlikely to relate to any of the business topics being discussed on the site, it may be seen as unprofessional or suggest a lack of understanding of how to use the networking tool.

You may use platforms such as Facebook for both work and play, but keep the division between your personal profile and your professional page clear. Professional profiles will almost always be completely public, and should be, because the point is to expose your offering to the right audience, and as many of those people as possible. Privacy settings can and should be used for personal profiles, to protect any private information and images that you do not want the world to see.

Just remember, however, that what your friends want to see may be very different to what your patients or colleagues want to see. If necessary, you can easily set up separate accounts on social media sites such as Facebook, Twitter and Instagram, and logging into separate accounts can help you keep the division between personal and professional clear. Register using your personal email address for your personal profile, and register using your work email address for your professional account.

Using social media platforms for their intended purpose

Gaining popularity or generating negativity?

Just because an online networking tool falls into the category of ‘social media’, that doesn’t mean each and every one is supposed to be used for the same purpose. Though it is technically possible to post a picture of your cat looking cute across any platform, that doesn’t mean you should. Some social media sites were designed for personal use, so you can document and share memories with your family and friends, and easily keep in touch with your social circle. Some were designed as networking tools for business professionals, and some were designed to be public forums for commentary.

If you post your cat photo on your private Facebook feed, your friends can ‘like it’, ‘comment’, or if they’re dog people, ignore it. On Twitter and Instagram, unless you’re in a tight group of cat fans, your photo will just join a sea of millions of cat photos, and is unlikely to attract

Public profiles on Instagram and Twitter give you the opportunity to reach a huge worldwide audience, or you can go private and only share with your chosen people. When you decide which way to go, this is your choice, and you should be prepared for the consequences.

You could end up an ‘Instagram celebrity’, with millions of followers ‘loving’ every post, but you could also be subject to negativity and comments on how you look, what you say, and other things personal to you. Keeping your profile professional is less likely to attract unwanted attention. If you say provocative things, you’re likely to provoke reaction and replies that may not be agreeable. If you post photos of yourself scantily clad (and we’re addressing both men and women here), you could receive some personal comments about your body. We’re not saying that you can’t post that gym selfie or give your opinion on current affairs, but just be aware that not everyone

Reproduced from Aesthetics | Volume 3/Issue 10 - September 2016

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GMC and NMC guidelines Both the General Medical Council (GMC) and the Nursing and Midwifery Council (NMC) acknowledge that social media does offer several benefits to practitioners, which include, building and maintaining professional relationships nationally and internationally; engaging people in public health and policy discussions; facilitating patients’ access to information about health and services, and being able to access resources for continued professional development.7,8 However, each council does note that using social media unprofessionally can have severe repercussions for a healthcare practitioner.

According to the GMC, ‘Serious or persistent failure to follow this guidance will put your registration at risk’,7 while the NMC states that, ‘Nurses and midwives may put their registration at risk and students may jeopardise their ability to join our register, if they act in any way that is unprofessional or unlawful on social media’.8 The GMC guidance outlines the suitable conduct for communicating publically, including speaking or writing in the media, and states that the standards expected of doctors do not change because they are communicating through social media rather than face-to-face or through traditional media.7 The guidance goes on to document specific advice for social media usage, highlighting the need for doctors to regularly review their privacy settings for personal profiles. It also encourages doctors to maintain boundaries on social media, noting that, ‘If a patient contacts you about their care or other professional matters through your private profile, you should indicate that you cannot mix social and professional relationships and, where appropriate, direct them to your professional profile’. When identifying yourself as a doctor on publically accessible social media, the GMC advises you should also identify yourself by name, as, ‘any material written by authors who represent themselves as doctors is likely to be taken on trust and may reasonably be taken to represent the views of the profession more widely’.7 Likewise, the NMC reiterates its’ Code which states that nurses and midwives should, “Use all forms of spoken, written and digital communication (including social media and networking sites) responsibly.” It goes on to state that, ‘As a nurse or midwife, you have a responsibility to ensure that any information or advice that you provide via social media is evidence-based and correct to the best of your knowledge. You should not discuss anything that does not fall within your level of competence and you should avoid making general comments that could be considered inaccurate’.8 The NMC also advises that practitioners should be aware of who and what you associate with on social media. For example, it states that, ‘acknowledging someone else’s post can imply that you endorse or support their point of view’. In addition, the guidelines emphasise that it is important to consider what you have posted online in the past, as posts can quite easily be retrieved.8 The General Dental Council also offers similar advice to dental professionals using social media, which includes the use of blogs, forums and social networking sites.9

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commenting online is a kind-hearted soul who only posts compliments.

Compliments from strangers can be a huge confidence boost, but criticism can hurt.

If you have public profiles and you do receive negative comments, then how you respond can make all the difference. It can be tempting to answer back and give as good as you get, but it’s best not to let yourself be dragged down to that level. If you let negativity rile you, you may end up saying something as foolish as the troll who started it. In words attributed to Mark Twain, “Never argue with a fool; onlookers may not be able to tell the difference.”6 Social media also provides patients with an extra channel for complaints, and is one that allows for them to air their grievances easily and publicly, without having to face you, or the staff member involved. If you receive a negative comment on social media that relates to your professional life or services provided, deal with it in the same way you would if a patient complained in your clinic, and follow the same complaints process. Don’t ignore a comment, but do politely request that the complainant contacts you via email or direct message, so you can continue the discussion out of the public domain.

If you receive a comment that is untrue and offensive, and would be considered abusive or slanderous, block that particular user so they cannot access your profile in future, and report the user to the site for inappropriate conduct. Social media moderators will be able to check for messages that have been deleted, but it may also be worth capturing a screenshot as proof.

Cleaning up and going private All social media platforms give you options so you can decide how much is on display, and to whom, and posts you regret can be deleted. You don’t necessarily have to delete every single photo deemed not work-friendly, just remember to curate and protect your content to stay professional in the digital domain.

And remember that even a profile set to be ‘private’ isn’t entirely that. You may have ‘protected’ your Instagram, Twitter or Facebook page, but your accepted followers can all see your posts, and could show other people.

Even if you delete a post you regret, it may come back to haunt you, so think carefully before you share your post. It only takes a few seconds to save a screenshot and re-share it on social media, and the damage to your reputation could last for years to come. Cleaning up your online presence for professional purposes doesn’t have to take the fun out of sharing on social media, just take care not to publish content publicly that could offend or alienate colleagues or patients. Present your best side to the world and you’ll get noticed for the right reasons.

Victoria Vilas is the operations and marketing manager at ARC Aesthetic Professionals, a recruitment consultancy specialising in the medical aesthetics and cosmetic surgery sector.

REFERENCES 1. Margaret McCartney, ‘How much of a social media profile can doctors have?’, BMJ, 344 (2012) <http://www. bmj.com/content/344/bmj.e440> 2. About Us (US: LinkedIn, 2016) < https://www.linkedin.com/about-us> 3. About Facebook (US: Facebook, 2016) < https://www.facebook.com/facebook/info?tab=page_info> 4. Company (US: Twitter, 2016) https://about.twitter.com/company 5. Matt Buchanan, Instagram and the impulse to capture every moment (US: The New Yorker, 2013) < http:// www.newyorker.com/tech/elements/instagram-and-the-impulse-to-capture-every-moment> 6. Mark Twain quotes (US: Good reads, 2016) http://www.goodreads.com/quotes/518524-never-argue-with-afool-onlookers-may-not-be-able 7. Doctors’ use of social media (UK: General Medical Council, 2013) http://www.gmc-uk.org/guidance/ ethical_guidance/21186.asp 8. Social media guidance (UK: Nursing and Midwifery Council, 2016) < https://www.nmc.org.uk/standards/ guidance/social-media-guidance/> 9. Updated social media guidance (UK: General Dental Council, 2016) <http://www.gdc-uk.org/ Newsandpublications/Pressreleases/Pages/Social-media-guidance-for-dental-professionals-updated.aspx>

Reproduced from Aesthetics | Volume 3/Issue 10 - September 2016

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Opening a Franchise Aesthetic franchisor Rudi Fieldgrass shares advice on franchising a clinic My experience Whilst EF MEDISPA has only recently offered franchise opportunities to aesthetic practitioners, the business model has been ten years in development. Each new clinic presented new challenges and the opportunity to refine the business model by trialling new equipment and developing new treatment protocols. Apart from the technical side, as the business progressed and new locations were added, marketing skills were developed in-house, and a specialist team of interior designers was built. As the business has grown, the

core values of patient care have been maintained. The challenge has been to preserve the personal clinic feeling of a small family run business, whilst developing professional management structures. The idea of offering franchises to aesthetic practitioners and investors arose from an interest of overseas clients, who appreciated the unique business model and wanted to offer the same service in their home countries. Then, when EF Medispa was awarded, amongst other awards, Best Clinic Chain in 2011 and Best Clinic Reception Team in 2012, followed

Introduction: why is franchising a good option?

Many aesthetic practitioners dream of having their own business, however, they may have little understanding of how to run it profitably, nor realise how much funding they will require. Of course, for the true entrepreneur, just being your own boss is half the appeal, but for the slightly more risk adverse, franchising offers the opportunity to own and operate your own business with the benefit of a proven business model, recognised brand, training, support and a myriad of additional benefits, which may include anything from increased buying power, to a supportive network of franchisees sharing best practice and pooling resources for national marketing campaigns. Currently, the UK franchise market turns over £15.1 billion, with 97% of them being profitable,1 which offers a strong indicator of the potential success that could be had through franchising.

What is a franchise?

In essence, franchising is actually quite a simple business arrangement. The owner of a company may choose to grow his or her business by offering suitably qualified individuals the opportunity to purchase the right to copy the company’s business model and trade under its brand name in a clearly defined geographical territory. These people are known as the franchisor and franchisee, respectively.

One of the main differences between franchising in industries such as food and beverage or office services, compared with the aesthetics sector, is the preference that the franchisee should have a medical qualification or experience in the aesthetics industry. This is not an essential requirement, but, if not medically qualified, the franchisee

by Best Clinic Chain in 2015, potential investors within the UK approached and expressed interest in licensing the EF MEDISPA brand and benefiting from the exceptional training and the strong marketing presence. For anyone hoping to franchise their clinic, I would advise spending time, as we did, to develop a strong brand identity and establish your clinic as a leading business within the industry. Once this has been achieved, you can then progress to the technical side of approaching potential franchisees and structuring your franchise model.

needs to have a good understanding of the specific challenges of running a clinic, and business experience in managing a team of professionals, as they will be organising a staff of doctors and/ or nurses. In my opinion, it is best business practice for a franchisor to provide the franchisee with: • A legal franchise agreement detailing precisely the responsibilities of both parties. The main purpose of this is to protect the brand.

This agreement may cover anything from nominating equipment and product suppliers, providing brand guidelines for signage and interiors, approving marketing and promotional campaigns, and insisting on minimum trading standards.

• A clearly defined (normally exclusive) territory in which to operate.

Franchisees may have preferences for location based on where they live or their knowledge of the local community. However, although the franchisee may have a preference for a particular area, ultimately, it is the franchisor who will have the experience to select the right location, based upon their business model.

• A comprehensive operations manual detailing precisely how to operate every single aspect of the business. This will contain everything that the franchisee needs to know on how to run the business. Examples of the type of points it includes are; a definition of the responsibilities of the various staff positions; an outline of the treatment protocols; a description of clinic opening and closing procedures, and complaint-handling advice.

• Initial training that should cover both the mechanics of operating the franchise and how to run your own business.

• Ongoing support to ensure the franchise has the greatest possible chance of thriving long term.

Reproduced from Aesthetics | Volume 3/Issue 10 - September 2016

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Where to start According to the British Franchise Association, there are more than 900 franchisor brands operating in the UK, but relatively few of these are in the aesthetics sector.1 One reason for this may be that unlike the food and beverage sector, for example, there are not dozens of strong national brands. The prospective franchisee needs to be very honest with themselves about what they want to achieve. If the goal is to make millions, the initial capital investment will be substantially more than if they simply want a business that allows choice of hours and freedom to work around family commitments.

Financial and legal implications Initial costs and profit Assessing whether or not you can afford a particular franchise requires the franchisor to be very clear about every cost involved. Many franchises will lead its marketing with the franchise fee that is payable upfront, which excludes VAT and working capital, and provides the license to trade within the exclusive territory. It also contributes to the cost of the initial training by the franchisor, any collateral materials, and support in the setting up and launch of the franchised clinic.2 Virtually all franchises work on the basis of the franchisee paying the franchisor a fixed percentage of the turnover (sales revenue excluding VAT), which normally ranges between 5-10% and is dependent on the business type. This should not be confused with the marketing fee, which is also a fixed percentage contribution and, in my case, is specifically used by the franchisor for their general advertising campaigns. In my experience, this will normally be 3% of the turnover.

The franchisor will be able to describe the financial model illustrating the potential profitability, but, ultimately, the financial success will be governed by many factors, including how well the franchisee runs the business. The franchisor provides the template, a successful business model and support in areas of training and marketing, however, much of the business risk, as well as the upside potential, falls on the shoulders of the franchisee.

Working capital Starting any business requires working capital; the money needed to start paying the bills (rent, electricity, wages, stock, money to survive on personally until the business can provide the owner with a salary or drawings); the cost of physically setting up the business, which will include fitting out the premises and purchasing specialties equipment; legal fees; accountancy fees; launch marketing budget; advertising for staff. The prospective franchisee will need to demonstrate that they have sufficient resources to cover set-up costs and initial working

Elena Hunt and Mark Willis, franchisees of EF MEDISPA “We had decided for some time that the aesthetics business was definitely our business of choice, providing the platform to combine our passion for making a positive impact on people’s lives with the opportunity for commercial success.

The one potential stumbling block was that, in spite of our passion for the industry, neither of us had any practical experience of operating a successful clinic – a franchise seemed to be the obvious answer. We started with the understanding that we wanted to offer the best that was available – looking at the number of awards and accolades gained over the last 10 years, EF MEDISPA was the obvious choice.”

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capital. The franchisor may be able to assist by introducing sources of bank or lease finance, but it is the franchisee’s business and they will be responsible for all the normal day-to-day running costs of the business. Initial discussions with the franchisor will involve a detailed understanding of the financing required.

Loaning and leasing One of the great benefits of choosing a franchise over starting a business from scratch is the willingness of the banks to offer funding to strong candidates who can demonstrate a good business plan. Based on our experience, a High Street lender can provide up to 50% financing for fitting-out costs and working capital where they are satisfied with the business model of the franchisor.

Again, in our experience, a leasing company can provide 75-90% financing, secured on the equipment, when the financial standing of the franchisee is satisfactory and where the leasing company has a good knowledge of the re-sale value of the specialist equipment. In many cases, franchisees can borrow up to 70% of the total funding required.

Legalities In terms of legal issues, the most important advice for anyone joining a franchise is to make sure the franchise agreement is fully understood. The only way to achieve this is to employ the services of a solicitor who has direct franchise experience. Many prospective franchisees make the mistake of relying on their family solicitor.

Negotiating the franchise agreement is not the same as signing a lease on a medical practice. Although, in the majority of cases, there will be standard terms in the franchise agreement that can’t be altered, it is vital that a competent solicitor can explain the legal implications of the agreement. Franchise agreements can be for five years with an automatic renewal, and some can be for as long as 20 years. Unlike a salaried job, it is not possible to decide simply one day to call the boss and hand in one’s notice.

Challenges There are challenges in opening any type of business; in the aesthetics sector, the normal challenges are there, but in addition, there is a host of compliance issues, best practice and ethical guidelines that come into play. Again, the franchisor can help, as their business system will already be coping with these issues and have systems in place to ensure regulatory compliance.

Choosing equipment Although the franchising model is not industry specific, there are particular aspects of the aesthetic industry that may influence a franchisees’ decision on what franchise brand to choose. The franchisor will always recommend equipment, but selecting a laser or radiofrequency device is a little different to a choosing a fish fryer and can require specialist advice. Some equipment manufacturers offer a franchise model, selling the same equipment to all franchisees, while other franchisors will do an independent review of the market and base their recommendations to their franchisees on their own experience of different equipment.

Ethics Another aspect of the aesthetic industry is the ethical dimension, which is so important when a practitioner is recommending an elective treatment. Ultimately, the recommendation must rest with the practitioner, but the franchisee should make their choice of which

Reproduced from Aesthetics | Volume 3/Issue 10 - September 2016

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franchise brand to purchase based on their comfort level with the ethical guidelines and regulatory compliance built in to the franchisor’s business systems.

Employment Staff issues are another area where a franchisor will be able to help the franchisee. Whilst ongoing training is vital, recruiting a good team is an area where many sole practitioners lack the experience and skill to make an appropriate selection of suitable personnel, which contributes to challenges when the practitioner endeavours to expand their business by adding a broader range of aesthetic treatments. The areas where the franchisor can help in recruitment include: selection of suitable web portals for job posting; shortlisting suitable candidates from CVs; joint interviews; trade testing of therapists or nurses for specific treatments. In many respects, a franchisee starting from scratch with a new franchisor is a far easier proposition for the franchisor than taking an existing business and re-branding it, because the franchisor has had no input on the staff that are already in place.

Aesthetics

Owning a franchise probably means working even longer hours, so gaining the support and understanding of those who will be impacted by the decision is essential right from the start. The rewards should come with hard work and following the franchisor’s successful business model, but they rarely come overnight.

The continuing growth in the aesthetics industry means that there will be profitable opportunities for running one’s own business. A careful choice of franchise partner is one way to benefit from these opportunities whilst limiting the business risks.

Rudi Fieldgrass began his career in advertising and video marketing, before spending the last 10 years involved in every aspect of clinic management, including front of house, financial reporting, marketing and promotions. He currently oversees EF MEDISPA’s Medical Division and supports the new business development of EF MEDISPA’s franchises.

REFERENCES 1. Franchise industry research (UK: British Franchise Association, 2016) <http://www.thebfa.org/aboutfranchising/franchising-industry-research> 2. Understanding franchise fees (UK: British Franchise Association, 2016) <http://www.thebfa.org/join-afranchise/understanding-franchise-fees>

Summary It is often said that investing in a franchise is being in business for yourself but not by yourself. This is true in so far as the franchisor is very much the franchisee’s business partner with a vested interest in the franchisee’s success. Whilst the franchisor is there for support, the franchisee needs to make sure that the people closest to them – family and dependants – support the decision.

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Writing an Effective Blog Post PR consultant Mike Nolan shares his advice on creating engaging content for your blog to retain and gain new aesthetic patients Blogging is brilliant for business, or so everyone keeps telling us, but if blogs are so great why isn’t everyone doing it? Like most forms of marketing, writing a blog requires an investment of time. Then there’s the learning curve – and in the modern world of instant results, that might put people off. However, if you have the patience to do the groundwork, then blogging can certainly put your business on the road to success. Writing effective blog posts, and ensuring that you do them often, could propel your site right to the top of search engine rankings – potentially putting you ahead of your competitors. Think of your blog as part of a journey, starting with a prospective patient searching for you on the internet, then reading your blog, looking more at your website and then booking an appointment. It is a journey where you are building trust and demonstrating your expertise. Done well, the reader will feel like they know you before you’ve even met and trust your competency in administering aesthetic treatments.

Who do you want to target?

Before you start tapping away on your keyboard, I can’t stress this strongly enough – do your homework first – take the time to research topics and really think ‘who’ you want to target. Are they male or female? What age group do most of them fall into? What kind of lifestyle do they have? What is their income bracket? Are they current patients or are you trying to attract new ones? The clearer the picture is of your target audience before you start, the sooner your posts will have an impact.

Keywords It is important to think about the keywords that are going to be necessary to make your blog a success before you begin. Keywords, used intelligently throughout your blog, is what Google and other search engines use when ranking all web content, and you have to remember that a blog is, in effect, adding a new page of content to your website. To understand how search engines work we should look at Google, which is the biggest search engine provider, with 64% of all searches on the net.1 Google has developed automatic algorithms that rank a website and check it for more than 100 indicators that work out whether your site is valuable or not. This information is useful to know about when considering search engine optimisation (SEO), which is the skill of structuring your content so that your website performs well in searches. These indicators include things like backlinks, which are links from other sites to your pages, domain age, traffic, and new content.

In terms of topics and content, put yourself in the position of a patient and think of the terms and keywords you would expect patients to look for. You can use Google’s Keyword Planner to freely search and play around with popular keywords and phrases in the industry to give you an indication of the amount of monthly searches that are undertaken.2 This isn’t

rocket science, but can take a little time to get used to. These could be keywords such as botulinum toxin, dermal fillers, cosmeceuticals, or anything that you think is relevant and of interest to your patients.

Really spend the time to optimise this tool and play with different combinations of words and phrases on the Google Keyword Planner to find what you think will work for you. Some words may be more popular than others, but if you hit on a niche saying you could do well. If you need help understanding this function, there are lots of great tutorials on YouTube that demonstrate how to use the planner effectively and teach you how to optimise keywords to increase SEO for blogs.

Blog writing So if I’ve convinced you to put in the groundwork first, then you must appreciate that the process of writing a blog post takes time, even if your writing skills are sharp.

From the lightbulb moment of an idea to finally hitting the ‘publish’ button, you might spend a good few hours planning and writing a single blog post – but this is time well spent. As a former journalist, I cannot stress enough how important it is to make every word count. Many people think they can write, but there’s a world of difference between being able to write an email or letter and writing in a way that will captivate an audience. If you can’t write a blog that reads well, has flow, and is interesting, then you need to find someone who can – don’t hesitate to delegate. Look amongst your team, or, if necessary, call in professional help. At the very least, ask someone you trust to proof read and give you feedback on your post prior to publication. If you do feel you’re up for the job, make sure you have time set aside in which you won’t be disturbed and can completely focus on creating your post.

Creativity starts when you are deciding upon your article concept. Always have a plan or a rough idea of the point you want to get across before you start. As a society, we are incredibly interested in our appearance and what’s happening with celebrities, so it is a good idea to keep up with industry trends, news and current affairs. Linking your blog to something happening in the media is a great way of looking switched on and aware, and can also provide you with great blog ideas and content. When you begin to write your blog, it is important to understand the structure of the blog itself. A good blog post should

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Content People are short on time and are bombarded with messages every day, so they often tend To retain your readers’ attention and create the most effective blog post, here is a to scan the first few paragraphs to decide list of things to avoid: whether they are going to carry on reading. As • Being too controversial: try to bear in mind that you could alienate people such, it is important to capture them straight this way away with a captivating introduction.

• Trying to be overly clever: big words may show that you’re bright, but using Ensure that the whole content of your blog is unfamiliar or complex words can slow readers down entertaining, relevant and, most importantly, • Punctuation and spelling mistakes: you’ll damage your reputation if you factually correct. I would advise trying not to can’t show you’re able to do this get bogged down in jargon and use simple • Large chunks of text: avoid this as it may put people off reading your post language. You should consider referencing for fear it will take too long. Separate blocks of words with spaces, images, facts, figures and statistics that you use to videos, pull-quotes or headings maintain your credibility. Ways to keep your • Too much selling: this is a no-no as your reader may not believe that you are reader interested and entertained could providing genuine advice and might feel alienated be, as mentioned above, to ask and answer questions. Think of queries that patients are have an appropriate title, an introduction, a middle and an end. It always asking you or provide solutions to common dilemmas. will also consider aesthetic appearance and visual aspects such as Think of content that provides solutions, useful information or images and white space. creative angles on existing information. What you say has to be presented in an easy manner for your readers to read and absorb.

Title Reading it has to be effortless – you can consider using analogies The title of your blog plays a huge role in the effectiveness of or metaphors to help put medical information into a perspective the content and will keep you on track when you are forming the that is easier for the reader to understand. main body of the blog. I would recommend starting with the title When it comes to the conclusion, it should be either thought as it will give you the direction needed, however many people provoking and/or helpful and should summarises the main choose to do this last because it enables you to adapt the title points mentioned in the introduction and body of the text. Finally, to your content, which can often change as you write. If your title get someone who isn’t in your industry to read the blog post is too long or too vague then you’ve lost your chance to capture afterwards to see if it makes sense to them and if they found it attention, so keep it short, and, most importantly, relevant to the interesting. People often ask how long blogs should be. To enable content of the article. Maybe ask a question – this can be both a high search optimisation, you would generally be looking at a compelling and intriguing for the reader who may be looking for post of around 700 words, but this can be less if you structure answers to questions they have about a procedure or treatment. your content well. Personally, I don’t like using too many words Once you’ve got their attention with your title, then it’s time to keep and try to keep it to under 1,000 words, as any longer demands them interested. more of the reader’s time and attention. Always bear in mind that maintaining the reader’s attention is paramount.

Bad blogging

Ensure that the whole content of your blog is entertaining, relevant and, most importantly, factually correct

Visual aspects As well as the content itself, it is also important to be aware of the visual considerations of blog writing. It is a good idea to use images and videos of perhaps before and after treatments, which require explicit consent and identity protection where necessary, as well as charts and infographics, to break-up huge blocks of text. Do be aware of copyright infringements and accredit any work to the relevant owner. To avoid this, you can use an image providing website for generic images such as Shutterstock, which costs a small fee. A blog should be pleasing on the eye, with white space used well to separate your text. You can also achieve this by using headings or pull-quotes, which are significant or interesting points in your blog that can be highlighted by making the text bigger, bolder, and/or a different colour if your system allows it.

Publishing your post For publication, blog posts can be published on your clinic or personal website, which will require a blogging facility that might require extra fees and costs involved with the setting up of this feature. The benefits of having your blog posts on your website is that you are able to share them to increase footfall to your website and provide patients with further information about

Reproduced from Aesthetics | Volume 3/Issue 10 - September 2016

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you and your offering, without them having to actively find it.

Alternatively, you can opt to post your blogs on free sites such as WordPress, Tumblr, LinkedIn or Blogger, which can then be linked to your website and social media accounts.

Share your work Once you start writing blog posts, I would suggest you maintain a consistent publication of posts to further establish yourself as a newsworthy and, more importantly, trustworthy blogger. Some experienced bloggers say to blog as often as you can, but this may be excessive and difficult to fit in to your schedule. Remember that it’s better to produce good quality blogs weekly than not so great ones more often. Think quality over quantity.

When each blog post is published, always share it on your social media platforms such as Twitter, Facebook and LinkedIn and make sure you have sharing tools at the bottom of each blog, so it’s easy for readers to share on their own platforms.

Of course you can enable comments on there too, which can encourage engagement and debate. However, be aware that spammers can target this and there are also ‘blog trolls’ who are people who just like to be rude for the sake of it. Should this happen, my advice is not to take the comment to heart and ignore it – do not respond. You can also choose to block, hide or delete the post or consider reporting it if it is on a third party blog site.

Alternatively there are often website settings that allow you to approve comments before they are published, which is a good option to consider.

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Conclusion Blogging is like all forms of marketing in that, if done well, it will reap rewards. However, blogs done badly won’t add any value to your brand and business and may do more harm than good. If you are serious about becoming an expert in your field and being valued by your patients and potential patients for great content, then take the time – do your homework, optimise your site and keep blogging regularly. I wish you well on your blogging journey.

Mike Nolan has worked in PR for more than a decade and is the founder and director of Nolan PR. Since he started his company in 2009 he has helped a broad range of clients from many industries design and implement successful social media marketing campaigns. Nolan also has news editing and journalistic experience at a daily newspaper.

REFERENCES 1. comScore, ‘comScore Releases February 2016 U.S. Desktop Search Engine Rankings’, (2016) <https://www.comscore.com/Insights/Rankings/comScore-Releases-February-2016-US-DesktopSearch-Engine-Rankings> 2. Google AdWords, Key Word Planner, Google, <https://adwords.google.co.uk/KeywordPlanner>

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Reproduced from Aesthetics | Volume 3/Issue 10 - September 2016

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“The best feeling is going home and having a great sense of accomplishment” Dr Tracey Bell shares the experience of her first visit to an aesthetic clinic and explains how it spurred her to join the specialty “My mum’s aspirations for me were to either work at the Isle of Man bank or be a taxi driver,” says dental surgeon and aesthetic practitioner Dr Tracey Bell. “But it was my headmaster that said, ‘No, you’ve got to go to university, Tracey!’”

Dr Bell grew up on the Isle of Man, a British isle with a population of just 85,000, and was the first in her family to go to university. “I was the eldest of four and my mum and dad were taxi drivers. In order to go to university I did my A levels and O levels early and then drove taxis from the age of 17 to pay my way.” Not being sure what to study, Dr Bell did work experience in veterinary science, a doctor’s surgery and then at a school dental practice, where she loved the fact that she could see the end result of anything that she produced. “I either had to rebuild a tooth or do orthodontics and I think it’s a bit like aesthetics; it’s not just about providing a procedure, it’s about understanding the patient. The best feeling is going home and having a great sense of accomplishment, knowing what you’ve done well today, knowing you’ve given something back.”

“My mum said, ‘Just do it!

Be fearless, relentless and do it with determined effort’” In 1993, Dr Bell qualified as a dentist at Manchester University and then completed vocational training in Chester in 1994. At the age of 24, in the same year, she opened her first dental practice on the Isle of Man. “When I look back, I was young; I was fearless. I had a great mum who used to say, ‘Just do it, give it a try’.”

Within three years she owned six surgeries, a mixture of private and NHS practices all in the Isle of Man, and had recently got married. But settling down to have a family didn’t put her career on hold. “By the age of 32 I had five children and I’d probably only had one day off work to give birth to each of them! Every morning I used to get up and try to put my makeup on with the lights off so the kids wouldn’t wake up.” But one morning, in a change to her routine in 2002, Dr Bell saw an unwelcome reflection. “I came downstairs and put the light on, looked in the mirror and thought, ‘Oh my goodness, I look old!’ So I phoned my mum, who was very wise, and I said, ‘Mum, I think I need a face lift!’ And my mum said, ‘No, you can get that Botox stuff!’”

Dr Bell boarded a flight to Bowden in Manchester to get a botulinum toxin treatment and it was here she saw a business opportunity.

“My mum and I went into the clinic and I saw a doctor. It was quite a dismissive experience; I felt ashamed and embarrassed even though I was paying for it. He gave me little eye contact and mentioned my age (32) on numerous occasions. He made me wonder if I was too young

or too vain,” she explains. “So my mum said to me, ‘You know what? you could do this’. I did some research and went on a botulinum toxin course where I met experienced trainers Dr Jacques Otto, Yasmin Khan and Amanda Cameron. Dr Otto came to the Isle of Man to give me further training and showed me what I should do and introduced some good cosmeceuticals to my dental practice.”

Before long, Dr Bell’s practice was busier with aesthetic treatments than it was dentistry and, at the time, she was the only practitioner on the Isle of Man offering aesthetic treatments. “I had my two dental practices on the Isle of Man and next to it I opened Kensington Aesthetic Clinic where we performed botulinum toxin injections, fillers and laser hair removal, and we just grew it through word-of-mouth. I trained all the nurses myself and they are all still with me to this day.”

Although an aesthetic practitioner, Dr Bell thinks it’s important to know about other specialities. “I’m not a plastic surgeon, but I can tell you how a tummy tuck is done and I can tell you about breast augmentation. I owe it to my patients to be able to tell them who the ‘best person for the job’ is in situations where other treatments are recommended.”

When it comes to her greatest achievement, Dr Bell says, “I can’t put my finger on one achievement; I’m happy with what I have achieved in everything; from making people happy, bringing my kids up and opening my practices – I think my life is an achievement.”

Do you have an ethos or motto you follow?

To be kind. If you are going to try and earn the respect of people, do what you expect of them.

What treatment or technology best complements you as a practitioner?

I love doing the 8-point-lift and volumising the cheeks.

What’s the best career advice you have been given?

My mum said, “Just do it! Be fearless, relentless and do it with determined effort.”

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

I don’t think regulation will come easily but I think we will get there. I also hope we will be done with the ‘puffy cheeks’ and the overdone-look.

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

The truth is, masses! However, I am not the type of person who looks back and says, ‘What if?’ I have travelled, loved, built a business, been a mum and done so many other things, but there is still plenty more to do.

Reproduced from Aesthetics | Volume 3/Issue 10 - September 2016

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The Last Word Physicist and bioengineer Mike Murphy argues that practitioners need to take more care to ensure they are using the correct laser safety glasses appropriately I have identified a worrying trend in UK laser clinics. As a certified laser protection adviser (LPA), it is my job to check that practitioners are using class 3b and 4 lasers, used for hair removal, tattoos, pigmentation and skin rejuvenation plus intense pulse lights (IPLs) safely. Unfortunately, in roughly 90% of the cases I have seen in the two years of doing LPA assessment, where more than one laser is on-site, I have found that incorrect laser safety glasses are being used, meaning both patients and practitioners are at risk of significant ocular damage.

Current requirements The standard is very clear on this issue – European Standard (EN) 207:20091 outlines the requirements for all laser safety glasses to ensure ocular protection and safety. This standard dictates that laser safety glasses should be able to withstand 100 pulses from a pulsed laser or a continuous beam for at least 10 seconds, without damage.

The two main points to note in EN 207:2009 are: 1. The wavelength range(s) and protection level(s) must be etched into the ‘glass’ – labels or prints are not adequate.

2. The ‘CE’ Mark must appear on both the glass and the frame.

In addition, The British Standards and International Standard Organisation standard 12609-2:20132 sets out the current requirements for IPL safety glasses. The safety standards for IPL glasses are quite different to those for laser glasses, with the minimum eye protection required being shade 3. If any of the above is not observed then the glasses are not legal under this requirement. It is very important to note that one set of glasses designed to protect against one type of laser may not give any protection against another laser – they are usually NOT interchangeable. As practitioners, you should label and store your glasses safely to ensure you do not mix them up for each laser you use.

The dangers If laser and/or IPL users are not wearing the correct glasses then they risk serious injury to their eyes. Wavelengths shorter than 400 nm and longer than 1400 nm will result in surface damage, while wavelengths between these limits can potentially damage the retina – in some cases, permanently.3 I know of a dermatologist who had many years’ experience with lasers. One day she started to treat a tattoo patient with a Q-switched laser. Unfortunately, she picked up the wrong safety glasses (her clinic had a number of lasers) by mistake. Human skin will normally reflect approximately 4% of incident light, plus back-scattered

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light, of at least another 4%. Given that Q-switched lasers can easily generate 150 million watt pulses, potentially 12 million watts of laser energy can find its way to the operator’s eyes (in reality, it would be considerably less than this due to divergence). By wearing the wrong glasses she was exposed to a severely damaging amount of laser energy resulting in a career-ending 60% loss of vision in one eye, and a 40% loss in the other. This should serve as a warning to anyone who may not be protecting their eyes appropriately. As well as the users, the companies supplying the devices must ensure that they are also supplying the correct safety equipment to comply with EU law. I must note, as of yet, nobody knows what will happen after the recent ‘Brexit’ vote, but all EU legislation will continue until at least the UK leaves the EU officially. If you have purchased a laser and are concerned that you may not have been supplied with the appropriate glasses, or have not received any at all, you should contact the laser company immediately and postpone treatment until you have received the necessary equipment. If you do not, you may be putting your, and your patients’, health at risk.4 How to solve the problem So, how can you check if your glasses are safe? The easiest way is to contact an LPA – there are two main organisations that can supply suitable candidates – the Association of Laser Safety Professionals (ALSP) and the Radiation Protection Adviser (RPA) 2000. They will be able to determine whether glasses comply with current regulations or not, very easily. Another path is to establish an on-site Laser Safety Officer (LSO). In my opinion, this should be a mandatory position in every laser clinic in the UK (with class 3b and/or 4 lasers). Suitable LSO candidates can be trained by an LPA and should be able to ensure safe practice on a daily basis with all the clinic’s lasers and IPLs. Conclusion Ultimately, it is the clinic owner’s responsibility to ensure the safety of their staff as well as patients. Since the CQC stopped registering laser clinics in England and Wales in 2010, the number of laser users attending training courses has dropped and the number of insurance claims has risen.5 If an ocular accident was to occur and it was found that the safety glasses were incorrect or inadequate, I believe that most insurance companies in the UK would wash their hands of any claim. This leaves the owner potentially open to a lawsuit, which seems to be becoming alarmingly common in recent years. Would your business survive a claim by a partially blinded patient? The answer to this problem is quite simple – check your safety glasses and be sure that they are protecting your staff and your patients properly.

Make sure that they are not damaged or cracked, and, if so, throw them in the bin! After all, we only have one set of eyes so we should do our utmost to protect them.

Mike Murphy is a physicist and bioengineer and began his career in medical lasers at Canniesburn Plastic Surgery Unit via Strathclyde University in 1986. He joined the clinical research group, which developed the Q-switched laser treatment of tattoos. Murphy has developed new laser and IPL devices and introduced them into markets around the world.

REFERENCES 1. Health and Safety Executive, European Standards and Markings for Eye and Face Protection, HSE, (2013) <http://www.hse.gov.uk/foi/internalops/oms/2009/03/om200903app3.pdf> 2. ISO, Abstract, ISO, (2013) <http://www.iso.org/iso/catalogue_detail.htm?csnumber=51551> 3. John Marshall, The safety of laser pointers: myths and realities, The British Journal of Ophthalmology, (1998) http://bjo.bmj.com/content/82/11/1335.long 4. Europa.eu, Regulations, Directives and other acts, European Union, (2016) <https://europa.eu/ european-union/law/legal-acts_en> 5. Department of Health : Review of the Regulation of Cosmetic Interventions (2013) <https://www.gov. uk/government/publications/review-of-the-regulation-of-cosmetic-interventions>

Reproduced from Aesthetics | Volume 3/Issue 10 - September 2016

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NOW APPROVED FOR

UPPER FACIAL LINES The first and only aesthetic neurotoxin approved for combination treatment of Upper Facial Lines including: • Horizontal Forehead Lines • Crow’s Feet Lines • Glabellar Frown Lines

CONFIDENCE IN MY CHOICE

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

Bocouture® (incobotulinumtoxinA) 50 units Prescribing Information M-BOC-UK-0007 Please refer to the Summary of Product Characteristics (SmPC) before prescribing. Presentation: 50 units of Botulinum toxin type A (150 kD), free from complexing proteins as a powder for solution for injection. Indications: Temporary improvement in the appearance of moderate to severe upper facial lines (glabellar frown lines, crow’s feet lines, horizontal forehead lines) in adults below 65 years when the severity of these lines has an important psychological impact for the patient. Dosage and administration: Unit doses recommended for Bocouture are not interchangeable with those for other preparations of Botulinum toxin. Reconstitute with 0.9% sodium chloride. Horizontal Forehead Lines: Intramuscular injection, the recommended total dose range is 10 to 20 units, a total injection volume of 0.25 ml (10 units) to 0.5 ml (20 units) is injected into the frontalis muscle in five horizontally aligned injection sites at least 2 cm above the orbital rim. An injection volume of 0.05 ml (2 units), 0.075 ml (3 units) or 0.1 ml (4 units) is applied per injection point, respectively. Glabellar Frown Lines: Intramuscular injection (50 units/1.25 ml). Total recommended standard dose is 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: Intramuscular injection (50 units/1.25mL). Total recommended standard dosing is 12 units per side (overall total dose: 24 units); 0.1mL (4 units) injected bilaterally into each of the 3 injection sites. Injections too close to the Zygomaticus major muscle should be avoided to prevent lip ptosis. Not recommended for use in patients over 65 years or under 18 years. Contraindications: Hypersensitivity to the active substance or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, Lambert-Eaton syndrome).

Infection or inflammation at the proposed injection site. Special warnings and precautions: It should be taken into consideration that horizontal forehead lines may not only be dynamic, but may also result from the loss of dermal elasticity (e.g. associated with aging or photodamage). In this case, patients may not respond to Botulinum toxin products. Should not be injected into a blood vessel. Not recommended for patients with a history of dysphagia

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

Frequency of adverse reactions by indication is defined as follows: very common (≥ 1/10); common (≥ 1/100, < 1/10); uncommon (≥ 1/1000, < 1/100); rare (≥ 1/10,000, < 1/1000); very rare (< 1/10,000). Upper Facial Lines: Very common: Headache.

Common: Hypoaesthesia, injection site haematoma, application site pain, eyelid ptosis, dry eye, facial asymmetry, sensation of heaviness, nausea. Glabellar Frown Lines: Common: Headache, Muscle disorders (elevation of eyebrow). Crow’s Feet Lines: Common: Eyelid oedema, dry eye, injection site haematoma.

For a full list of adverse reactions, please consult the SmPC. Overdose May result in pronounced neuromuscular paralysis distant from the injection site. Symptoms are not immediately apparent post-injection. Bocouture® may only be used by physicians with suitable qualifications and proven experience in the application of Botulinum toxin. Legal Category: POM. List Price 50 U/vial £72.00 Product Licence Number: PL 29978/0002 Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer Landstraße 100,60318 Frankfurt/Main, Germany.

Date of Preparation: July 2016. Further information available from: Merz Pharma UK Ltd., 260 Centennial Park, Elstree Hill South, Elstree, Hertfordshire WD6 3SR.Tel: +44 (0) 333 200 4143

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

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

1. Bocouture® 50U Summary of Product Characteristics (SPC).

April 2016. Available from: https:/www.medicines.org.uk/emc/ medicine/23251 2. Carruthers A et al. Multicentre, Randomized, Phase III Study of a Single Dose of IncobotulinumtoxinA, Free from Complexing proteins, in the Treatment of Glabellar Frown Lines. Dermatol Surg. 2013:1-8 3. Prager W, et al. Comparison of Two Botulinum Toxin Type A Preparations for Treating Crow’s Feet: a Split-Face, DoubleBlind, Proof-of-Concept Study. Dermatol Surg. 2010 Dec; 36 Suppl 4:2155-60 4. Kerscher M, et al. Efficacy and Safety of IncobotulinumtoxinA in the Treatment of Upper Facial Lines: Results From a Randomised, Double-Blind, Placebo-Controlled, Phase III study. Dermatol Surg 2015;41:1149-1157 5. BOC-DOF-012 Bocouture® Convenient to Use, August 2015 BOCOUTURE® is a registered trademark of Merz Pharma GmbH & Co, KGaA. M-BOC-UK-0025 Date of Preparation August 2016

PURIFIED1• EFFECTIVE2, 3,4 • CONVENIENT5

Botulinum toxin type A free from complexing proteins

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

The VYCROSS™ Collection includes:

JUVÉDERM® VOLBELLA® with Lidocaine

JUVÉDERM® VOLUMA® with Lidocaine

JUVÉDERM® VOLIFT® with Lidocaine

JUVÉDERM® VOLIFT® Retouch® with Lidocaine

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

UK/0721/2015

Date of Preparation: October 2015