Aesthetics july 2014 by Aesthetics & CCR

s ! r ic ay te het od En est 4 T A 1 e 20 Th rds a Aw

VOLUME 1/ISSUE 8 - JULY 2014

WHAT SHE SEES

WHAT YOU SEE She may narrow her focus on one area, but together we help her appreciate a holistic approach to peri-orbital treatment.

An eye for detail.

Allergan and You. You provide your skills and passion, while we provide a unique portfolio of innovative products. Together we are committed to revitalising the peri-orbital area. UK/0053/2014 January 2014

Botulinum Toxin CPD Article 14906 UK Aesthetics Journal Front Cover_June 14_V2.indd 1

An examination of the literature and emerging indications by Mr Dalvi Humzah, Professor Andy Pickett and Anna Baker

Pain Management

The Aesthetics Awards 2014

Invasive or 15:21 04/06/2014 non-invasive?

Practitioners discuss their preferred methods of keeping patientsâ&#x20AC;&#x2122; discomfort to a minimum

How to enter, and why we should be celebrating innovation and excellence in medical aesthetics

Mr Adrian Richards on the surgical and non-surgical options for aesthetic treatments

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Contents • July 2014 INSIDER 06 News The latest product and industry news 13 On the Scene Out and about in the industry this month 14 Understanding the government’s response to the Keogh review We report on the recent Westminster Briefing

CLINICAL PRACTICE Pain Management Page 22

16 Research and Development: Galderma A look at Galderma’s R&D facility in Uppsala, Sweden 18 Training Report: The Facial Aesthetics Masterclass We find out about Dr Raj Acquilla and Dr Tapan Patel’s training academy 20 American Academy of Facial Plastic and Reconstructive Surgery Wendy Lewis reports on the AAFPRS congress in New York

IN PRACTICE Patient Retention Page 57

CLINICAL PRACTICE 22 Special Feature: Pain Management Practitioners discuss their preferred methods of minimising patient discomfort 28 CPD Clinical Article Mr Dalvi Humzah, Professor Andy Pickett and Anna Baker examine advanced botulinum toxin techniques 34 Clinical Focus Dr Mervyn Patterson explains why a good skincare line is essential 38 Techniques Mr Adrian Richards outlines the invasive and non-invasive options for aesthetic treatments 42 Advertorial Dr Rita Rakus discusses the benefits of INTRAcel 44 Treatment Focus Dr Askari Townshend dispels myths surrounding hydroquinone 46 Clinical Study A summarised study exploring into a new method for treating acne scarring 50 Advertorial Skinceuticals introduce their new antioxidant formulation: Resveratrol B E 52 Abstracts A round-up and summary of useful clinical papers 54 Aesthetics Awards Special Focus The latest news and developments from The Aesthetics Awards 2014

IN PRACTICE 57 Patient Retention Gary Conroy on how to ensure long-term patient loyalty 60 Patient Relations Wendy Lewis shares her advice on engaging with female patients 62 Treatment Portfolio Dr Rita Rakus explains how to tailor your treatment menu 64 Business Process Alan Rajah shares his advice on how to be a successful business leader 66 In Profile Dr Tapan Patel details his journey into aesthetic medicine 68 The Last Word Sharron Brown argues for the importance of patient education

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

Clinical contributors Wendy Lewis has authored 11 books on anti-ageing and cosmetic surgery and lectures internationally. She is the president of Wendy Lewis & Co Ltd and founder/editor in chief of Beautyinthebag.com Dr Sarah Tonks is an aesthetic doctor and previous maxillofacial surgery trainee with dual qualifications in both medicine and dentistry. She practises cosmetic injectables and hormonal based therapies. Mr Dalvi Humzah is a consultant plastic, reconstructive and aesthetic surgeon and medical director at Plastic and Dermatological Surgery. He lectures and is an examiner internationally. Professor Andy Pickett has worked on botulinum toxin for over 27 years. Andy has delivered over 400 lectures to audiences worldwide and has an extensive list of publications. Anna Baker runs a nurse-led cosmetic and dermatology clinic. She is currently undertaking post-graduate study in Applied Clinical Anatomy, specialising in head & neck anatomy. Dr Mervyn Patterson is a co-owner of Woodford Medical and has worked in aesthetic medicine for the past 15 years. He specialises in the latest injectable anti-ageing treatments. Mr Adrian Richards is a plastic and cosmetic surgeon with 12 years of specialism in plastic surgery at both NHS and private clinics. He is a member of BAPRAS and BAAPS. Dr Askari Townshend is an international Sculptra trainer as well as lead UK Sculptra trainer and medical consultant for Sinclair Pharma. His interests include injectables, lasers and peels.

NEXT MONTH • IN FOCUS: Lifting and Tightening • Special focus: Neck and jaw tightening • Preparing the skin for treatment • Clinic design

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Editor’s letter In our profession, do we have patients or clients? This is a question that I find myself frequently asked and I suspect that we all have our own opinions. However what really matters is how you interact Amanda Cameron with the individual coming in to your clinic Editor looking for treatment, and what you do to offer them the best possible experience. Aesthetic medicine comprises all medical procedures that are aimed at improving the physical appearance and satisfaction of our patients, using non-invasive to minimally invasive cosmetic procedures. Patients not only want to be in good health, they also want to be fit and minimise the effects of normal ageing. Indeed, patients are now increasingly requesting quick, non-invasive procedures with minor downtime and very little risk, and it is up to us to make their experience a positive one. We need to understand our patients and to know about their lifestyle, which will help us to advise the best treatment options for them. We must be realistic about what is within the patient’s capacity and discuss what they are willing to do at home to support the process. We should also be realistic about downtime and discuss potential side effects as part of the initial consultation – for example if they are going to a big event in a few days then a treatment with a needle may not be a good idea.

Aesthetics is a service industry, and we cannot select who walks through the clinic door but we can do our utmost to educate them and offer the best treatment and experience. In this issue we look at some key components of the patient experience. As we deal with elective procedures, the issue of discomfort during and after treatments is often a significant consideration for patients. For our special feature this month we spoke to practitioners regarding the methods that they employ, both pharmacological and holistic, in order to manage pain in aesthetics (p. 22). Our business features include advice on retaining patient loyalty and how to talk to your female customers. It is crucial to be honest with your patients and create a partnership in which to share information, as discussed in The Last Word by Sharron Brown, where she gives her opinion on patient education and the role it plays in creating a safer industry (p. 68). Ultimately we go about interacting with patients as we see fit, but one thing we should continually remember is that procedures and outcomes need to be a collaborative experience. Setting expectations at the start while also trying to listen and understand the patient’s desires are critical to achieving the best results. And whether we’re at the first consultation or have been treating a patient for 20 years, we must never forget that our relationship with patients remains the cornerstone of the procedure performed.

Editorial advisory board We are honoured that a number of leading figures from the medical aesthetic community have joined Aesthetics journal’s editorial advisory board to help steer the direction of educational, clinical and business content Dr Mike Comins is president and Fellow of the British

Sharon Bennett is chair of the British Association of

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

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

Mr Dalvi Humzah is a consultant plastic, reconstructive

Dr Raj Acquilla is a cosmetic dermatologist with over 11 years

and 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.

experience in facial aesthetic medicine. UK ambassador, global KOL and masterclass trainer in the cosmetic use of botulinum toxin and dermal fillers, in 2012 he was named Speaker of the Year at the UK Aesthetic Awards. He is actively involved in scientific audit, research and development of pioneering products and techniques.

Mr Adrian Richards is a plastic and cosmetic surgeon

Dr Sarah Tonks is an aesthetic doctor and previous

with 12 years of specialism in plastic surgery at both NHS and private clinics. He is a member of the British Association of Plastic and Reconstructive Surgeons (BAPRAS) and the British Association of Aesthetic Plastic Surgeons (BAAPS). He has won numerous awards and has written a best-selling textbook.

maxillofacial surgery trainee with dual qualifications in both medicine and dentistry, based at Beyond Medispa in Harvey Nichols, she practises cosmetic injectables and hormonal based therapies.

PUBLISHED BY EDITORIAL Chris Edmonds • Managing Director T: 0207 148 1292 | M: 07867 974 121 chris@aestheticsjournal.com Suzy Allinson • Associate Publisher T: 0207 148 1292 | M: 07500 007 013 suzy@aestheticsjournal.com Amanda Cameron • Editor T: 0207 148 1292 M: 07810 758 401 mandy@aestheticsjournal.com Betsan Jones • Journalist T: 0207 148 1292 | M: 07741 312 463 betsan@aestheticsjournal.com Chloé Gronow • Journalist T: 0207 148 1292 M: 07788 712 615 chloe@aestheticsjournal.com

ADVERTISING Hollie Dunwell • Business Development Manager T: 0203 096 1228 | M: 07557 359 257 hollie@aestheticsjournal.com Craig Christie • Administration and Production T: 0203 096 1228 | support@aestheticsjournal.com MARKETING Laura Weir • Marketing Manager T. 0203 096 1228 laura@aestheticsjournal.com Claire Simpson • Events Manager T: 0203 096 1228 | claire@aestheticsjournal.com DESIGN Peter Johnson • Senior Designer T: 0203 096 1228 | peter@aestheticsjournal.com Chiara Mariani • Designer T: 0203 096 1228 | chiara@aestheticsjournal.com

Material may not be reproduced in any form without the publisher’s written permission. For PDF file support please contact Craig Christie; support@aestheticsjournal.com © Copyright 2013 Aesthetics. All rights reserved. Aesthetics Journal is published by Synaptiq Ltd, which is registered as a limited company in England; No 3766240

DISCLAIMER: The editor and the publishers do not necessarily agree with the views

expressed by contributors and advertisers nor do they accept responsibility for any errors in the transmission of the subject matter in this publication. In all matters the editor’s decision is final.

Insider News

Talk Aesthetics #aestheticsurgicalstandard Nigel Mercer / @NigelMercer #CENTC403 will help protect patients seeking aesthetic surgery in Europe and thank you to all those who worked so hard to achieve this! #patientsafety BAAPS Press Office / @BAAPS Media BAAPS Prez: It’s little wonder that we constantly hear horror stories…when many shouldn’t have undergone the procedure in the first place! #sunprotection The BAD / @HealthySkin4All The message that people should take away: Sunscreen is just one aspect of sun protection, protective clothing and shade v. important too! To share your thoughts follow us on Twitter @aestheticsgroup, or email us at editorial@aestheticsjournal.com Sunscreen

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Awards

Entry for The Aesthetics Awards 2014 to close on June 30 Entry for the prestigious Aesthetics Awards 2014 will close on June 30 following six weeks of entries from the best in the medical aesthetics profession. The Awards, which celebrate achievement, innovation and clinical excellence, will be held on December 6 at the Park Plaza Hotel in Westminster. By highlighting the achievements of the past year, The Aesthetics Awards support the raising of standards and promote those who uphold the values of best practice and patient safety within medical aesthetics. High quality entries have been received so far in the twenty-one select categories, and with a new stringent entry criteria, the finalists and winners will truly represent the best in the profession. In addition to categories recognising the leading products, treatments, suppliers, distributors and manufacturers, The Aesthetics Awards also honour individual practitioners, aesthetics clinics, training initiatives and industry associations. Further details of The Aesthetics Awards are on pages 54 and 55 of this month’s issue. Entries can be made up until June 30 by visiting www.aestheticsawards.com Accreditation

BAD issues response to “drinkable sunscreen” claims

Save Face to provide accreditation to qualified non-invasive cosmetic practitioners

The British Association of Dermatologists (BAD)has issued a response on its website to recent stories in the consumer press regarding a new “drinkable sunscreen” product – Harmonised H20 UV Protection. The product, which alleges to offer a sun protection factor of 30, is formulated and marketed by Osmosis Pur Medical Skincare. Experts from the BAD wrote to the company’s founder, Ben Johnson, asking for evidence to back up claims of sun protection, as well as a list of the product’s ingredients. In his reply, Johnson confirmed that Harmonised H20 UV Protection is made from 100% water, which has been treated with ‘scalar’ waves, which he claimed will cancel UVA/UVB rays by vibrating next to the skin. In its response, which was aimed to protect the public, the BAD said, “The British Association of Dermatologists await further evidence supporting the use of ‘scalar waves’ to block harmful ultraviolet light on the skin. We strongly advise people not to rely on such unproven methods and to continue to protect their skin from the UK’s most common cancer type, skin cancer, by using traditional, topically applied sunscreens, clothing and shade.”

A new organisation, Save Face Ltd, will operate an independent scheme to provide accreditation and regulation to qualified practitioners carrying out non-invasive procedures. The company aims to act as a platform to acknowledge, promote and reward best practice. Director of Save Face, Brett Collins, said, “The explosion in the market place in recent years resulted in a sea of operators – many of whom are not trained, qualified or audited. It is an area of great concern, which has been identified but not yet fully addressed.” The organisation will aim to support practitioners, and act as a resource for consumers to make informed decisions about both their choice of treatment and provider. “Through our website, consumers can search for and find only the very best practitioners who adhere to the highest industry standards,” said Collins. Save Face claims it will highlight the associated risks of non-invasive procedures, and the complications and effects consumers may face if they opt for treatments by untrained and unqualified practitioners. The company’s business model was developed in response to the Keogh report, which advocated clear standards of practice and formal accreditation of all cosmetic practitioners. To achieve accreditation by Save Face, practitioners must have achieved accredited qualifications, and must operate from premises meeting certain requirements. Practitoners must also adhere to a code of conduct that covers handling complaints, insurance, responsible advertising and consent packages, and demonstrate continued competence through an annual appraisal. Co-director, Ashton Honeyball, said, “An industry benchmark which informs and protects the consumer is long overdue. Equally, it is high time that clinicians who constantly seek to improve and invest in best practice are acknowledged, differentiated and rewarded.” Save Face will officially launch at the Facial Aesthetic Conference and Exhibition (FACE) in London in June.

Aesthetics | July 2014

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News in Brief

Cryolysis

LipoContrast to be distributed by NUA Aesthetics European fat cryolysis machine, LipoContrast, is to be distributed exclusively in the UK by NUA Aesthetics. It is claimed that the product can target most areas of the body including waist, hips, thighs, back and abdomen. Gynecomastia, arms and chin can be reached via multi-sized applicators. Engineered with new patent technology, clinical trials for LipoContrast report 33% improved results compared with normal cryolysis procedures. NUA said that the new technology delivers rapid results, promising that more than 30% of the treated fat tissue will be eliminated, and approximately 80% of the final result will be visible within 20 days. Director of NUA aesthetics, Donnamarie McBride, said, “Having being involved with cryo technology fat reducing treatments for almost three years now, I have been constantly researching the science and technology behind it. Through research and networking I found Lipocontrast, a new innovative European made machine that is one step beyond normal cryo. Lipocontrast is an exciting concept that we are proud to represent to the UK.” Psoriasis

Studies show positive results for new oral psoriasis drug A study had recorded that psoriasis patients have noticed a 75% reduction in the disease after taking new oral drug tofacitnib. An oral Janus kinase (JAK) inhibitor, tofacitinib, is part of a new class of medicines in development for the treatment of moderate to severe chronic plague psoriasis. Pfizer Inc. announced results from the Oral treatment Psoriasis Trial (OPT), a phase three study, into the treatment of adult patients with the disease. It showed that 44% and 68% of patients who received tofacitnib, 5mg and 10mg twice daily, achieved at least a 75% reduction in the Psoriasis Area and Severity Index (PAS175), two commonly used measures of efficacy in psoriasis. Lead investigator, Robert Bissonnette, MD of Innovaderm Research, said, “The OPT Retreatment data showed that patients who stayed on therapy with tofacitinib maintained their rates of response and for those who stopped therapy, a proportion of patients were able to regain their original clinical response when retreated with tofacitinib. The study also found that no patients experienced a psoriasis rebound and 42% and 63% of patients who received tofacitinib, 5mg and 10mg twice daily, achieved a PGA response of “clear” or “almost clear” skin, respectively. Side effects included nasopharyngitis and upper respiratory tract infection. Post-procedure

Hilotherapy now available in home care kits Hilotherapy, which has been used for some time in both NHS and private hospitals and clinics to reduce post-procedure pain and swelling, is now available in a home use package. The technology, which delivers temperaturecontrolled water to affected areas using anatomically designed cuffs, aims to provide instant post-operative pain relief and reduction in swelling. Hilotherapy is also used in aesthetic clinics to reduce swelling following non-invasive treatments, such as the injection of dermal fillers and the use of laser and chemical peels. The home care kit is a lighter, more portable version of the larger clinic equipment. Aesthetics | July 2014

Meditelle launch new aesthetics chair Specialists in producing healthcare equipment, Meditelle, have launched a new aesthetics chair. Designed to offer versatility to aesthetic practitioners with its variable electronic adjustments, the new Christie Chair aims to suit a variety of minor surgical applications. Meditelle’s anti-microbial vinyls and framework incorporate an infection proof additive that is effective at reducing the spread of bacteria such as E coli and MRSA. New study into non-invasive diagnosis of skin cancer Michelson Diagnostics has teamed up with the Melanoma Institute of Australia to launch a clinical study investigating the use of its Vivosight system to diagnose basal cell carcinoma. The study, run by Dr Pascale Guitera FACD PhD, will evaluate VivoSight’s ability to triage lesions which are superficial enough to be treated non-invasively and monitor the success, or otherwise, of non-invasive therapies. The study is expected to complete in 2015. Dermatologists are diagnosing patients via smartphone app US based dermatologists can now diagnose their patients via computer or smartphone. The launch of a unique teledermatology consultation programme aims to reduce waiting times and offer customised skin care advice. By offering prescription-based treatments, PocketDerm claims they can eliminate 84-90% of acne lesions, compared to 16-34% of nonprescription treatments. The FDA has approved all the ingredients used in the prescriptions as safe and effective treatments for acne. However as PocketDerm make prescription bottles depending on patients needs, each individual bottle is not FDA approved. Vida launches carboxytherapy and oxygen infusion Vida Health and Beauty have announced the launch of two new technologies to provide carboxytherapy and oxygen infusion, which the company claims will provide treatments complementary to their existing mesotherapy system. Carboxytherapy consists of localised microinjections of medical CO2, administered subcutaneously and/or intradermally using a tiny needle inserted into a disposable, sterile tube connected to the carboxytherapy machine. The aim is to increase skin tone, elasticity and brightness.

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Conference

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Research

Exhibitors confirmed for ACE 2015 Following the success of the 2014 event, exhibition space for The Aesthetics Conference and Exhibition 2015 is filling up fast. Those already confirmed include Boston Medical Group, Insititute Hyalual, 4-T Medical, Advanced Beauty Training, Medira, The Marketing Clinic and Zanco Models. To be held on Saturday 7 and Sunday March 8 2015 in London, the larger exhibition space will feature all the leading companies from medical aesthetics, affording practitioners the opportunity to find out key information on all the newest and most innovative products, treatments and services in the market. With the academic agenda coming together and a huge number of live clinical demonstrations planned for an even more comprehensive programme, ACE 2015 will offer practitioners everything that they need to grow their business, keep up to date with the latest clinical developments and practice medical aesthetics successfully. Visit www.aestheticsconference.com to keep up to date with the latest developments. Cellulite

Medixsysteme launch HIFU cellulite treatment A non-invasive fat removal and cellulite treatment has been launched in Europe this week. Medixsysteme, a global manufacturer of medical equipment, has introduced the S-shape. The new technology combines 635nm laser therapy with second-generation high intensity focused ultrasound (HIFU). A spokesperson from Medixsysteme said, “S-shape is the first HIFU combination therapy that has been specifically designed for all kinds of cellulite – aquae, fibrosis and fat.” They claim the dual performance gives longer lasting results for cellulite sufferers. The product was tested on 54 patients over a three-month period, with 92.5% reporting that they were satisfied with the improvements S-shape made to their cellulite. Medixsysteme also plans to launch a smartphone App available for both physicians and patients. “Patients can follow their results and share them online with their friends on social networks,” said the spokesperson.

Anti-diabetic drug slows ageing and increase lifespan Belgian researchers have found that the most common anti-diabetic drug, metformin, slows ageing and increases lifespan. Metformin is the first-line drug of choice for the treatment of type 2 diabetes and can also be used to treat polycystic ovary syndrome. The findings, reported in the Proceedings of the National Academy of Sciences journal, showed that the lifespan-extending effect of metformin is dependent on the increased production of reactive oxygen species. Head researcher Wouter De Haes said, “Antioxidants, compounds that remove these reactive oxygen species, abolished the lifespanextending effect of metformin.” Whilst antioxidants are often promoted as having anti-ageing qualities and reducing the risk of disease, De Haes said this study adds to the growing body of evidence that they are not as beneficial for health as generally assumed. With a lifespan of only three weeks, the roundworm, Caenorhabditis elegans, was used to test the theory. De Haes, said that because they are known for showing signs of ageing, the roundworms were helpful in uncovering the mechanisms underlying healthy ageing. “While one should be careful not to over-extrapolate findings from model organisms to humans, the study is promising as a foundation for future research,” he said. The team of researchers also identified the protein, belonging to the group of peroxiredoxins, which seem to be responsible for the increase in reactive oxygen species. However De Haes recommended more research into the exact workings of peroxiredoxins needed to done. “Understanding how organisms control the ageing process, and how activation of peroxiredoxins leads to an increase in healthy lifespan, may lead to more targeted interventions in the future,” he said.

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BEL093/0314/FS Date of preparation: April 2014

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Skin tightening

Skin layer grown in lab could replace animal testing

New LipoTripsy Face Firmer proves popular

The first lab-grown epidermis has been developed by a team led by King’s College London and the San Francisco Veteran Affairs Medical Centre (SFVAMC). According to the research team, the epidermis could help to develop new therapies for rare and common skin disorders such as ichthyosis and atopic dermatitis, while offering an alternative lab model to animals for testing drugs and cosmetics in other countries. King’s College London team leader, Dr Dusko Ilic, explained that human epidermal equivalents representing different types of skin could be grown and tailored to study a range of skin conditions. He said, “Atopic dermatitis affects more than 20% of the population and was treated for years as a disorder of the immune system, usually treated with topical and sometimes systemic corticosteroids. Only recently, it was discovered that the actual underlying cause is a defective permeability barrier in the skin.” The barrier lets through pathogens from the environment and the body reacts negatively to this. “The defective barrier is due to mutations in genes involved in barrier formation and it will be easy to make a skin model from stem cells carrying such mutation. Barrier defect in our lab model will mirror defects in the human skin and numerous new treatments can be tested in order to improve the quality of the barrier,” said Dr Ilic. The new study uses human induced pluripotent stem cells (iPSC) to produce an unlimited supply of pure keratinocytes – the predominant cell type in the outermost layer of skin. They closely match keratinocytes generated from human embryonic stem cells (hESC) and primary keratinocytes from skin biopsies. These keratinocytes were then used to manufacture 3D epidermal equivalents in a high-to-low humidity environment to build a functional permeability barrier, essential in protecting the body from losing moisture and preventing the entry of chemicals, toxins and microbes. To explain their progress, Dr Ilic said to imagine the permeability barrier as a roof on a house. While the roof protects the house from the environment and rain coming in, the skin protects the body from the environment and losing water. He said, “We are the first who have succeeded to make a ‘roof’ of such good quality. Other groups built ‘houses’, though the roofs were always leaky and could not be used as dependable models for testing drugs.” Although testing cosmetics on animals is banned in the European Union, it still takes place in the US and China. Dr Ilic claims companies are looking for alternative solutions they can use to test and develop new ingredients. “The human epidermal equivalents that we have generated might present the best available answer at this moment,” he said. A comparison between the epidermal equivalents and normal human skin showed no significant differences in structure or functional properties. The research team are currently in discussion with several companies who are interested in implementing their model. “We are optimistic and glad that the work caught the attention of the right people in the pharmaceutical and cosmetic industry,” said Dr Ilic.

Face Firmer is a new application for the Lipotripsy system, which the manufacturers claim will promote cell renewal to improve skin density and elasticity and reduce wrinkle depth. Lipotripsy, which uses radial wave therapy and aims to aid fat breakdown, collagen synthesis and lymphatic drainage, has had a lot of coverage in the consumer press since its launch and has proved a popular treatment for cellulite reduction and body shaping. Face Firmer uses the same radial wave technology as the cellulite treatment, but the facial applicator has been adapted to penetrate less deeply into the skin. Face Firmer is proving to be popular among patients according to some aestheticians, who have added the procedure to their clinic offering. Jill Zander, of the Jill Zander Skin Rejuvenation Clinic in Esher, who has taken on the treatment, said, “The new Lipotripsy Face Firmer treatment has been very well received in my clinic. This non-invasive treatment harnesses acoustic wave technology to stimulate collagen synthesis making the skin look firmer and smoother.” Jim Westwood, MD of Spectrum Medical Innovations Ltd, creators of LipoTripsy, explains, “Lipotripsy Face Firmer Treatment is a pioneering new painless and non-invasive treatment that promotes the production of collagen and elastin to lift and tighten the skin. “We are very excited to launch Lipotripsy Face as it complements our current body sculpting and cellulite treatment and allows clinics to offer Lipotripsy from the face down to the feet.” Supplements

Aesthetic Source to distribute Aneva Derma A collagen boosting drink supplement is to be distributed in the UK and Ireland, exclusively by Aesthetic Source. The nutraceutical drink, Aneva Derma, contains Arthred – a hydrolysed powdered collagen that is clinically proven to support, maintain and promote cartilage tissue throughout the body. Director of Aesthetic Source, Lorna Bowes, said, “This is an exciting time for Aesthetic Source as we expand our product portfolio. Aneva Derma fits our criteria of being clinically proven and science driven.” Bowes said that it would also compliment Aesthetic Source’s skincare brands, NeoStrata and Exuviance. The product, that should be consumed once a day, claims to improve skin elasticity and density as well as enhancing the effects of medical aesthetic treatments. A UK-based study testing these claims is underway, with the 10-week interim data set to be presented at FACE later this month. “Aneva Derma will be supported by strong training, marketing and PR campaigns together with focused customer support activities,” said Bowes.

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Diagnosis

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Standards

Adare Aesthetics to distribute MoleMax in UK and Ireland Adare Aesthetics has signed an agreement with Derma Medical Systems, Austria, to distribute MoleMax and their dermoscopy equipment in the UK and Ireland. Derma Medical Systems manufacture advanced mole mapping and dermoscopy equipment. Adare Aesthetics aims to bring these products to private clinics as well as the major hospitals. Derma Medical Systems’ latest technology, MoleMax HD PRO, offers the “Body Mapping” function. This provides guided photographic documentation of the entire body that identifies new moles for melanoma prevention. Designed to examine and document all skin diseases, MoleMax HD PRO allows the user to photograph either 33 body segments at a time or 10 segments, for quick examination. Images taken at different dates can be compared in real time, allowing doctors and dermatologists to study mole alterations. The company says that providing software to assist doctors and dermatologists with diagnosis and record keeping is essential, especially with the increased awareness of skin cancer among the general public. Advertising

Cosmetic websites in Scotland fail to meet advertising standards A study, published in the Journal of Plastic, Reconstructive & Aesthetic Surgery, has revealed that one in five Scottish websites offering cosmetic procedures has failed to meet advertising standards currently in place. Out of the 125 sites reviewed, 26 did not adhere to the rules set by bodies that include the General Medical Council (GMC) and Advertising Standards Authority (ASA). Companies were offering procedures inappropriately and 26.6% failed to display practitioner’s qualifications online. Alternative treatments to fillers and botulinum toxin injections were rarely advertised, and neither were their side effects. Guidance on good medical practice set by the GMC states that when advertising services, the information you publish must be factual and must not exploit patients’ vulnerability or lack of medical knowledge. The study concluded that although the majority of websites reviewed adhered to advertising standards, greater regulation of all aesthetic practitioners was needed. 10

Aesthetics

European Aesthetics Surgery Standard gains CEN Approval On June 12 the European Aesthetics Surgery Standard, which has been in development for the past three and a half years, was approved. The work, coordinated at a European level by the European Committee for Standardisation (CEN), was carried out by member states including the UK, with two public consultations held across the whole of Europe. The resulting draft of the standard was sent out for final vote to all national committees several months ago, with the voting period ending on June 10. The vote was successful and the document will be published within the next few months as European standard EN 16372, with the title: Aesthetic Surgery Services. The standard was developed with the aim of improving the level of aesthetic surgery services in order to enhance patient satisfaction and safety, and reduce the risk of complications by promoting consistently high standards for providers across Europe. The standard provides a set of requirements considered essential for the provision of aesthetic surgery services by private facilities, and covers the entire service level before, during and after procedures have been carried out. This includes ethics and marketing, consultation, competencies, management and patient communication, available facilities, and categorisation and risk level of procedures. The British Standards Institute (BSI) worked in collaboration with professionals within the industry to produce the document and highlighted the importance of creating a ‘level playing field’ in Europe. Patients often travel to other countries to have procedures, where currently markets can be unregulated. Other organisations involved in the consensus-based development of EN 16372 include; the British Association of Aesthetic Plastic Surgeons (BAAPS), British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS) and Independent Healthcare Advisory Services (IHAS). Nigel Mercer, vice president at BAPRAS and past president of BAAPS said, “We often hear and see cases within aesthetic surgery where patients have suffered complications or faced unnecessary risks as a result of poorly qualified practitioners. Patient safety has to be the primary consideration for everyone working within this specialized field. Now, the impending European standard for Aesthetic Surgery Services means that patients can have the peace of mind that they are being treated by an appropriately qualified practitioner, in an appropriate facility, in accordance to set guidelines, which include standards on advertising.” The surgery standard has been developed in conjunction with a second proposed European Standard on non-surgical cosmetic treatments, which is still under deliberation.

Aesthetics | July 2014

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Vaginal rejuvenation

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Medical tattooing

Petit Lady offers non-surgical vaginal rejuvenation A new product offering women vaginal rejuvenation, without surgery, will be launched in the UK later this year. Lutronic’s Action II Petit Lady has received CE mark clearance for the treatment of vaginal relaxation syndrome (VRS) and stress urinary incontinence (SUI). International sales director of Lutronic, Mr S Ko, said, “The market opportunity for Action II Petit Lady procedure in developed countries is substantial and we’re looking forward to establishing our presence in Europe.” The original Action II technology was used to treat dermatological issues such as scars, epidermal benign disorder and epidermal pigment lesions, and the company are now focusing on expanding its clinical application. Laser and energy based systems company Lutronic claim the HD edition will enable doctors to effectively treat a wide range of vulva-vaginal conditions such as VRS, common after childbirth and in older women. Action II is an Erbium YAG laser that aims to treat the target area with micron-level precision and very little thermal conduction, aiming to be as comfortable as possible for the patient. Ko said, “The dual mode has overcome traditional Erbium YAG laser’s limitations and accumulates more controllable thermal effect to target tissues.” Lutronic claim that the laser tightens vaginal tissues, remodels collagen and rejuvenates the vulva to revive the sensations whilst revitalizing the tissues of the vagina. Action II Petit Lady has already been successful in both Asia and the Middle East.

Lack of communication and education on nipple tattooing is hinders aesthetic results A significant disconnect between the cosmetic and traditional tattoo industries has hindered patients’ aesthetic results, according to a report published in the Plastic and Reconstructive Surgery Journal. The report, by American Society of Plastic Surgeons (ASPS) member, Dr Eric Halvorson and colleagues, suggested that the two industries should share best practices and establish education programmes to achieve improved results for patients. Micropigmentation is a popular procedure for women to undertake following breast reconstruction surgery. But the technique is unregulated and according to micropigmentation specialist, Caron Vetter, there is a lack sufficient training across the medical industry about the procedure. She said, “Nurses and surgeons are often unaware of the guidance and standards of best practice. We often have patients we need to rectify because of nurses’ insufficient training.” Vetter has been delivering training to health-care professionals for 14 years and over the past 18 months has specialised in threedimensional nipple-areola complex tattooing training. “With more patients opting not to have a nipple made after their reconstruction, nurses need to be taught the latest 3D nipple techniques,” she said. Vetter explained that patients are not given enough information about medical tattooing following their breast reconstructions, so are instead turning to traditional tattoo parlours. This can hinder the 3D appearance, as tattooists use inks instead of semi-permanent pigments. The micropigmentation specialist agreed with the research, and said that the UK needs to set a standard of education for medical practitioners. She suggested they should provide evidence of competency and be able to manage the consultation and after-care procedures appropriately. “When any medical professional takes on a new nursing role it needs to be done within a framework,” she said. Vetter does not agree that traditional tattooists should be carrying out micropigmentation and said, “I do not feel a high street tattoo shop is the right place for a patient, who has been through cancer, to end up.”

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Melanoma

Research shows almost half of melanoma deaths are from cancers that look like pimples A study published in the Australian Journal of Dermatology has found that almost 50% of skin cancer deaths are caused by nodular melanomas, which are often dismissed by doctors, as they look very much like innocent pimples or moles. The lesions, which grow at four times the rate of other melanomas, do not present as typical skin cancer, and are therefore not easily recognised by non-dermatologists. Associate Professor John Kelly, from the Victorian Melanoma Service, Australia, said in order to reduce the death rate both patients and doctors need to be more aware of the spots. Nodular melanomas account for just 15% of melanomas, but nearly 50% of deaths, which Kelly suggests is due to the rapid growth of the lesions as well as frequent mis-diagnosis. “Lack of pigmentation is a key reason for failure to recognise these unusual presentations as melanoma,” Kelly said. He advises that if the red nodules are firm and growing progressively for more than a month, they should be checked as a nodular melanoma. Associations

EASAPS to meet in Madrid, November 2014 EASAPS, the European Association of Societies of Aesthetic Plastic Surgery, will be holding their 2014 meeting on November 28 and 29 in Madrid. The scientific programme will be finalised soon, and will focus on facial rejuvenation. President of EASAPS, Mr Nigel Mercer, said, “The meeting will bring together, in one of Europe’s most beautiful and vibrant cities, a faculty of some of the best surgeons in Europe to teach their techniques and philosophies.” The Association was founded in 2007, with the aim of providing a channel of communication between the European societies. “Even more than in 2007, Europe needs a forum for surgeons to develop the European philosophy of aesthetic surgery of aiming for our patients to look better, not different,” said Mr Mercer.

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Aesthetics

Vital Statistics

10% 42%

...of alopecia areata suﬀerers have a family history of the condition Hair Restoration Blackrock

In 2013 the US spent

$1.9 billion

on skin rejuvenation

American Society for Aesthetic Plastic Surgery

Women who suffer five or more blistering sunburns between the ages of 15-20 have an 80% increased risk of developing melanoma Cancer Epidemiology, Biomarkers & Prevention

$6.5 billion

The global aesthetic market is expected to reach $6.5 billion by 2017 Markets and Markets

In their forties and ﬁfties, 5% and 8% of European women suffered from acne, respectively. Journal of Drugs in Dermatology

Industry

Nestle expands skincare offering in the US Food giant Nestle has announced that it will expand its skincare unit in North America by buyng the commercial rights to some Valeant Pharmaceuticals Inc products, including Restylane, Perlane and Dysport. The Swiss company – which already sells those products outside of the US, having bought out L’Oreal’s share of Galderma in February – will also acquire global rights for Sculptra. Nestle is boosting its skin health division, known as Nestle Skin Health SA, as its main food business flounders – this year the company reported its worst first quarter sales since 2009. “[The takeover] is strategically sensible, since Nestle had signaled it is interested in building a dermatology business long term,” said Eddy Hargreaves, an analyst at Canaccord Genuity Corp. 12

Aesthetics | July 2014

There was a 273% increase in American men undergoing cosmetic procedures between 1997 and 2013 American Society for Aesthetic Plastic Surgery

72.5% of Harley Street survey respondents expect to see an increase in patient numbers over the next 12 months Harley Street survey

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Industry

WILL THERE BE A V-ALLERGAN? By Wendy Lewis The relentless pursuit by Valeant Pharmaceuticals to acquire Allergan, the proverbial jewel in the crown of aesthetics, has everyone on high alert. There is a lot at stake, after all. In a nutshell, Valeant’s CEO and chairman J. Michael Pearson teamed up with Pershing Square Capital Management, Allergan’s biggest shareholder led by hedge fund billionaire William Ackman. They offered to buy Allergan for $53B USD, then amended it to $72B USD. Allergan rejected all offers and refused to negotiate, setting the stage for what the Street has deemed ‘one of the year’s most protracted takeover battles.’ “Valeant’s revised proposal substantially undervalues Allergan, creates significant risks and uncertainties for Allergan’s stockholders and does not reflect the Company’s financial strength, future revenue and earnings growth or industry-leading R&D,” said David E.I. Pyott, Allergan’s chairman of the board and chief executive officer, in a press release dated 10 June 2014. Allergan has strenuously pointed out flaws in Valeant’s business model, claiming that it turns its back on R&D in favor of a short-term strategy of aggressive acquisitions, which they consider to be unsustainable. Valeant has acquired a roster of major players in the course of just a few years, including Bausch & Lomb, Obagi Medical Products, Solta Medical, Medicis Pharmaceutical Corp, Dermik, Ortho Dermatologics, and Precision Dermatology. They are known to consolidate marketing, slash budgets, and cut the fat from every company they snag. Lots of smaller companies are hoping to catch Pearson’s eye and chequebook as well. Valeant raised $1.4B USD in cash by selling its filler and toxin enterprise, including all rights to Restylane, Perlane, Emervel, Sculptra, and Dysport. These rights were sold to Nestle S.A., who will operate them through Galderma. Larry Potgieter, managing director, Galderma UK and Ireland, said, “The recent development in the US where Nestle has shown its strong commitment to aesthetic dermatology through the agreement to acquire the rights to Restylane, Perlane and Dysport in the USA and Canada is very encouraging. I believe that Galderma is and will remain a major worldwide company in the aesthetic market with a heritage of science, innovative solutions and clinical rigor.” This deal was reportedly done to avoid potential anti-trust concerns about Valeant’s Allergan bid. In another development, Ryan Weldon, executive vice president and company group chairman, will be stepping down after six years with Valeant. In light of Allergan’s defiance, Ackman and Pearson are likely plotting their next manoeuvre to go right to Allergan’s shareholders. Valeant recently announced USA FDA clearance for Restylane® Silk Injectable Gel with 0.3% Lidocaine for lip augmentation and dermal implantation for correction of perioral rhytids. At the end of the day, it will come down to numbers. Allergan’s board has a fiduciary responsibility to its shareholders to maximize the long-term value of the company. The question is whether Valeant can come back with an offer that is grand enough that it cannot be refused. But before this deal is done, you can be sure that Pyott will also have some tricks of his own. At the time of going to print Valeant Pharmaceuticals announced that the company has commenced an exchange offer for the common stock of Allergan, taking its May 30 proposal directly to Allergan’s shareholders. Pearson said, “We believe Allergan’s stockholders should have the opportunity to express their views and we are confident that Allergan’s stockholders will support this combination. This offer, together with Pershing Square’s ongoing efforts to call a special meeting of Allergan stockholders, is part of Valeant’s clear path to complete a transaction with Allergan. Aesthetics | July 2014

Insider News

Events diary 20th September 2014 British College of Aesthetic Medicine BCAM Conference 2014, London www.bcam.ac.uk 25th - 26th September 2014 The British Association of Aesthetic Plastic Surgeons - BAAPS Meeting 2014, London www.baaps.meetings.org.uk 3rd October 2014 British Association of Cosmetic Nurses BACN Meeting 2014, London www.cosmeticnurses.org 6th December 2014 The Aesthetics Awards 2014, London www.aestheticsawards.com 7th - 8th March 2015 The Aesthetics Conference and Exhibition 2015, London www.aestheticsconference.com

Acne

Trial finds CO2 laser with radiofrequency offers effective treatment for acne scars A study has shown that CO2 laser plus radiofrequency offers more effective treatment for acne scarring than CO2 laser alone. Ten patients, with a mean age of 39.2 years, took part in the study, and all were treated in a single session, using either CO2 laser plus radiofrequency or CO2 laser alone. The researchers took digital photographs, dermatoscopy and in vivo reflective confocal microscopy before and immediately after treatment, and at one week and three months post treatment. By the three-month follow-up, the researchers reported that clinical improvement was seen in patients with boxcar and rolling acne scars. In patients treated with CO2 laser plus radiofrequency, 50% categorised their results as “excellent”, 50% “good”, and none “sufficient”. In those treated with CO2 laser alone, results were reported as “excellent” in 30% of cases, “good” in 40% and “sufficient” in 30%. 13

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Aesthetics editor Amanda Cameron and editorial advisory board member Dr Sarah Tonks report on the recent Westminster Briefing

Understanding the government’s response to the Keogh review The field of aesthetic medicine has been criticised for many years for its unregulated nature. The very term “aesthetic medicine” is a nebulous concept, incorporating many groups of professionals, carrying out a wide range of procedures from dermal filler injections to hair transplantation. In practice, the market is served by prescribing nurses, doctors and dentists, however there is concern that there is not enough regulation of this and patients are being put at risk by unscrupulous practitioners who are primarily concerned with financial gain, and less so with patient safety. A Mintel estimate puts the number of cosmetic procedures carried out in the UK in 2012 to be 1.3 million, with non-surgical procedures comprising 92% of this number.1 With such high figures and so many interested parties, the issue of regulation within the industry naturally proves contentious. The Westminster Briefing – a ‘Review of the Regulation of Cosmetic Interventions: Understanding The Government’s Response’ – took place on May 15, chaired by director of Independent Healthcare Advisory Services (IHAS), Sally Taber. Set up in 2007, IHAS maintains a voluntary register of aesthetic medicine practitioners but has not gained traction in the industry. The lack of compulsory regulation and the low public recognition of the quality logo meant that many practitioners did not see any benefit of joining, financial or otherwise. Noel Griffin, team leader of Public Health Policy and Strategy from the Department of Health, began the first session with an overview of the aesthetics industry and explained the purpose of the review. He outlined how the PIP scandal prompted the Keogh Review team to examine the standards of cosmetic surgery and products within the industry, including botulinum toxins, dermal fillers and breast implants. The Keogh Report was published in April 2013 and contained 40 recommendations. After a lengthy delay, the government’s response was published in February 2014 and agreed with the majority of the recommendations. Patient centred and proportionate, it was in line with the heart of the initial report, although many argued that it did not go far enough to provide regulation

for the industry. A work programme with associated partners was subsequently created, comprising three arms: “High Quality Care” (Royal College of Surgeons, General Medical Council (GMC), Care Quality Commission and Health Education England), “Safe Products” (Medicines and Healthcare products Regulatory Agency, Clinical Practice Research Datalink, Care Quality Commission) and “Informed and Empowered Public” (The Royal College of Surgeons of England (RCS), NHS England, Department of Health).

Aesthetics | July 2014

EXPECTED OUTPUTS RCS

GMC

CQC

CPRD

MHRA

HEE

Cosmetic Standards

Certification

Registration Criteria

Pilot Study Report

Dermal Fillers = Medical Devices

Training Framework

Outcome Measures

Code of Ethics

Guidance

Breast Implant Registry

UDI

Accreditation

Patient Decision AIDS

(No specialist register)

Adverse Reports

Course Delivery

The expected outputs from associated partners

In addressing the government’s response, Griffin explained that as part of the government policy to decrease regulation in the professions, it was decided that there would not be a separate register for aesthetic practitioners; a disappointing result for many practitioners. Griffin said that as each group already had an existing professional body responsible for their regulation, practitioners would remain regulated by them. Neither would there be a separate register or certification for surgeons practicing cosmetic surgery. There will, however, be credentialing held by the GMC, with requirement placed by the RCS, starting in 2016. Other agreed developments include a breast implant registry, and the re-categorisation of dermal fillers to medical devices, and the establishment of a National Institute for Aesthetic Research (NIAR) to address the data vacuum existing in aesthetic and cosmetic treatments. Mr Simon Withey, consultant plastic surgeon at the Royal Free Hospital, went on to explain that eligibility to apply for credentialing in cosmetic surgery would be restricted to those already on the specialist register for a relevant surgical specialty. It is unclear whether those carrying out procedures such as minimally invasive liposuction will need to be on the specialist register, or have the MRCS qualification. It was noted that hair transplant surgery was not covered by these regulations. Mr Withey argued that the UK had become a base for trainee surgeons from Europe. He said there was a tendency for some to leave the country and operate beyond their area of competence. Because of this, the RCS has been asked to set up a committee to look at standards of training and practice, outcome measures and patient information. Director of Standards and Policy at the Professional Standards Agency, Christine Braithwaite, discussed the Accredited Voluntary Register (AVR), a body set up to accredit voluntary registers such as IHAS. Capable of identifying high performing practitioners, it provides accountability and protection when things go wrong. When accrediting, the AVR looks for governance, education and training, register

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maintenance and a formal complaints and concerns service. It regulates bodies such as The National Counselling Society, The Federation of Holistic Therapists and The British Acupuncture Council. Although in its infancy, it is believed that in the future, the AVR will regulate a voluntary register for aesthetic practitioners. Dr Trevor Ferguson,, dean of The Faculty of General Dental Practice UK discussed the General Dental Council’s position on dentists working in the aesthetics industry, saying, “Nonsurgical cosmetic injections can be part of a dentist’s scope of practice providing they are competent and indemnified and have gained the necessary additional skills.” He highlighted that every dental practice is visited and inspected by the CQC, and recommended that cosmetic practices should be inspected in the same way. The afternoon session saw Carol Jollie, performance and delivery manager of cosmetic non-surgical procedures for Health Education England, go on to discuss the review of the qualifications required for non-surgical cosmetic procedures. Commissioned as part of the Keogh review, this working group is still in its early stages of development, and the suggested framework of education, detailed below, has not yet been finalised. Carrying out this work, the HEE Cosmetic Non-Surgical Interventions Expert Reference Group has representatives from medicine (including dermatology), plastic surgery, dentistry, pharmacy, nursing, beauty therapy, laser therapy, environmental health, industry and users. The scope of treatments covered by Keogh, (botulinum toxin, dermal fillers, chemical peels, laser treatments, IPL), has been expanded by HEE to include LED therapy, hair restoration surgery, skin rejuvenation therapies, microneedling and mesotherapy. The proposed future framework would be designed to also cover new devices and treatments, with a phased implementation and transition period, however the specifics of this are yet to be determined by the group. Jollie explained that in the proposed framework there will be accreditation of prior learning and a range of entry points for the administration of treatments, including dermal fillers. Botulinum toxin will continue to be administered by doctors, dentists and nurses in line with pharmaceutical regulations, and continue to be classified as a prescription-only medicine. Although dermal fillers will in future be classified as medical devices it is still unclear whether, in practice, a prescription would be necessary to obtain the product through UK suppliers. This could herald remote prescribing along with its associated problems. Interestingly, those permitted to prescribe may expand to independent pharmacist prescribers. Although it is yet to be determined which entry point applies to doctors, nurses and dentists, various access courses would be available to those outside these professions. Jollie explained that the proposed framework would begin with module four, which covers the foundation core knowledge, skills and competencies required before embarking on specific modules. There are to be five options, covering hair restoration surgery, chemical peels and skin rejuvenation, botulinum toxins and dermal fillers and lasers, IPL and LED treatment. Each module and level covers three themes that include psychology and patient support, risk assessment and diagnostic skills, and values, behaviours and attitudes. Jollie explained that a practitioner, for example, , for example, must have completed level six to carry out botulinum toxin injections to the upper face, and level seven for lower face and hyperhidrosis. At this stage only nurses, doctors and dentists would be permitted

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The proposed future framework would be designed to also cover new devices and treatments, with a phased implementation and transition period, however the specifics of this are yet to be determined by the group. to use toxins. Dermal fillers fall under a different category and a practitioner would only inject fillers if they had met the level requirements. It was explained that at level six, temporary fillers could be used to inject lines and folds; level seven would include temporary fillers to the tear trough, temples, cheeks, nose and the use of collagen stimulating fillers. Level eight would be reserved for permanent fillers. The afternoon’s session raised issues around what the outcome would be if someone practiced outside their scope, how the levels will be funded, how this will impact on insurance and whether it will have the intended outcome of improving patient safety. It was communicated to the audience that phase two of the HEE project will see the group outline content for standards and training, produce a review of treatments not currently within the scope, explore options and recommendations for accreditation and look at delivery of qualifications as prerequisites to regulation. Sharron Brown, Clinical Nurse Specialist and Board Member of the British Association of Cosmetic Nurses, closed the day’s Briefing with an eloquent presentation on the importance of evidence-based medicine, and the factors which make for a safe cosmetic nurse. The Briefing concluded with an audience far better informed of what is happening in government to develop Keogh’s recommendations. However with a lack of clear structure at present, the day did not provide an overall sense of confidence that new tax funded bodies will be able to provide quick and effective regulation. Question marks remain over the possible financial implications for those wishing to gain accreditation, as well as concern as to whether industry professionals will be able to adapt to the new framework successfully. This could be a great opportunity to regulate our profession, to improve patient safety and prevent harmful practices. However, there is the danger that if mishandled, it could have a negative impact on the working lives of many practitioners and make little positive impact on patient safety. REFERENCES 1. Mintel. (2013). Attitudes towards Cosmetic Surgery. Available: http://oxygen.mintel.com/display/638098/.

Aesthetics | July 2014

Insider On the scene

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MYA Fitzroy Hospital Opening, London Make Yourself Amazing cosmetic surgery celebrated the opening of its new central London hospital on June 2, with an evening of champagne, cupcakes and a tour of the hospital. Situated on 14 Fitzroy Square, the new site is now MYA’s flagship hospital in central London, designed to allow patients to complete their entire treatment journey under one roof, from initial consultation to aftercare. MYA cosmetic surgery chairman, John Ryan, said, “The hospital offers a full range of surgical procedures carried out by our highly experienced and skilled surgeons in the glamorous setting of Fitzrovia. The MYA Fitzroy provides an exciting new venue to provide our patients with the best possible results, support and care in cosmetic surgery.”

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Body Face Couture Launch, London The launch for Body Face Couture, a new business opportunity for aesthetic clinics, took place at The Royal Society of Medicine on June 13. Manufactured and delivered by Medisico Aesthetic Medicine (formerly Clinical Lasers), Body Face Couture offers a portfolio of branded aesthetic treatments – from Omniface Fractional RF to noninvasive lipo – for Body Face Couture accredited clinics, whilst at the same time allowing those clinics to keep their own identity. As a manufacturer, Medisico Aesthetic Medicine works to deliver clients to the clinics. The event saw a presentation from CEO Stephen Soos, who gave a detailed account of the new business model, describing it as a way of “selling outcomes,” for clinics. He said, “It’s a pleasure to be able to present our new thought leading transient business model that is genuinely and mutually beneficial to all involved. This, combined with our rigorous clinic accreditation process, sets us in good stead to lead the aesthetic industry by example.”

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From production line to clinical practice A look at Galderma’s Centre of Excellence for Aesthetic & Corrective Medical Solutions Based in Uppsala, Sweden, the site for Galderma’s Centre of Excellence for Aesthetic & Corrective Medical Solutions has been manufacturing brands such as Restylane, from 1996, and Macrolane since 2007. Fomerly Q-Med ground, the site was obtained by Galderma – the company founded in 1981 as a joint venture between L’Oreal and Nestlé – following an acquisition of the Swedish medicaldevice company in 2011. Fully dedicated to the manufacturing of products in the aesthetic category, the long-standing science site is to this day a hive of development, employing over 400 people. In May this year, Aesthetics was invited to take a look behind the scenes at Galderma’s aesthetic portfolio in production. On entering the building, visitors and staff are greeted by a large sign which reads, ‘Welcome to the place where the world’s first hyaluronic acid filler, Restylane, was invented.’ Indeed, Uppsala is the home of the original, nonanimal hyaluronic acid (HA) dermal filler Restylane, the first HA dermal filler aesthetic treatment to be approved by the FDA. With an annual production capacity of 10 million units, Uppsala houses the production of Galderma’s entire dermal filler range; Emervel, Restylane and Macrolane, a hyaluronic filler formulated especially for use in the body. The site also manufactures Restylane Skinboosters and Restylane Skincare. Moreover the centre, less than an hour’s drive from Stockholm, is home to Galderma’s strategic brand management for the entire aesthetic and corrective portfolio. But why invite outsiders to view the ins and outs of your production process? Julian Popple, head of aesthetic marketing at Galderma, says, “It’s important that the industry, and therefore practitioners, are aware of the Research and Development work carried out by Galderma, and the level of science, technology and R&D that goes into all our products to make them as high quality as possible.” Karin

Falck, public and media relations officer for Galderma, agrees. “We are extremely proud to welcome journalists from all over the world to Galderma’s facilities in Sweden. This is the cradle of HA fillers, where Restylane was invented. Today this site manufactures the largest portfolio of HA fillers in the world.” Alluding to the original team at Q-Med, Falck points out, “What’s so amazing is that the team who pioneered the aesthetic industry is still here, with the same passion for quality and innovation.” The site at Uppsala is one of five manufacturing locations belonging to Galderma (others are situated in France, Canada, Switzerland and Brazil), and one of five R&D centres across the globe (France, Sweden, Switzerland, USA and Japan). As a company, Galderma invests approximately 19% of revenues each year to discover and develop new solutions, products and technologies. Galderma’s investment in continued R&D is evident: its research centre in Sophia Antipolis, France is the largest dermatology research site in the world. But it is the 80 researchers at the R&D centre in Uppsala who strive for excellence in aesthetics. Recent developments include a new ergonomic Restylane syringe, launched at this year’s 12th annual Anti-Aging Medicine World Congress, as well as a new Restylane Skinboosters Syringe, designed with a built-in audible dosage control, which dispenses ~10 μL microdroplets. The company have also recently announced the Phase 1 study results of a brand new proprietary toxin currently under development, which the team at Uppsala claim will be an ultra pure fourth generation toxin. From the hands of those working at Uppsala’s research labs to those carefully monitoring production on the factory floor, Galderma’s aesthetic products are minutely monitored from all angles until they reach the hands of practitioners. This holistic approach toward aesthetics is shared by both manufacturer and the aesthetic practitioners that work in partnership with Galderma. Dr Per Hedén, co-founder of Akademikliniken in Scandinavia, was an early user of BoNT A, and the first user of HA for body contouring. Using both the Emervel and Restylane range in his aesthetic work, Dr Hedén describes his approach as, “Facial shaping, balancing the whole face. It’s not merely wrinkle filling anymore.” Looking to the future, Dr Hedén considers whether, “Aesthetic treatments may be as important for health as food and exercise,” going on to emphasise the connection between how we look at ourselves in the mirror and how we feel within ourselves. The patient’s emotional wellbeing as well as their aesthetic result is of clear importance to Galderma’s work in going forward. With a mantra of “Positive change,” signified with a red plus sign across the company’s branded literature, the focus is, “About connecting the outside with the inside,” according to Lena Jonsson, strategic area manager at Galderma. With the recent Galderma IMPACT study dedicated to identifying patient motivations, and the as yet unpublished ANGEL study exploring patient satisfaction, the company’s rounded approach to dermatology and aesthetics is demonstrated by a continued pursuit of excellence, at Galderma’s aesthetics HQ. Aesthetics | July 2014

Insider Training Report

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Aesthetics reports on the training academy conducted by Dr Raj Acquilla and Dr Tapan Patel on May 16 and 17

The Facial Aesthetics Masterclass The Facial Aesthetics Masterclass, presented by Dr Raj Acquilla and Dr Tapan Patel, was held at the PHI clinic on Harley Street in May. The ethos of the training academy, “World class mentors sharing a wealth of experience”, fuelled by optimised learning, using the purpose-built lecture room at PHI and its clinical rooms for demonstration and practical work. As Dr Patel explained, delegates come from a range of backgrounds, with different knowledge and skills, therefore each person must be assessed and their needs identified to produce a personalised and bespoke course. Along with a discussion of the science and history of botulinum toxin and fillers, the course covers each area of the face and the results that can be achieved with non-surgical facial injections, including those into the lips, nose and eyes. Day one comprised of lectures in the morning and extensive demonstration sessions in the afternoon, whereby each doctor demonstrated complete pan facial beautification using fillers and botulinum toxin. Day two centred around practical training for delegates using their own model, exploring the techniques that they had learnt on day one of the course, with close supervision from the lecturers. On day one, Dr Acquilla and Dr Patel began by discussing the concept of beauty with delegates. They highlighted that although beauty is subjective and patients must be assessed on a case-by-case basis, there are consistent geometric ideals and the golden ratio (1:1:618), is known to play a key role in beautification. A key focus of the training was the art of analysis, with Dr Acquilla and Dr Patel explaining that although many courses are available to train practitioners in what to do and how to do it, it is crucial to be aware of why procedures and treatments need to be done – through the study of aesthetics and the effects of the ageing process on the body. The anatomy and physiology of ageing is important on this course, a topic rarely covered in medical training. Although learning from diagrams and books is beneficial, a good knowledge of functional anatomy and surface anatomy through observation of live injection and cadaver dissection is necessary in order to be able to apply techniques to clinical practice. 18

Dr Acquilla and Dr Patel highlighted a study by Shaw et al in 2011 on the ‘Ageing of the Facial Skeleton: Aesthetic Implications and Rejuvenation Strategies.’1 The study discusses how the facial skeleton changes during the ageing process in both male and female subjects and what the implications are from an aesthetic perspective. The presenters stressed that these physiological ageing processes must be considered when providing aesthetic treatment. Volume loss is well known but other aspects were highlighted, such as: • Frontal elongation • Brow lid ptosis • Eye bags • Tear trough development • Lid cheek junction extension • Malar descent • Philtral elongation • Lip inversion • Oral commissure development • Jowl sag • Chin rotation Facial fat has also recently been studied and we now know that there is a superficial fat layer and a deep fat layer. Injection depth is critical as the superficial fat moves but the deep fat does not. In addition, two years ago, new research discovered that ligaments divide the facial fat into compartments.2 This impacts injection technique as sometimes these ligaments need to be broken in order to achieve the best results, which can be done with cannulas. This knowledge of anatomy and ageing allows a very different approach to anti-ageing medicine. In the past, fillers were injected in the face just to eradicate lines but now treatments are more precise, as our awareness of the physiology increases. Facial treatments now address the causes of ageing rather than the symptoms, whereas previously lines were treated directly, with little consideration as to why. Dr Acquilla and Dr Patel stressed that today we are in the lucky position that not only has clinical study advanced to provide us with more information about the anatomy of ageing, but also that more can be achieved with the fillers of today due to the lower viscosity and greater cohesiveness of the products. Fillers can also be used to block muscle, in a similar fashion to that of a splint, which leads to a greater variety Aesthetics | July 2014

of indications treated. It was emphasised during the presentation that no two faces are the same so each treatment plan is different and doses are changed depending on the desired result of the patient. The presenters explained that practitioners must be flexible and thorough in their consultation process in order to accurately assess both the expectations and the particular facial anatomy of each patient. “Non surgical facial aesthetics is a fast moving and dynamic specialty with constant updates in product development, technical strategy and the results we can achieve.” Dr Raj Acquilla explained, “This has resulted in a re-education of our clinical practice to achieve the highest standards in results and the minimisation of adverse events. Our Masterclass simply delivers the latest in knowledge and technique to allow delegates to deliver optimum results and ultimately grow their practice to its full potential.” A comprehensive training programme with emphasis on hands on practice, customised to the individual’s needs; it would seem impossible to attend and not to learn something new about injection technique, anatomy or ageing. Masterclass training days are held on a regular basis. For more information visit www.the-masterclass.co.uk REFERENCES 1. RB Shaw Jr, EB Katzel, PF Koltz, MJ Yaremchuk, JA Girotto, DM Kahn and HN Langstein, ‘Aging of the facial skeleton: aesthetic implications and rejuvenation strategies’, Plastic Reconstructive Surgery, 127(1), (2011), 374-83. 2. Safa E Sandoval, Joshua A Cox, John C Koshy, Daniel A Hatef and Larry H Hollier Jr, ‘ Facial Fat Compartments: A Guide to Filler Placement,’ Seminars in Plastic Surgery, 23(4), (2009), 283-87.

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The American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) celebrated its 50th birthday in style with a five-day congress in New York. Wendy Lewis reports.

Every four years, the AAFPRS and the International Federation of Facial Plastic Surgery Societies (IFFPSS) host a joint symposium that spotlights the latest trends and technologies in facial aesthetics. This year, it was held May 27-31, 2014 in New York City with nearly 1,000 physicians in attendance. The meeting brought together the world’s best practitioners from the US, Canada, Latin America, Europe and Asia who specialise in facial plastic surgery, plastic surgery, cosmetic dermatology and oculoplastic surgery. Among the highlights of the congress were cutting edge talks and workshops on robotic hair restoration, fat transfer, the use of platelet rich plasma, fibrin glues, fat grafting, microneedling and nonsurgical periorbital rejuvenation. New York facial plastic surgeon and programme chair, Dr Anthony Sclafani, said, “We were very excited to have leading experts from around the world share their expertise from multiple disciplines in panel and video sessions, describing their refined surgical techniques, new instructional courses and focused workshops on laser technology and minimally invasive procedures.” The opening session of ‘Changing World Changing Faces’ featured a panel of world-renowned experts who gave their perspectives on the face of beauty. This was followed by the ‘Titans of Facial Plastic Surgery’ session where twelve physicians gave their personal and historical perspectives on facial aesthetics. Albany, NY-based facial plastic surgeon Dr Edwin F. Williams III, discussed the business side of facial plastics, Dr Jonathan M. Sykes from Sacramento, California, shared insights on his personal evolution in caring for patients, Dr Robert Goldberg, from Los Angeles discussed the future of oculoplastic surgery, and Chicago-based facial plastic surgeon Dr Dean M. Toriumi, explained how he pushes the limits in rhinoplasty. The programme did not shy away from controversy – it pushed the field forward and encouraged attendees to think outside of the box. A session called ‘Minimally Invasive Treatments -- Salvation or Curse?’ moderated by Dr Theda C. Kontis, a Baltimore-based facial plastic surgeon, challenged conventional wisdom about the use of fat grafts, dermal fillers neurotoxins, mini-lifts and skin resurfacing with lasers. The robust two-day marketing programme included a line up of superb panels that discussed navigating online ratings and reviews, mastering social media marketing, and how to avoid getting sued. A special media-training workshop, featuring nine-time Emmy award winning broadcast journalist, Jane Hanson was sold out. There was a session to explore the pros and cons of branded procedures, and business panels covered how to evaluate lasers and light-based systems. How to determine whether you are getting your money’s worth from online marketing was also discussed. UK-based facial plastic surgeon, Mr Julian Rowe Jones moderated a successful panel on cosmetic practice tips, with Dr Pietro Palma from Milan. Kentucky-based facial plastic surgeon Mr Donn Chatham and New York-based facial plastic surgeon Mr Steven Pearlman assembled a stellar panel on ‘East Coast (California) vs. West Coast (New York/ Miami)’, with a roster of eight leading surgeons divulging what has worked and not worked for them in terms of PR, SEO, PPC, patient referrals, and other forms of marketing. A star of the successful series Dr 90210 (E! Channel) Dr Paul Nassif, was video-conferenced in from Beverly Hills, and 20

Aesthetics Journal

offered his views on how television has changed the way patients think about cosmetic procedures. Dermatologist Dr David J. Goldberg, facial plastic surgeon Mr Minas Constantinides, and nurse Susan Sullivan presented valuable insights on ‘The Cosmetic Consultation Revisited: Managing Today’s Patients panel.’ Ideals and standards of beauty from around the world were discussed, treatment concepts and how they could successfully be applied to diverse ethnicities were exchanged and explored, and results were critically appraised – making it a truly interactive meeting. The realm of facial rejuvenation on a cellular level was discussed in a panel presentation. Current and future methods to reverse the signs of ageing and enhance wound healing through manipulation of cells were discussed, and future avenues for exploration were described in a panel titled, ‘The Beautiful Cell: Facial Plastic Surgery on a Cellular Level’. Dr Greg Chernoff talked about the use of autologous stem cells for facial rejuvenation, Dr David Hom discussed enhancing wound healing with platelet rich plasma (PRP), dermatologist Hema Sundaram spoke on the use of growth factors for facial rejuvenation (platelet derived as well as animal and plant derived), and Dr Sclafani presented on the scientific basis and evidence of platelet derived growth factors for facial rejuvenation. There were several new exhibitors on hand to introduce their technologies. Of note, Puregraft showcased their sterile fat graft processing system using dual filtration for superior outcomes in volumising and contouring, Advanced Biologics introduced LipoAMP, an acellular adipose-derived filler, and Aquavit Pharmaceuticals displayed the Aquagold Fine Touch, a novel handheld single use microneedle delivery system for topical agents, toxins and fillers. Alphaeon Corporation also debuted the new skincare range from Teoxane Laboratoires. The next AAFPRS conference will be held in Orlando, Florida on September 18-21, 2014. www.aafprs.org

Aesthetics | July 2014

Wendy Lewis is president of Wendy Lewis & Co Ltd, Global Aesthetics Consultancy, the author of 11 books on anti-ageing and cosmetic surgery, and founder/editor in chief of Beautyinthebag.com. She is an international presenter and lecturer and has written over 500 articles for medical journals and consumer publications.

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Clinical Practice Special Feature

Pain management in aesthetics Clinicians today have a whole toolbox of options to keep patient discomfort to a minimum. Kathryn Senior speaks to practitioners about their preferred methods for managing pain. Any aesthetic procedure in which the skin is penetrated or modified is potentially painful, but individual patients vary enormously in how they perceive the sensation and how much it bothers them. It is well known that anxiety and fear play a huge role in elective as well as unplanned medical procedures. This is particularly true for facial aesthetic treatments; our sense of self is intimately related to our facial appearance and expectations of what may go wrong can play a major role in pain perception. “I would say that patients attach more psychological pain to not having what they want corrected, enhanced or fixed, than to the physical pain that they fear may be caused by the procedure,” says Sloan Sheridan-Williams, clinical hypnotherapist and life coach for clinicians. Managing pain is just as much about managing expectations and perceptions as it is about using a pharmacological approach to limit the nerve impulses generated by pain receptors. Today’s aesthetic professionals must create a clinic environment and an experience that minimises the fear of pain, as well as dealing effectively with any physical pain that ensues. FIRST IMPRESSIONS ARE CRUCIAL Health professionals who deliver potentially uncomfortable aesthetic procedures on a daily basis agree that the opportunity to minimise pain starts at the initial consultation. Dr Rachael Eckel, cosmetic dermatologist, believes it is possible to pick up many crucial insights at this first meeting. She asks herself, “Is this an anxious patient? Has this patient had a bad experience? Does he or she seem to have a low pain threshold? Is this patient showing signs of body dysmorphic disorder?” “Past experiences play a huge role in how a patient perceives any type of treatment,”

observes Sheridan-Williams. Taking a detailed history from each patient to identify any concerns is therefore essential. “If you don’t know that a patient has fainted in the past, you are going to come unstuck,” cautions Dr Ravi Jain, consultant aesthetic physician and owner of Riverbanks Clinic. “You really have to understand the patient’s needs and concerns about pain, their attitude to needles, and then plan accordingly,” he advises. ADDRESSING THE ISSUE To fulfil the requirements of informed consent, the amount of pain that a patient can expect during an aesthetic procedure has to be discussed but, as Dr Jain points out, “You have to be careful; if you ask people about pain before you start, you will set them up for pain.” Dr Eckel agrees that there is a fine line between not giving enough information, and giving too much. “If you don’t explain every step of what is going to happen in a procedure – such as a chemical peel – and suddenly the patient feels burning or stinging, he or she will naturally assume something is going wrong. They need to be prepared, but you don’t say, ‘This will be very painful.’ You have to be wise in the words you use,” she says. A BESPOKE AND HOLISTIC APPROACH Creating the right atmosphere in your aesthetic clinic is paramount. Experienced aesthetic practitioners aim to create a welcoming, relaxing ambience in their clinics, as far removed from a traditional ‘hospital’ atmosphere as possible, to help decrease stress and dissipate anxiety. Dr Jain’s treatment room at Riverbanks overlooks beautiful gardens and a river. “Straight away patients are de-stressed by looking out onto the gardens, rather than thinking about their treatment. Having the Aesthetics | July 2014

radio on works too, because they can listen to it and comment on it,” he says. Making sure people don’t feel rushed is also a priority: “During a consultation, the patient is the most important person in the world to you at that moment, that’s what they need to believe, you need to have a nice calm voice and exude confidence.” Dr Vincent Wong of La Maison de L’Esthétique rarely wears scrubs, or a suit and tie, preferring to meet patients wearing semi-casual, everyday clothes. “This is something that new patients will not expect – and almost immediately I get a nonmedical conversation going to get to know the patient better as a person,” he says. At every stage, managing pain means dealing with anxiety. “When your client is calm, collected and relaxed, any actual pain will be minimised” says Sheridan-Williams. ENGAGING ALL THE SENSES Many techniques can be used within the context of a holistic approach to distract the patient from any discomfort. Together, they form a strategy that fits into the holistic approach, complementing and supporting pharmacological pain relief. Dr Eckel deploys a five-pronged approach to managing pain for the patient, addressing all the senses to ensure that the patient is calm and relaxed. • Sight – An aesthetic procedure needs to take place in an environment that is clean, clear and calm, says Dr Eckel. Beautiful scenery is a bonus. • Hearing – It’s easy, thanks to technology and the web, to enable every patient to listen to the music they want during a treatment. Talkesthesia, distracting the patient using conversation, is also a useful therapy. Dr David Eccleston, aesthetic physician and clinical director of MediZen prides himself on his skills in this area, saying, “I have, on more than 23

Clinical Practice Special Feature

•

one occasion, had patients fall asleep during a procedure involving multiple injections.” Smell – Dr Eckel often lights a scented candle in the treatment room and offers each patient a warm scented towelette on arrival. “I have a generalised minted theme in my clinic – mint candles and mint-basil fragranced towelettes. Mint is a calming, soothing, relaxing scent, and it sets the tone for the whole experience.” Taste – Dr Eckel also offers a small helping of homemade mint chocolate ice cream, or a healthier mint protein shake after the procedure, other practitioners also give chocolates. “It’s

good that patients have something before they leave that is going to make them feel good and lift their spirits. Sweet treats also deliver a surge in serotonin and raise blood sugar,” she says. “This also means they are much less likely to faint – we always advise people to eat normally beforehand too,” adds Dr Jain. Touch – Hand massages during facial treatment offer a pleasant distraction, but there are many other options. During Botox procedures Dr Eckel favours having an assistant tap in the middle of the patient’s forehead, lightly but repetitively as a distraction, having learned the technique in Australia. Dr Eccleston offers patients a stress ball to squeeze – “or, if they wish, a friend or member of staff just to hold their hand.”

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PHARMACOLOGICAL PAIN RELIEF Traditional pain relief has an important role to play in enhancing patient comfort during and after aesthetic procedures, but it should be treated as a well integrated part of making each patient feel calm, relaxed and cared for. Today, aesthetic clinics are able to offer the latest pain relief delivery technology as well as the range and formulation of active compounds available. Creams such as EMLA (lidocaine plus prilocaine), LMX4 (lidocaine) and Pliaglis (lidocaine and tetracaine), are used by many practitioners. Dr Jain favours the latter for procedures such as Smart Xide CO2 laser resurfacing and tattoo removal. “EMLA and LMX4 take about an hour to take effect and they need to be occluded, which means wrapping the face in film. The nice thing about Pliaglis is that it is effective in 30 minutes and it self-occludes. It just peels off when it’s dry, so it’s easy to put on and easy to take off.” Plastic surgeon Mr Dalvi Humzah’s practice uses a Clarisonic brush to clean the facial skin before applying a topical anaesthetic. “It has to be proven yet, but we think that using the brush to clean the skin to an ultra level, taking the surface layers off, helps with the absorption of the local anaesthetic. It also gives the patient a twominute time-out period before the procedure, which is psychologically very calming.” The general consensus is that having a separate room for patients to sit privately once the cream has been applied is essential to the patient’s overall experience. Mr Humzah is very much against the idea of patients sitting in the general waiting room with white cream on their face for 30 minutes. He uses nerve block injections around the face, near to the nerves that supply the area to be treated. Nerve blocks work quickly, within 15-20 seconds. “The other advantage is that when the area is completely numb, you can really concentrate on getting the result right, rather than simultaneously working hard to allay a patient’s anxiety and fear because they are feeling some discomfort,” explains Mr Humzah. “You also need to make sure you inject nerve blocks properly, which means very slowly,” he adds. Dr Eckel also uses a complete facial nerve block, consisting of nine injections before a chemical peel. “I combine lidocaine with epinephrine to Aesthetics | July 2014

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give me a faster onset of action and reduced toxicity, which means I can double the amount I use before running into problems,” she says. Dr Eckel also buffers the lidocaine with sodium bicarbonate to reduce the pH, and warms the solution before injection, again to reduce pain during injection and to speed up onset of action. For patients particularly susceptible to the initial pain of any injection, using Coolsense, a small device with a metal cartridge that is kept in a freezer and then applied to the skin for four seconds, gives 10 minutes of instant numbness. “Coolsense works the same way as ice, but ice can get messy with water dripping all over the face once it melts,” says Mr Humzah. Although it needs to be applied carefully during the procedure to avoid burning the skin, some patients are able to tolerate Botox injections with cooling only. TREATMENT TECHNIQUES TO DECREASE DISCOMFORT When delivering injectable therapies such as botulinum toxin or dermal fillers, good technique and the use of supportive therapies can help minimise discomfort. For filler injections, it is important to think about the volume being delivered, “The evidence shows that the greater the volume of product injected, the greater the displacement of tissue and the greater the pain level. We try to use products with small volumes to give the best results,” Mr Humzah explains. “Splitting a larger dermal filler volume into two sessions a couple of weeks apart can also reduce pain.” Dr Jain tends to use a cannula rather than a needle to introduce dermal fillers because, he says, “this means only 1-2 pin pricks on each side of the face rather than several, which reduces pain significantly.” It’s also Mr Humzah’s experience that cannula injections are better tolerated than those administered with a needle. “Interestingly, the bigger the cannula, the less painful it is; I discovered that by accident but I always use the biggest one possible for each procedure now.”

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Clinical Practice Special Feature

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INVASIVE PROCEDURES Intravenous sedation is available in an aesthetic clinic, at a level similar to that used before a colonoscopy. “I have an anaesthesiologist come into my practice for procedures and patients that require sedation – it essentially makes the patient feel very relaxed during the procedure and then dims their memories of it afterwards,” says Dr Eckel. Mr Chris Inglefield, consultant surgeon at London Bridge Plastic Surgery and Aesthetic Clinic, uses Hilotherapy after the most invasive procedures or for treatments that are likely to induce swelling. “Hilotherapy is beneficial for filler treatments, particularly facial voluminising, fractional laser treatments, laser lifting, mid to deep chemical peels and all facial surgery such as blepharoplasty and mini-facelift,” he says. Water at the required temperature is passed through a mask or cuff that is applied directly to the skin, providing

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the optimal temperature for healing. “The technique minimises swelling, bruising and pain after a procedure, which is just as important for patient experience as managing their comfort during that procedure,” explains Mr Inglefield. PAIN MANAGEMENT FOR 2014 AND BEYOND With so many approaches, techniques and pain relief formulations available in aesthetics, clinics need to keep their protocols under constant review. The best practitioners operate a feedback system with patients, learning from individual experiences, adapting how to tailor future experiences. “We have enough tools available to us that patients should come in looking forward to the treatment they are having. The old saying, ‘No pain, no gain’ should not have a place in aesthetics in 2014,” concludes Dr Eckel.

Case study: Pain management during ultherapy It is rare to find published studies that assess pain perception during aesthetic treatments, or that determine the impact of strategies used to reduce that pain. The collection of small but randomised and double-blinded trials that have been performed for Ultherapy are therefore of great interest. These have sought to assess the impact of different forms of analgesia and to explore procedural techniques that could help to reduce discomfort. ABOUT ULTHERAPY Ultherapy uses six DeepSEE transducers to deliver ultrasound into the dermis, deep dermis, or the subdermal tissues to tighten and lift the brow, face, neck or chest. The high-intensity ultrasound stimulates new collagen formation, lifting the skin back into a firmer, younger-looking position at the surface. Some of the treated tissue is coagulated during treatment, which can stimulate pain receptors in the skin. RESEARCH FINDINGS • Patients given a single dose of 800mg ibuprofen 60 minutes before Ultherapy experienced statistically comparable discomfort (p=0.14, no significant difference) as those given 10mg hydrocodone, combined with 500mg paracetamol (acetaminophen), and they were able to drive immediately afterwards. • In a second study, patients receiving Ultherapy were given 800mg ibuprofen an hour before treatment and then had either LMX4 cream or a placebo cream applied to the treatment area. No difference in the level of pain reported was seen between the two groups. • In a third study, patients were treated on one side of the face with the highest energy level of ultrasound per transducer, and with the lowest energy setting on the other side. All also received 800mg ibuprofen an hour before treatment. In the study there was a significant reduction in the overall levels of discomfort reported on the sides of the face where the lower energy was used, but there was no difference in efficacy between sides. WHAT THE STUDIES DEMONSTRATED Ibuprofen at an over-the-counter dose is a suitable method of pain relief for Ultherapy but patient comfort can be further enhanced without compromising beneficial effects if energy levels are reduced. Ultherapy’s Amplify software was upgraded in 2012 to incorporate lower Amplify settings. According to Dr Matthew White, Director of Facial Plastic and Reconstructive Surgery at the Langone Medical Center, New York, this upgrade results in increased patient comfort during the procedure, demonstrating that pain management is a key consideration across the industry.

Aesthetics | July 2014

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Emerging aspects in Botulinum Toxin use A L Baker, A. Pickett, D. Humzah

Abstract With an established number of licensed medical indications, Botulinum Toxin type A (BoNT-A) is also globally acknowledged to effectively refine many of the senescent changes which occur in the ageing face. BoNT-A is widely considered to be an effective first line therapy to eradicate dynamic lines, as well as an adjunctive treatment for a number of aesthetic rejuvenation strategies in softening more established rhytides. The exceptional popularity of the products for aesthetic use and the new potential applications currently under investigation remain unabated. Such demand reinforces the importance of continuous educational updates for the medical practitioner to provide valuable information on the evolving aesthetic and medical modalities, ensuring an optimal understanding of the uses of the product, and safe treatment outcomes for the patient. Key words: Botulinum Toxin type A, emerging indications, delivery devices, pharmacology, dermatology, pain Introduction In this article, we will examine the currently available literature surrounding the emerging indications for Botulinum Toxin type A (BoNT-A), as well as recent pharmacological developments. BoNT remains one of the most extensively researched drugs to date1,2 and a very popular treatment for patients. A recent annual survey by the American Society of Plastic Surgeons indicates that there were over over 6 million aesthetic treatments with BoNT-A alone during 20133, reinforcing to the practitioner the importance in maintaining an awareness of current developments. Clinicians should therefore continue to develop their clinical knowledge and practice to ultimately deliver an enhanced aesthetic result. The history of BoNT in medicine is well known. Initially isolated from an outbreak of food poisoning, the causative organism Clostridium botulinum soon became of intense interest due to the exceptional potency of the neurotoxin produced (Fig. 1). Following the isolation of BoNT, clinical trials and the path to product registration were followed, both in the United States with the product Oculinum (eventually Botox) and Europe as the product Dysport. Since then, the molecule has been isolated and characterized (Fig. 2), but there are still unknown aspects about the mode of action that are elusive and not yet fully determined. For example, why does the activity of the molecule persist for many months when normally, any foreign proteins in the body are rapidly identified and eliminated? Recent evidence indicates that the common phenomenon of phosphorylation may play a role, although this may also significantly reduce enzymatic activity.4 Currently there are a number of BoNT-A products available worldwide, with regional products and others in development (Fig 3) – a recent number emerging from South Korea in particular. The pharmacology of BoNT-A, when used in aesthetic treatments and for medical indications, has been the subject of considerable discussion in recent years. Attempts have been made, based on pseudo-scientific arguments, to distinguish certain products from the others. However, the arguments used were identified as incorrect some years ago.5 Originally, these arguments related to the 28

existence of the so-called BoNT complex, a natural formation of the active neurotoxin, produced by the bacteria, that serves to protect the neurotoxin element in the natural environment. The neurotoxin molecule is naturally protected by a family of related proteins. However, unlike certain claims, these accessory proteins were found to dissociate from the neurotoxin molecule during reconstitution of the products in the vial.6 Apparent product differences relating to, typically, the size of the BoNT-A complex were therefore inaccurate and misleading. Additional features of BoNT-A pharmacology are defined by the injection itself and what occurs subsequently. Diffusion refers to the BoNT complex moving from an area of high concentration to an area of low concentration during the binding to receptors, whereas Spread refers to the physical movement of the product once injected, which may be caused by factors such as dilution volume, needle gauge and injector.6 The pharmacodynamics of BoNT-A, in particular its uptake into the neuromuscular junction (NMJ), is of clinical importance. Recent reports indicate a rapid uptake with no residual BoNT-A in the injected muscle within 20 minutes. Thus questioning post injection protocols currently being promoted. The main areas to consider in the use of BoNT represent: 1. Toxin effects on muscles, 2. Effects on glands, 3. Pain relief, 4. Dermatological uses and 5. Methods of delivery. 1. BoNT effect on muscles The specific target for BoNT is the NMJ, where the nerve synapse connects to the muscle systems. This is a highly complex, universal connection within the body and much about how the NMJ functions is still a subject of investigation.7 In particular, the existence and role of the neurotransmitters involved in overall signaling processes continues to be an area of discovery.8 The specific anatomical distribution of the NMJ within a muscle is of critical importance in understanding the effects of BoNT-A on muscle dynamics. Unlike other muscles in the body, facial muscle fibres have single or multiple NMJ’s which determine the ability to control very fine and intricate muscle movements.9-11 However, apart from limited studies to date, we have little information on these target sites in the majority of other facial muscles, even though knowledge of the gross anatomy of these muscles, with respect to use of BoNT-A, has recently been described.12 A more detailed understanding of the effects of BoNT-A on facial muscle activity with respect to dose, action and recovery, through the use of electromyography, is also being gained.13,14 Detailed understanding is essential in optimization of the dose-effect relationship for BoNT-A, in order to gain the best aesthetic results for the patient, with minimal doses. Facial aging is a universal process that affects many different aspects of size, shape, volume and function.15 However, in addition to ageing effects on muscle size and strength, there is one additional effect that has been overlooked until now – the ageing of NMJs.16 With clear evidence of such ageing processes,

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HISTORY OF BOTULINUM TOXIN AND FIRST CLINICAL USE JUSTINUS KERNER

1820

TOXIN

EMILE van ERMENGEM

1895

ORGANISM

KEMPNER

1897

ANTITOXIN

IVAN HALL

1916

EPIDEMIOLOGY

SOMMER (USA)

1926

PURIFIED

BIOLOGY DEPT. PORTON (UK)

1940

UK ARMY

EDWARD SCHANTZ (USA)

1944

US ARMY

CARL LAMANNA

1946

CRYSTALLINE TOXIN

DUFF

1957

IMPROVED PROCESS

MRE (UK)

1951

UK DEFENCE

UNIV. WISCONSIN

1974

FOOD RESEARCH

ALAN SCOTT & ED SCHANTZ

1968

INVESTIGATIONS OF USE IN MAN

OCULINUM INC

STARTED LATE 1970’S

CENTRE FOR APPLIED MICROBIOLOGY & RESEARCH

1982

FIRST UK TOXIN IN MAN

OCULINUM INC

1989

FIRST OCULINUM® APPROVAL

PORTON PRODUCTS

1990

FIRST DYSPORT® APPROVAL (UK)

Figure 1

there is a likelihood that BoNT-A may produce different responses, perhaps less pronounced, in the older patient. Indeed, one of the BoNT-A products has a qualification within the Summary of Product Characteristics (SmPC) that there is a different response between patients over 50 years of age and under that age: efficacy is less for patients over 50 years old and lower in men than women.17 2. Glandular effects The effects of BoNT-A on hyperhidrosis are well documented, with over 160 publications covering nearly 20 years of use.18 The products have widespread acceptability for treatment of the condition, wherever occurring on the body, in both paediatric and adult applications,19 despite only being approved for axillary hyperhidrosis. BoNT-A is also used to treat gustatory sweating (Frey’s Syndrome). Additional recent applications include the use for treatment of salivary glands for control of drooling by reduction of hypersecretion. This continues to be a wellstudied area,20-24 although a recent Cochrane Review found insufficient evidence to inform clinicians clearly about clinical interventions using BoNT for drooling in children with cerebral palsy.21 There is generally no consensus which glands should be injected and studies looking at both the parotid and submandibular glands have been carried out. 22, 25-27 BoNT-A has also been reported to be useful in correcting the exaggerated appearance of the submandibular gland following a neck lift. 28 A novel application receiving attention in modern clinical trials is the treatment of benign prostatic hypertrophy (hyperplasia).29-31 Additional benefits for such a condition, over and above the normal radiation or drug therapies, will always be of considerable clinical value to patients. In this case, a reduction in prostate volume and

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measurements related to prostate effects have been reported.30 3. Pain relief The use of BoNT for the relief of pain has been studied in many different conditions.32 To date, only the prophylactic treatment of migraines has been approved by the licensing authorities for one of the products. Nevertheless, use of BoNT for routine treatment of many pain conditions has found a widespread, off-label usage.33-36 There is little doubt that further, detailed clinical trials, yet to be performed, will bring established use of BoNT in these types of pain conditions. There are close links between certain aspects of the pain indications under investigation following treatment with BoNT, and a number of painful dermatological conditions, as discussed below. 4. Dermatological uses The dermatological potential for BoNT-A has recently been investigated with early findings in support of treating symptoms associated with rosacea, certain types of psoriasis, facial inflammatory diseases and acne. OnabotulinumtoxinA has been used experimentally to treat erythema and flushing in rosacea and been shown to demonstrate, through the neurogenic component, an ability to actively address vascular dysfunction and inflammation, with potential to reduce hyper seborrhea. Dayan and colleagues37 conducted a two-year survey comprising a small number of subjects (13) presenting with rosacea. The authors utilised an intralesional microdroplet injection technique (0.05ml) of onabotulinumtoxinA, which was 100 units in a dilution of 7ml. Multiple injections were performed intradermally, which gave a dose on average from 8-12 units per affected side. Subjects were reviewed at three weeks and again at three months with a visible reduction in erythema reported, with the authors measuring outcomes on the basis of before and after photography, as well as verbal feedback. Some subjects experienced longevity of results beyond three months. The findings indicate a decrease in persistent as well as intermittent flushing, as well as reduced erythema and inflammation. A range of painful facial conditions, often involving inflammation, have also been studied. These include notalgia paresthetica,38-40 refractory erythromelalgia,41 and hidradenitis suppurativa.42 Other developments include additional knowledge on the effect of BoNT-A on fibroblasts – showing a positive effect with collagen production.43 This data, and others, indicate the potential role of BoNT-A to affect the growth of fibroblasts. Recent work has indicated that BoNT-A is a competitor for the fibroblast growth factor (FGF) receptor, 3,44 adding further weight to direct effects to reduce scar formation and improve wound healing. The ability to modulate scar tissue has been investigated further in an in-vivo animal study to show a reduction in capsule formation around a silicone implant.45,46 5. Methods of Delivery Several areas need to be considered in delivering the treatment of BoNT-A: I. II. III. IV.

No-needle techniques Pain on injection Accuracy of dosage No-needle injections

Studies to inject BoNT-A using several delivery devices have looked at the ability to drive the product through the epidermis and dermis.

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Figure 2

This can be readily achieved with the electrical technique of iontophoresis.47-51 However, pressure delivery using the Dermojet has also been evaluated and is a BINDING ENZYMATIC REGION REGION technique to deliver the product into different TRANSLOCATION areas, for example, REGION for treating palmar hyperhidrosis. However there is no control over depth of injection and the toxin may be delivered deeper than required, resulting in adverse consequences. More recent research is looking at techniques to modulate the skin barrier and allow penetration of BoNT through the dermis. Here, formulation of the BoNT using various carriers is a key area. The US-based company Revance has completed limited Phase 3 testing of a topical BoNT-A gel. This would allow treatment of conditions such as hyperhidrosis and wrinkles due to superficial muscles – typically Crow’s feet, without a needle to puncture the skin. The company is one of around four in the world examining the potential for topical application of BoNT, but the doses required are known to be much higher than used for injection, and the effects are limited to the more superficial facial muscles; not the stronger and deeper muscles of the glabella complex. II Pain The volume of solution injected is directly related to the volume used for reconstitution of the product from the powder form, which is provided for each commercial product. Each manufacturer has

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specific recommendations for the volume of reconstitution of their product, based specifically upon the format used in the registration clinical trials. These can be different for each product. Many clinicians, however, have preferred volumes of reconstitution based on volumes of injection that they are used to. Therefore there is considerable variability between the injection techniques used – with regard to volume from the official recommendations. Trials have been carried out on different volumes of injection, with the same units being administered in each treatment, but the results have demonstrated either no difference in onset or duration of the effects obtained52 or the opposite, contrary result.53 Volume of injection has been reported as unlikely to have an effect over the standard range of product reconstitution volumes recommended.54 In one study, the volume of injection was found to be related to pain on injection, with a higher volume giving more pain. Unfortunately, there were insufficient patients in the study to conclude significance, but nevertheless a guide was established.55 Since the initial use of BoNT-A for aesthetic corrections, clinicians have often chosen to use a diluent containing a preservative (benzyl alcohol) instead of the diluent recommended by the manufacturers: unpreserved saline. To date, nothing has been published directly from the manufacturers when using preserved saline for their products but clinician-led studies are available,56-58 and these indicate a reduction in pain on injection when using preserved saline. There are two possible reasons for this. Firstly, normal (pharmacopoeial) 0.9% saline is incorrectly considered to be a physiological solution.59 Therefore any change from this state, especially if the pH is nearer to neutrality, could improve the pain perception upon injection. But secondly, benzyl alcohol is also recognized to have a minor anesthetic effect when injected. The net effect is likely to be a combination of these and other factors.

MAIN BoNT-A PRODUCTS Product™

Production Strain

Process

U/vial [Product specific]

Excipients (in vial)

Dysport®

Hall

Fermentation Dialysis Chromatography

500 sU

HSA 125 ug

Lactose 2.5mg

Azzalure®

Hall

Fermentation Dialysis Chromatography

125 sU

HSA 125 ug

Lactose 2.5mg

Botox®

Allergan “hyper”

Fermentation Precipitation “Crystallisation”

100 B

HSA 500 ug

NaCI 0.9mg

Vistabel® & Vistabex®

Allergan “hyper”

Fermentation Precipitation “Crystallisation”

50 V

HSA 500 ug

NaCI 0.9mg

Xeomin®

Hall

[Unpublished]

100 X

HSA 1mg

Sucrose 5mg

Bocouture®

Hall

[Unpublished]

50 B

HSA 1mg

Sucrose 5mg

BoNT-A PRODUCTS FROM ASIA Product™

Production Strain

Process

U/vial [Product specific]

Excipients (in vial)

BTXA

Hall

Crystallisation, dialysis

50/100 u

5 mg Gelatin 25 mg dextran 25 mg Sucrose

Meditoxin/Neuronox/Siax

Hall

unknown

50/100/200 u

0.5 mg HSA 0.9 mg NaCi

Botulax/Zentox/Regenox

CBFC26

Protamine sulphate DEAE sepharose chromatography

50/100/200 u

0.5 mg HSA 0.9 mg NaCi

Nabota

unknown

100 u

unkown

Figure 3

Aesthetics | July 2014

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One aspect of injection pain often overlooked is the needle size being employed. Only limited work has been undertaken, but the latest study, from a group of clinicians in Turkey, indicates a smaller 33 gauge needle gives less pain in four areas of the face studied when compared to a 30 gauge needle.60 To further minimize patient discomfort during the injection procedure, Kim and colleagues61 describe findings from their survey comprising 181 participants on their satisfaction after receiving BoNT-A, reconstituted with 1% lidocaine & epinephrine 1:100,000. The addition of lidocaine achieved an immediate paralysing effect on the treated muscles, with the epinephrine reducing spread to adjacent muscles. The findings presented no decrease in pharmacological potency or increase in adverse effects, with some subjects reporting longer duration of aesthetic effect. The survey established no hypotheses for the possible causes of such finding. The statistical data reflects positively in favour of utilising the combination of lidocaine and epinephrine, since 85.7% (78/91) of the participants felt that such combination was superior, 35.7% (56/157) reported no difference in the result and 6.4% (10/157) stated no improvement. However, this is a single study with limited data and no recommendations on this technique may be made without more supporting evidence. III Accuracy of Dosage With low volumes of solution being injected, it is important to be able to deliver accurate dosages and minimise loss of BoNT due to deadspace in the equipment being used. New devices are being developed to deliver BoNT-A, such as the 3Dose Injection Syringe, which has been developed to enable the injector to place and deliver specific doses using a click feedback system. Incorrect doses and placement may potentially result in a debilitating and unsightly (even unbalanced) Mr Dalvi Humzah is a consultant plastic, reconstructive and aesthetic surgeon and medical director at Plastic and Dermatological Surgery. He lectures and is an examiner internationally. Professor Andy Pickett has worked on botulinum toxin for over 27 years. Andy has delivered over 400 lectures to audiences worldwide and has an extensive list of publications. Anna Baker runs a nurse-led cosmetic and dermatology clinic. She is currently undertaking post-graduate study in Applied Clinical Anatomy, specialising in head & neck anatomy.

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appearance with a dissatisfied patient. The device features a low dead-space syringe and low dead-space needle hub reducing the dead–space loss by 0.08mls compared to the conventional needle and syringe combination. Combined with a 33 gauge needle this reduces product wastage and causes minimal pain from the needle stick. Such devices can enable the practitioner to accurately deliver the required dose to the target muscle, however to achieve optimal results, an accurate knowledge of anatomy is essential. Conclusions: The advancing science and applications of BoNT strengthen the importance for practitioners to have knowledge of current developments in the field. Further developments, resulting in numerous “off-label” indications, continue to be identified. Knowledge of BoNT is constantly evolving within aesthetic practice, moving from purely treating dynamic lines and facial contouring (masseter) to treating dermatological conditions with significant clinical benefits to patients. BoNT continues to be developed with adjunctive technologies being added to deliver toxin to specific areas with accurate dosage. Intricate and detailed anatomical knowledge, together with these advances, will allow practitioners to achieve optimal results. Disclosures Andy Pickett is Director and Founder of Toxin Science Limited, Wrexham UK and Adjunct Professor at the Botulinum Research Center, Institute of Advances Sciences, Dartmouth, USA. He is also a Senior Programme Leader in Galderma Aesthetic and Corrective Business Unit. His views and opinions are his own and those of Toxin Science Limited alone.

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the management of pediatric drooling’, The Journal of craniofacial surgery, 24(1) (2013), 28-33. 28. (Humzah; personal communication: 21/02/2014). 29. Marchal C, Perez JE, Herrera B, Machuca FJ, Redondo M, ‘The use of botulinum toxin in benign prostatic hyperplasia’, Neurourology and urodynamics, 31 (1) (2012), 86-92. 30. Arnouk R, Suzuki Bellucci CH, Benatuil Stull R, de Bessa J, Jr., Malave CA, Mendes Gomes C. ‘Botulinum neurotoxin type A for the treatment of benign prostatic hyperplasia: randomized study comparing two doses. The Scientific World Journal’, 2012;2012:463574. 31. Dasgupta P. ‘OnabotulinumtoxinA in benign prostatic hyperplasia’. Eur Urol. 2013;63(3):504-5. 32. Pickett A. ‘Re-engineering clostridial neurotoxins for the treatment of chronic pain: current status and future prospects’, BioDrugs. 2010;24(3):173-82. 33. Singh JA. ‘Use of botulinum toxin in musculoskeletal pain’, F1000Research. 2013;2:52. 34. Avendano-Coy J, Gomez-Soriano J, Valencia M, Estrada J, Leal F, Ruiz-Campa R, ‘Botulinum toxin type a and myofascial pain syndrome: A retrospective study of 301 patients’, Journal of back and musculoskeletal rehabilitation, (2014). 35. Paterson K, Lolignier S, Wood JN, McMahon SB, Bennett DL, ‘Botulinum toxin-a treatment reduces human mechanical pain sensitivity and mechanotransduction’, Annals of neurology, 75(4) (2014), 591-6. 36. Schilder JC, van Dijk JG, Dressler D, Koelman JH, Marinus J, van Hilten JJ, ‘Responsiveness to botulinum toxin type A in muscles of complex regional pain patients with tonic dystonia’, J Neural Transm, (2014). 37. Dayan SH, Pritzker RN, Arkins JP, ‘A new treatment regimen for rosacea: onabotulinumtoxinA’, J Drugs Dermatol, 11(12) (2012), 76-9. 38. Weinfeld PK. ‘Successful treatment of notalgia paresthetica with botulinum toxin type A’, Arch Dermatol, 143(8) (2007), 980-2. 39. Maari C, Marchessault P, Bissonnette R, ‘Treatment of notalgia paresthetica with botulinum toxin A: A double-blind randomized controlled trial’, J Am Acad Dermatol, 70(6) (2014), 1139-41. 40. Perez-Perez L, Garcia-Gavin J, Allegue F, Caeiro JL, Fabeiro JM, Zulaica A, ‘Notalgia paresthetica: treatment using intradermal botulinum toxin A’, Actas dermo- sifiliograficas, 105(1) (2014), 74-7. 41. Lin KH, Wang SJ, Fuh JL, Chen SP, ‘Effectiveness of botulinum toxin A in treatment of refractory erythromelalgia’, Journal of the Chinese Medical Association: JCMA, 76(5) (2013), 296-8. 42. O’Reilly DJ, Pleat JM, Richards AM, ‘Treatment of hidradenitis suppurativa with botulinum toxin A’ Plast Reconstr Surg, 116(5) (2005), 1575-6. 43. Oh SH, Lee Y, Seo YJ, Lee JH, Yang JD, Chung HY, et al, ‘The potential effect of botulinum toxin type A on human dermal fibroblasts: an in vitro study’. Dermatol Surg, 38(10) (2012), 1689-94. 44. Jacky BP, Garay PE, Dupuy J, Nelson JB, Cai B, Molina Y, et al, ‘Identification of fibroblast growth factor receptor 3 (FGFR3) as a protein receptor for botulinum neurotoxin serotype A (BoNT/A)’, PLoS pathogens, 9(5) (2013), e1003369. 45. Kim YS, Hong JW, Yoon JH, Hwang YS, Roh TS, Rah DK, ‘Botulinum Toxin A Affects Early Capsule Formation Around Silicone Implants in a Rat Model’, Ann Plast Surg, 2013. 46. Lee SD, Yi MH, Kim DW, Lee Y, Choi Y, Oh SH. ‘The effect of botulinum neurotoxin type A on capsule formation around silicone implants: the in vivo and in vitro study’, International wound journal, 2014. 47. Kavanagh GM, Oh C, Shams K, ‘BOTOX delivery by iontophoresis’, Br J Dermatol, 151(5) (2004), 1093-5. 48. Pacini S, Gulisano M, Punzi T, Ruggiero M, Transdermal delivery of Clostridium botulinum toxin type A by pulsed current iontophoresis, J Am Acad Dermatol, 57(6) (2007), 1097-9. 49. Davarian S, Kalantari KK, Rezasoltani A, Rahimi A, ‘Effect and persistency of botulinum toxin iontophoresis in the treatment of palmar hyperhidrosis’, The Australasian journal of dermatology, 49(2) (2008), 75-9. 50. Andrade PC, Flores GP, Uscello Jde F, Miot HA, Morsoleto MJ, ‘Use of iontophoresis or phonophoresis for delivering onabotulinumtoxinA in the treatment of palmar hyperidrosis: a report on four cases’, Anais brasileiros de dermatologia, 86(6) (2011), 1243-6. 51. Montaser-Kouhsari L, Zartab H, Fanian F, Noorian N, Sadr B, Nassiri-Kashani M, et al, ‘Comparison of intradermal injection with iontophoresis of abobotulinum toxin A for the treatment of primary axillary hyperhidrosis: a randomized, controlled trial’, The Journal of dermatological treatment, 25(4) (2014), 337-41. 52. Carruthers A, Carruthers J, Cohen J, ‘Dilution volume of botulinum toxin type A for the treatment of glabellar rhytides: does it matter?’ DermatolSurg, 33(Special Issue 1) (2007), S97-104. 53. Abbasi NR, Durfee MA, Petrell K, Dover JS, Arndt KA, ‘A small study of the relationship between abobotulinum toxin A concentration and forehead wrinkle reduction’, Arch Dermatol, 148(1) (2012), 119-21. 54. Rzany B, Fratila AA, Fischer TC, Hilton S, Pavicic T, Rothhaar A, et al, ‘Recommendations for the best possible use of botulinum neurotoxin type a (Speywood units) for aesthetic applications’, J Drugs Dermatol, 12(1) (2013), 80-4. 55. Kranz G, Sycha T, Voller B, Gleiss A, Schnider P, Auff E, ‘Pain sensation during intradermal injections of three different botulinum toxin preparations in different doses and dilutions’ Dermatol Surg, 32(7) (2006), 886-90. 56. Kwiat DM, Bersani TA, Bersani A, ‘Increased patient comfort utilizing botulinum toxin type a reconstituted with preserved versus nonpreserved saline’, Ophthal Plast Reconstr Surg 20(3) (2004), 186-9. 57. Sarifakioglu N, Sarifakioglu E, ‘Evaluating effects of preservative-containing saline solution on pain perception during botulinum toxin type-a injections at different locations: a prospective, single-blinded, randomized controlled trial’, Aesthetic Plast Surg, 29(2) (2005), 113-5. 58. Allen SB, Goldenberg NA, ‘Pain difference associated with injection of abobotulinumtoxinA reconstituted with preserved saline and preservative-free saline: a prospective, randomized, side-by-side, double-blind study’, Dermatol Surg, 38(6) (2012), 867-70. 59. Awad S, Allison SP, Lobo DN, ‘The history of 0.9% saline’, Clinical nutrition 27 (2) (2008), 179-88. 60. Sezgin B, Ozel B, Bulam H, Guney K, Tuncer S, Cenetoglu S, ‘The Effect of Microneedle Thickness on Pain During Minimally Invasive Facial Procedures: A Clinical Study’, Aesthet Surg J. (2014). 61. Kim A, Jung J, Pak A, ‘Botulinum toxin type A reconstituted in lidocaine with epinephrine for facial rejuvenation: results of a participant satisfaction survey’, Cutis; cutaneous medicine for the practitioner, (2013), Suppl:13-8.

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Why we sell cosmeceutical skincare Dr Mervyn Patterson explains why a good skincare line is an essential tool in any clinic’s armamentarium Skincare is the basic ingredient of any customer’s treatment regime and, as a clinic focused on helping everyone achieve their best results, using a skincare line that suits their needs and delivers the best possible results is essential. Customer satisfaction increases loyalty Giving customers a quality experience, with everything we do, should lie at the heart of any clinic’s ethos. Our skincare must feel and smell pleasant to use and give the customer the desired consistency to suit their preferences and skin type. With a population that ranges from those who prefer the very lightest of feel, through to those where the desired feeling after application is an intensely moisturised sensation, the skincare line has to comprise of a range of different formulations. One can have the most effective product in the world but if it is unpleasant to use then it won’t be very popular. An example of this is sunscreen; the desire to use high SPF values has to be tempered with the ability to produce elegant, pleasant formulations. We recommend sun protection as part of our anti-ageing strategy and it 34

is a requirement to all our post procedure regimes. Some chronic conditions such as melasma require absolute adherence to a sun protection strategy. Daily application of a high SPF is an essential part of any regime to achieve and maintain improvements. Sunscreens with combinations of physical, chemical and biological components can achieve high levels of UV protection and, at the same time, appear virtually invisible on the skin. Mineral make-up can also be utilised to add UV protection, with at least one line achieving SPF ratings of 50 in a “barely there” look. Proven results Our customers come to our clinics because they expect to see results. Many will have spent years researching the approach to their skin, their chosen treatments and skincare regimes. This is to be lauded and not criticised. These are exactly the customers we want to see through our doors; the ones who do their homework and base decisions on considered evidence. Increasingly, the modern savvy woman is rejecting the overhyped marketing spin and looks to see what evidence exists to help justify her spend Aesthetics | July 2014

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and achieve the desired results. Likewise, we as doctors and nurses are being asked to base our decisions on evidence-based science. It is therefore imperative that we have considered the science behind all of our procedures and treatments. Skincare lines are now increasingly presenting evidence for their claims, but in many instances these are anecdotal and lack scientific robustness. In my opinion, it was a pivotal moment for the skincare industry when a cosmeceutical company went head-to-head against a prescription product — previously considered as the gold standard in topical anti-ageing therapy. In the first study of its kind, a blend of botanical agents was shown to be equivalent in treating all the measured signs of skin ageing, without the high levels of irritation and reactions seen with the tretinoin 0.05%.1 Logical science If the skin becomes healthy, then it will look its best. This simple, logical statement should underpin everything we do in aesthetics. Repairing the external top 10 to 15 skin cells and restoring optimal barrier function is essential to skin health. A healthy roof helps to protect the underlying skin from a range of “insults” that want to penetrate the deeper layers of our skin. Cleansers, toners and moisturisers must be designed with the correct balance of lipids to ensure the correct mix of the three key lipids between the surface cells. Controlling chronic inflammation in the skin is another critical component of any skincare regime. Unchecked, inflammation leads to unwanted pigmentation, vein formation, abnormal skin cells, destruction of collagen, sagging and wrinkling. Choosing moisturisers with a wide anti-inflammatory effect is now considered an essential aspect of modern skincare. We have chosen a moisturiser containing both barrier repair and anti-inflammatory properties that, in an independent clinical study, was shown to be highly effective in treating the signs of skin ageing.2 Optimal cell nutrition is also a logical step in achieving healthy skin. Human skin cells have a basic requirement for a balanced, physiologically appropriate level of vitamins and trace nutrients to achieve ideal function. Now formulators have achieved a combination of oil and water-soluble ingredients in a single preparation to encompass all the key vitamins — A,B,C,D and E. In an independent clinical study a novel formulation containing these ingredients was shown to be significantly more effective, with less irritation, than another established brand.3

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Safety and tolerability In order to achieve a satisfied, loyal client we need effective regimes that are pleasant and safe to use in the long term. We do not want complaints about anything we do. It is therefore essential that our skincare line is proven to be safe and well tolerated. On the contrary, some skincare brands pride themselves on the harsh approach. “Prescription strength” is a term often used — the impression conveyed is that the more aggressive the skincare regime, the better the result will be. This is not a philosophy we support. Reactions and irritation mean more queries to answer and more time spent on the phone reassuring clients. In my experience, problems such as redness, dryness, flaking and peeling dramatically reduce consumer satisfaction, ruin compliance with the regime and make future use of the product less likely. The incidence of cosmetic sensitivity is now becoming an important issue for those of us involved in the skin and aesthetic industry. A questionnaire study looking at self-reported incidence of skin sensitivity was sent to a random 3,300 women and 500 men in Buckinghamshire. The response rates were 62% for women and 52% for men, with the incidence of self-reported skin sensitivity being 51.4% and 38.2%, respectively. 10% of women and 5.8% of men described themselves as having very sensitive skin. 57% of women and 31.4% of men had experienced an adverse reaction to a personal product at some stage in their lives, with 23% of women and 13.8% of men having had a problem in the last 12 months.4 Nielsen et al patch-tested patients in Denmark in 1990 and 1998 and reported that contact sensitisation to cosmetic related allergens had doubled.5 Set against this backdrop of high and rising incidence of cosmetic skin reactions, it is essential that clinicians recommend skincare products that are safe and tolerable. Management of chronic skin complaints Melasma is an example of a chronic skin disease that may need a lifetime of adherence to a skincare regime to control and minimise its appearance. In addition to daily high factor sunscreen, the use of regular de-pigmenting agents that suppress melanin production is essential to optimise control. Agents such as hydroquinone and high strength retinoids carry a significant risk of irritation. If use is discontinued, because of their tendency to disrupt the skin barrier and increase chronic inflammation, the 36

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pigmentation can rebound to levels worse than before starting to use the products.6 In an independent clinical trial, a novel blend of botanical depigmentors was shown to be as effective as a combination of hydroquinone 4%, tretinoin 0.05% and vitamin C at reducing pigmentation, and the botanical regime was significantly less likely to cause irritation and rebound.6 Optimising results of our clinic treatments We offer a wide array of treatments to help modify or improve the skin. Intense Pulsed Light (IPL), fractional non-ablative laser treatment, microdermabrasion, handheld and machine microneedling, peels and any number of combinations, depending on the clinical indication. The Dermafrac, a combination of microdermabrasion infusion combined with vacuum-controlled microneedling and LED light therapy, is a very popular procedure within our clinic. The combination of microdermabrasion and peeling has been a longtime favourite. Combinations of IPL and moderate strength peels are now emerging as exciting treatment strategies for resistant acne and photodamage. Many of these treatments share the same underlying principle: controlled skin injury producing an inflammatory response, which in turn leads to some degree of reabsorption and skin repair. Persistent barrier disruption and inflammation, beyond the acute reaction, are features that are unlikely to be helpful for optimal skin health. For this reason we choose skincare that is proven to rapidly close the external skin barrier post procedure. In a split face study on laser resurfacing, a proprietary blend of lipids and botanical ingredients improved re-epithelialisation and visibly reduced erythema faster than alternative products used in 75% of the patients. All of the study patients preferred the feel and ease of application of the proprietary product. In a second aspect of this study the key complex within this cream was tested for its ability to normalise barrier function after tape stripping or skin peeling. It produced an 89.6% reduction in trans epidermal water loss TEWL, 45 minutes after application compared to 43.1% reduction with application of 100% petrolatum. Two hours after resurfacing, the stratum corneum had completely normalised whereas petrolatum had reduced TEWL by only 55%.7 By considering the evidence available, we have been able to choose a skincare line that works well for our patients needs and supports the treatments that we offer in our clinic. Aesthetics | July 2014

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Advanced combination treatments The combination of IPL and mid range peel is a very effective treatment for resistant acne and photo damage. A treatment consists of an IPL, followed directly by a skin peel and combines the positive effect of both treatment modalities. In a clinical study, four combined IPL/peel treatments over a 12-week period with an at-home skincare regime, utilising keratolytics, was shown to be highly effective at clearing acne that had failed to respond to various topical and oral treatments. A follow up one year after treatment confirmed a significant long-term effect.8 There are thousands of skincare lines now available on the market, with more being added each week. Every manufacturer has the answer, be it the doctor or famous plastic surgeon behind the brand, the “made by NASA” claim, the magic ingredient or the patented formulation that sets them apart. Revisiting basic skin physiology and examining the quality of the supporting evidence remains a vital step for a clinic owner in deciding the best skincare range to use. As a co-owner of Woodford Medical, Dr Mervyn Patterson is a highly experienced aesthetic doctor providing a wide range of non-surgical treatments. Financial disclosures: Medical director at Eden Aesthetics, distributor of Epionce / Agera skincare, Colorescience mineral make up, and Dermagenesis microdermabrasion and Dermafrac micro-needling machines. @drmervpatterson REFERENCES 1. Comparing Epionce and prescription Renova. http://www. epionce.com/wp-content/uploads/2011/09/1_ClinicalStudy_ EpioncevRenova.pdf 2. Renewal Facial Cream reduces the signs of ageing. http:// www.epionce.com/wp-content/uploads/2011/09/2_ ClinicalStudy_RenewalPhotoaging.pdf 3. Comparing Epionce Intense Defense Serum & Skinceuticals CE Ferulic® http://www.epionce.com/wp-content/ uploads/2013/03/2013_03_IDS_Study-Summary_Skinceuticals. pdf 4. Willis, CM., Shaw, S., De Lacharrière, O., Baverel, M., Reiche, L., Jourdain, R., Bastien, P., Wilkinson, JD., ‘Sensitive skin: an epidemiological study’, British Journal of Dermatology, 145 (2) (2001), pp. 258-63. 5. Nielsen, NH., Linneberg, A., Menne, ‘ T., Madsen, F., Frølund, L., Dirksen, A., et al. ‘Allergic contact sensitization in an adult Danish population: two cross-sectional surveys eight years apart (The Copenhagen Allergy Study)’, Acta Dermato-Venereologica 81 (2001), pp. 31-4. 6. Melano Corrective System vs. Obagi® Nu Derm for Hyperpigmentation http://www.epionce.com/wp- content/uploads/2011/09/5_ClinicalStudy_EpionceMCSvObagi. pdf 7. Medical Barrier Cream superior in cutaneous healing. Clinical Assessment results. http://www. epionce.com/wp-content/uploads/2011/09/10_ClinicalStudy_ EpionceSuperiorinCutaneousHealing.pdf 8. Refractory Acne Vulgaris responds dramatically to a novel IPL / Chemical Peel regimen. Carl Thornfeldt: Presented at 34th Annual Conference of the American Society for Laser Medicine & Surgery (2014)

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Surgical or nonsurgical? Knowing when to use the knife Mr Adrian Richards outlines the invasive and non-invasive options for facial aesthetic treatments As Abraham Maslow said in 1966: “I suppose it is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail.” In other words – if all you can do is surgery, it’s tempting to decide that every patient needs a surgical solution. Likewise if your focus is nonsurgical treatments, these tend to be considered the Holy Grail. But to achieve the best aesthetic results for our patients, we need to have an understanding of all the tools available to us. My background, as clinical director of Aurora Clinics, is in plastic surgery; I came relatively late to nonsurgical treatments. And many of my esteemed plastic surgery colleagues still know little about non-surgical treatments, despite having wellestablished facial plastic surgery practices. In this article, I will endeavour to present the best surgical and non-surgical options for each facial area. Hopefully this outline of treatment options may help you when it comes to deciding on the best treatment for your next patient. For simplicity, I will start at the top.

THE FOREHEAD AND GLABELLAR In this area, non-surgical treatments are the undisputed king. Whenever I train Cosmetic Courses delegates, I encourage them to analyse the four factors of facial ageing in their clients: active lines, gravitation changes, volume loss and skin quality. Children and young adults have temporary lines on their foreheads and glabellar when they raise their eyebrows and frown, but in their late 20s and 30s these lines become ingrained and are present at rest. As these are active lines, caused by contraction of the underlying muscles, they are best treated with muscle relaxing injections. Although botulinum toxin injections are best in this area, there are surgical options–the most common being division of the procerus and corrugators surgically. Access to these muscles is either from above, via scalp incisions during a brow lift, or from below during an upper blepharoplasty. Surgery has the advantage of providing a permanent relaxation of these muscles, but in the vast majority of cases muscle relaxing injections offer the safest and most convenient option.

THE SCALP Few of us treat the scalp, but hair thinning, baldness and grey hair can be extremely ageing. Treatments for thinning hair can be non-surgical or surgical. Non-surgical options include Regaine, a topical treatment containing minoxidil that stimulates blood flow to the hair follicles, increasing follicular size and the diameter of the hair shaft. Surgical options include hair transplants, which involve removing a sample of donor hair (usually from the nape of the neck, but newer techniques also use body hair), isolating the hair follicles and re-implanting where hair is thinnest. Scalp treatments are usually performed in specialist clinics but companies such as Parkwood Clinic in Harley Street will provide a visiting service to your clinic. Even if you choose not to offer these treatments, it’s still useful to have the details of a reputable treatment centre to suggest to your clients.

THE BROW AND UPPER EYES Surgical treatments tend to dominate in this region. In my opinion there are no effective long-term, non-surgical solutions to lowering of the eyebrows, or removal of excess skin and fat in the upper eyelid. This is where surgery comes into its own. The brow can be lifted surgically, which is either performed endoscopically (typically through five incisions in the scalp), or by an open technique, which uses an incision in the hairline stretching from ear to ear. In both techniques the Excess skin on the upper eyelids forehead is freed from its underlying attachments, allowing the surgeon to elevate the brow. A variety of fixation techniques are used but the outcome is that the eyebrow sits in a higher position. But brow lifts don’t suit every face, and many faces with low brows – Cindy Crawford is a famous example – are also considered very attractive. When considering brow lift surgery it is important to analyse every case in detail. Just because it is possible to elevate the brow, it doesn’t mean it’s appropriate for everyone. When the brows drop with age, it can also contribute to the development of excess skin in the upper eyelid. Some

Aesthetics | July 2014

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people, however, have excess skin in the upper eyelid without significant brow ptosis. The eyeball is supported in the eye socket by fat pads. These fat pads can herniate forwards, producing bulges in the eyelids. In the upper eyelid this occurs most commonly in the medial compartment towards the inner side of the eyelid. I challenge you to look in detail at the upper eyelids of the patients you see in the next week. Do they have a low brow position? Are their eyebrows in their natural position or have they been shaped? Do they have excess skin on their upper eyelids, and do they have a bulge on the inner aspect from fat herniation? Look particularly carefully at any Asian patients–in most cases they do not have a defined upper eyelid crease due to different locations of muscle attachment. Asian blepharoplasty, producing a European type fold in the upper eyelid, is one of the most common operations in the Far East, although it is seldom performed in the UK. Often the solution to excess skin and fat in the upper eyelid is an upper blepharoplasty. This is performed, most commonly, as a local anaesthetic procedure taking less than an hour. If asked, I tell my patients that if there’s one cosmetic surgery procedure they should consider, it’s an upper blepharoplasty–it is a relatively simple procedure with reliable long-term results. It brightens the eyes, makes it easier to apply make-up, and can increase the patient’s field of vision. THE LOWER EYES Who wins in this area? In my opinion, overall honours should be shared. Surgery is better for the more severe conditions, whilst non-surgical options are great for milder issues. When looking at the lower eyelids, look for skin excess, prolapse and herniation of the fat pads and conduct the ‘snap test’. Skin excess results in folds of skin bordered by wrinkles. The four fat pads of the lower eyelid can move forward and produce puffiness, and the eyelid becomes looser with age. Assess the tension in the lower lid with the snap test. Gently pull the eyelid away from the eyeball — it should snap back firmly. If there’s any lag in it snapping back, be careful not to weaken the orbicularis oculi muscle of the lower lid with Botox injections. This can further weaken the eyelid and cause it to lie away from the eyeball, a condition known as ectropion. Lower blepharoplasty can be performed via an incision inside the eyelid (trans-conjuctival blepharoplasty) or via an incision just below the eyelashes. In both techniques the fat pads that produce puffiness can be reduced. The advantage of the trans-conjuctival approach is that there is no external scar; the disadvantage is that it’s not possible to remove excess skin from the lower eyelid. If this is required, skin tightening in most cases is achieved with a chemical peel. Non-surgical solutions to the lower eyelids tend to focus on rejuvenating and tightening the skin. I avoid dermal filler treatment to the tear troughs. 40

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Although it works well in the majority of cases, I have seen too many cases of longterm, often untreatable swelling to advocate this treatment. THE CHEEKS My vote goes to non-surgical treatments for this area. Cheek implants are often inserted from inside the mouth without external scars. They offer a more permanent solution to volume loss in the cheeks but they are prone to rotation and displacement and to insert, they require an operation. For these reasons, I prefer the new generation of dermal fillers designed for deeper placement. They offer safety and reliability without the need for an operation. The only downside being that they need repeating. AROUND THE MOUTH Both surgical and non-surgical treatments share equal merit in the peri-oral region. For treatment of the naso-labial folds, upper lip lines and marionette areas, only re-volumising treatments will do. In my opinion, facelifts do not reliably lift and soften the naso-labial folds. So what do we use to re-volumise this area? If you’re a surgeon often the answer is fat. If you’re not a surgeon, it is likely to be dermal fillers. Both offer reliable correction of age-related volume loss in these areas. Most surgeons now offer fat transfer as part of a facelift procedure. If the patient is asleep it makes sense to harvest fat from the lower body and use it to restore lost volume in the face. If the patient is awake and fat is not easily accessible, dermal fillers are the logical choice. But beware – fat cells maintain the identity of the area they were removed from and will behave like them. So if the fat cells came from the abdomen and are programmed for fat storage, they will enlarge their new home if the patient gains weight. THE LIPS This must be a draw. Traditional surgical options for lip enhancement have been limited but there’s now a new implant available - PermaLip. This offers permanent, reliable, adjustable lip augmentation with a simple procedure. It is performed under local anaesthetic and takes PermaLip after approximately 30 minutes. The procedure is well tolerated by patients who, in most cases, say it was better than going to the dentist. The down side of PermaLip is that it requires a degree of surgical training and the use of local anaesthetic. For this reason dermal fillers offer a safe alternative, with the only disadvantage being that they again need to be repeated regularly. PermaLip before

Pictures before and after MACS facelift, upper blepharoplasty and fat transfer by Adrian Richards

Aesthetics | July 2014

THE JOWLS Surgery can be said to win overall in this category, although in the early stages non-surgical treatments can be very effective. Selective re-volumising of the face when combined with reduction in the downward pull on the jowls, from the platysma in the neck, can reverse early jowl formation. For more advanced jowling, however, it is my opinion only surgery will suffice. For patients with skin laxity of the neck, particularly centrally, a facelift and neck lift is the ideal option. For anyone in the 40-55 year-old bracket without significant neck laxity, a MACS facelift is a great option. THE NECK A neck is often the best place to look to ascertain a person’s age. The main issues with the neck are loss of skin tone, excess skin folds and a build-up of sub-cutaneous fat. The best solutions to each these, in turn, are non-surgical skin resurfacing or tightening to improve skin tone, and fat dissolving or removing treatments to refine the contour of the neck. Loose neck skin and bands are caused by a combination of gravity and the downward pull of the platysma muscle. This also contributes to jowl formation. Selective injections of botulinum into the platysmal bands or below the angle of the jaw (referred to as the ‘Nefertiti lift’), can be effective in cases of mild skin excess. In my opinion, surgery is the best option for true skin excess in the neck. So what are the surgical options for a neck lift? Essentially an incision is made behind the ear in the hairline and in the natural fold in front of the ear. The platysma muscle is identified and lifted into its youthful position, with sutures tightening and lifting the skin of the neck. To achieve a really youthful neck contour some surgeons recommend a central platysmaplasty. This involves stitching the medial borders of the platysma together via an incision under the chin as well as lifting it laterally. We explain to patients that if they imagine their platysma was a curtain, pulling it from one side without securing it in the middle would not flatten it. Securing it in the middle and then lifting it from the side would however produce a firm, youthful tightening. CONCLUSION To provide the best possible results for our patients, it is vital to have an understanding of all the options for each issue, and continued education is crucial for this. It’s important that we continue to learn from each other; I would encourage those whose focus is on non-surgical treatments to spend time in clinics and theatres with a plastic surgeon. In turn, and as part of their revalidation and ongoing training, all our surgeons at Aurora undergo regular refresher courses on the latest developments in the non-surgical field. Communication, continuous learning, and the humility to realise that yours is not the only way, is truly the best way to treat our patients. Mr Adrian Richards is a consultant plastic and cosmetic surgeon who has specialised in aesthetics for more than 15 years. He is the clinical director and founder of nationwide cosmetic surgery group Aurora Clinics, as well as training provider Cosmetic Courses, which offers aesthetic training to medical professionals.

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A letter to Rita

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Dr Rita Rakus shares her view of Fractional Radiofrequency Microneedling– a quantum leap for cosmetic dermatology?

When I brandished my first Botox needle, cosmetic dermatology was in its infancy. There were a few brutal laser devices, bovine collagen and a ‘poison`; the most effective solution was often surgery. We have all seen sophisticated devices come and go; promising much and usually disappointing. Experience and competition have taught me that evolution is the secret to survival and success. I’m always looking out for effective, intelligent technology delivering compelling results, engendering loyalty in the often fickle patient. There are many ways of assessing a new technology; clinical papers, conferences, demonstrations, but for me the most reliable source has always been trusted colleagues. I smiled when I received this email from one of my closet colleagues, Dr John Curran. If he was enthused, I was interested!

Dear Rita, Every so often you discover a technology that proves to be a game changer. I was at IMCAS Paris; mostly seeing the same old faces telling you that last year’s over sold and promised bit of kit wasn’t as good as the sales pitch after all but this year’s upgrade was really going to deliver. I’m not the only one who has bought based on the mixture of fear of being left behind and the surety that if my respected colleagues had invested then it must be good. For my sins I’ve more than a few expensive corridor fillers sitting gathering dust! Not being surgeons, we love devices and tools that can emulate the skills of the knife with little downtime. The trouble is, they seldom deliver. RF gets results but it’s hard work. Laser resurfacing is great but the downtime is a barrier to repeat business. Fractional treatment was a brilliant idea but you still had epidermal trauma and hyperpigmentation. Then I saw it, “fractional, insulated needling, radiofrequency; INTRAcel”. It just made sense. Bypass the epidermis at multiple predetermined depths, use insulated micro needles to deliver energy only from the tip where you want it in the dermis, and space the treatment zones allowing for lateral healing. Then add RF as your energy source in bipolar and monopolar modality options; fantastic. That’s all very well but we had been there before. No downtime and any skin type: who were they kidding? They lost me on the “multiple applications” promise. I suppose it was when yet another laser patient told me she loved the

Rather than a quantum-leap, I see Fractional RF Microneedling as a number of cosmetic innovations coming to fruition together, producing significant results that we only dreamt of 15 years ago! Deep dermal heating causes neocollagenesis improving skin texture, tightening and limiting downtime to redness for 24-48 hours with possible skin dryness for up to one week. Many clinical conditions are effectively managed with the variable levels of needle penetration and three modalities of RF delivery. Clinic audit (Figure 2) shows exceptional patient satisfaction for expected outcomes; skin tightening, acne scarring resolution and rhytid improvement.

Before

results but never again, that I dug out the papers to sort fact from fiction. The due diligence was all there; science, evidence, independent clinical endorsement and stunning cosmetic dermatology treatment applications. I‘m sure I‘m not alone in experiencing that nervousness which accompanies the excitement of new technology in the clinic, basted with post purchase dissonance. I respond by waxing lyrical about the virtues of the treatment but cautiously undercharge (if at all), fearing the derisory rebuke of a KOL patient telling friends, “that was rubbish”. Validation came in Cannes at the Five Continents Conference. INTRAcel and needling; fractional RF was the topic of every conversation. Interest in surgical techniques paled in comparison as dermatologists vied to show their newly honed skills with RF. Sure there was downtime if you turned it up too high. It needs a topical anaesthetic and, occasionally, antibiotic cover. Clinical protocol seemed to vary from one physician to the other but all agreed that something new had happened. In my clinic the word has gone viral. Friends of patients ask for the treatment and it has re-invigorated my Thermage business by combining the two treatments to create the ‘RF Facelift’. INTRAcel won’t be the only device of this kind and others will follow, but I don’t often say this Rita. ‘’Needling RF is simply fantastic” and I haven’t even turned on the sublative function yet!

Good luck! John

(Figure 1) INTRAcel delivers RF energy; monopolar, bipolar and sublative into the dermis at various levels through insulated microneedles. Unlike lasers, such as CO2 and erbium, the epidermis is spared from significant thermal damage with energy being delivered at the level of the un-insulated tip, firing only when deep in the dermis.

16% Pleased

After 3 Treatments

3% Satisfied 25% Exceeded expectations

56% Very pleased (Figure 3) Before and after photo, courtesy of Dr Rita Rakus

Aesthetics | July 2014

(Figure 2) Patient survey conducted by Dr John Curran from patients who had INTRAcel treatment at his clinic. Survey conducted in Jan 2012. Complications in this group include 1 prolonged bruising up to 10 days, 1 prolonged redness and bruising up to 7 days and 1 minor infection with antibiotics issued on day 2 and healed by day 5.

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The truth about Hydroquinone Dr Askari Townshend presents the facts about this controversial skincare ingredient For a drug that has been used by millions of people for decades, giving great improvements to their pigmentation disorders, hydroquinone (HQ) has a bad reputation. How and why it started I’m unsure, but the two comments I often hear (in my experience, usually from those that don’t use it) is that it can cause cancer and has been banned. Neither of these is entirely true – there have been no reports or evidence of human malignancy as a result of hydroquinone use. In 2001, countries of the European Union had hydroquinone banned from over-the-counter products yet in the USA, hydroquinone is still available up to 2% over the counter.

several names including quinol and 1-4 dihydroxy benzene. It is an anti-oxidant with several uses that take advantage of it being a soluble reducing agent – it is a major component of black and white photographic developers. In dermatology, HQ has long been used to treat pigmentation disorders and is very effective in doing so. The first (and rate limiting) step of melanogenesis is the oxidation of tyrosine to dopaquinone catalysed by tyrosinase. As a tyrosinase inhibitor, HQ interferes with melanogenesis and results in a reduction of the amount of pigment (melanin) in skin. Pigmentation disorders are common, especially in darker skin types. Excluding vitiligo, El-Essawi et al1 found that 56% of Every so often there is a media story, quite 401 Arab-Americans complained of skin rightly, exposing the risks of the illegal discolouration. When using larger groups sale of strong HQ products in the UK. (1,074 and 1,000), Alexis et al2 and Dunwell Unfortunately, these are often accompanied et al3 found 20% and 23% complaints by medical comments overstating the respectively. The most common diagnoses risks. I was recently asked to comment for were post-inflammatory hyperpigmentation Channel 4 News, but made it clear that I (PIH), melasma and solar lentigines. By far, am a great fan of this useful medicine and the most common condition causing PIH is would not do any more than state the facts acne. At their Skin of Color Centre in New - they found someone else. Here I present York, Alexis et al4 surveyed 1412 patients the facts without the spin. and found that acne was the most common HQ is a phenol compound known by reason for attendance, as it was for white patients, followed by dyschromia which did not feature in the top ten reasons for patients with white skin. HO OH Dyschromia in dark skins can be difficult to treat as there is a Hydroquinone greater risk of PIH after peel or laser treatment than when treating OH white skins. HQ is particularly useful in treating this patient group and is also used as a prophylactic adjunct with peels and laser to reduce the risks. It is important to treat the underlying condition (e.g. acne) before tackling the resulting Phenol Benzene dyschromia.

OH 44

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There are a wide range of topical lightening agents including other tyrosinase inhibitors such as retinoids, kojic acid, azelaic acid and arbutin. Many preparations combine these ingredients (and others) for greater efficacy. A Cochrane review of interventions for melasma found that: 4% HQ is more effective than 2%; combining 4% HQ with tretinoin is more effective than either alone and the addition of a mild steroid e.g. fluocinolone acetonide, is even more effective.5 There is no doubt that HQ is a potent treatment for pigmentation disorders, but what about safety? As with almost all of the topical alternatives, HQ can cause irritation and dryness. However, this is more common with tretinoin and azelaic acid.5 Advice to avoid strong sunshine and wear good quality, high protection SPF is applicable to all topical treatment. This is not just because many of them make the skin more sensitive to sunlight, but also because the sun will drive the problem of melanogenesis. The biggest myth about HQ is that it

Every so often there is a media story, quite rightly, exposing the risks of the illegal sale of strong HQ products in the UK. Unfortunately, these are often accompanied by medical comments overstating the risks.

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Benzene 1979 the numbers had reached “epidemic proportions”.10 Several factors have been suggested that may have contributed to this: Strong concentrations of HQ, use of additional depigmentation agents, alcohol lotion to increase absorption and lack of sunscreen use. The Apartheid regime may well explain the popularity of skin lightening creams in South Africa – the amounts used may have been greater than elsewhere. In a review, Levitt11 noted that long-term use of HQ-containing products, rather than high concentration, may be the greatest risk factor for the development of EO.

Dermatology Association recommended, “no change in the status of either OTC or prescription HQ containing products”.12 This was in response to a proposed status change of HQ by the FDA in light of its assessment that the benefits of HQ products to the US public far outweigh the risks. Before prescribing HQ it is important to exclude EO. This is easily done through asking patients about any history of HQ (or other depigmenting cream) use. If in doubt, careful examination with a dermatoscope or histology should be performed. The continued use of HQ will exacerbate EO and should be stopped immediately. Treatment of EO is challenging and should include application of sunscreens along with hydrocortisone and/or retinoic acid13. Additional treatments include antibiotics, dermabrasion (alone or in combination with CO2 laser) and Q-switched ruby laser (11, 13, 14) , though these have variable results. In summary, 4% hydroquinone is a powerful and effective skin-lightening agent especially when used with tretinoin and a mild steroid. It is safe when used correctly and has no links to human malignancy with topical application, and EO is extremely rare. It can be used prophylactically with other treatments on those with dark skin to minimise the occurrence of PIH, and it should be considered as a first line treatment in these patients when appropriate.

HQ has been on sale in the USA since 1955 but despite acquiring 10 million users, only 28 cases were reported between 1983 and 2000, showing that EO is very rare. In 2006, the American Academy of

Dr Askari Townshend is an international Sculptra trainer as well as lead UK Sculptra trainer for Sinclair Pharma. In addition, he is the UK medical consultant providing support for Sculptra practitioners.

O O

HO HO

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causes cancer. As you might expect, there have been several studies (both animal and human) looking at any possible link. McGregor6 found an increased incidence of renal tubule adenomas in male rats but this was after they had been given 25 times the normal human dose (orally rather than topically). He said, “This disease is particularly prominent in male rats,” and concluded, “the increased incidence of renal tubule adenomas in HQ-dosed male rats is without human consequence.” This confirmed the conclusion already put forward by Hard et al7 and Hard.8 A real, but often overstated, risk is one of exogenous ochronosis (EO). Ochronosis refers to brownish-yellow or ochre coloured collections of pigment found in patients carrying the disease. It is an inherited condition in which the enzyme homogentisic acid oxidase is missing, allowing homogentisic acid (and its oxide alkapton) to accumulate. EO was first described in 19128 after phenol use on a leg ulcer, and presents as a blue/ black discolouration in the skin without the systemic problems of endogenous ochronosis. The blue appearance is due to the depth of the pigment (Tyndall effect). The condition can develop after topical use of HQ, phenol, resorcinol or oral antimalarials.9 EO was reported as a big issue in South Africa, where HQ creams were sold from 1961. By 1969, there were increasing reports of EO being problematic, and by

REFERENCES 1. El-Essawi D, Musial JL, Hammand A, et al, ‘A survey of skin disease and skin-related issues in Arab Americans’, J Am Acad Dermatol, 56 (2007), 933-938. 2. Alexis AF, Sergay AB, Taylor SC, ‘Common dermatologic disorders in skin of color: a comparative practice survey’ Cutis, 80 (2007), 387- 394. 3. Dunwell P, Rose A, ‘Study of the skin disease spectrum occurring in an Afro-Caribbean population’ Int J Dermatol, 42 (2003), 287-289. 4. Alexis AF, Sergay AB, Taylor SC, ‘Common dermatologic disorders in skin of color: a comparative practice survey’ Cutis 80 (2007), 387- 394. 5. Rajaratnam R, Halpern J, Salim A, Emmett C, ‘Interventions for melasma (Review)’, The Cochrane Library 7 (2010). 6. McGregor D, ‘Hydroquinone: an evaluation of the human risks from its carcinogenic and mutagenic properties’ Crit Rev Toxicol, 37 (2007), 887-914. 7. Hard GC, Whysner J, English, JC, Zang E, and Williams, GM, ‘Relationship of hydroquinone-associated rat renal tumors with spontaneous chronic progressive nephropathy’ Toxicology and Pathology 25 (2007), 132-143, 8. Beddard AP, Plumtre CM, ‘A further note on ochronosis associated with carboluria’, Q S Med, 5 (1912), 505-507. 9. Charlín R, Barcaui CB, Kac BK, Soares DB, Rabello-Fonseca R and Azulay-Abulafia L, ‘Hydroquinone-induced exogenous ochronosis: a report of four cases and usefulness of dermoscopy’, International Journal of Dermatology, 47 (2008), 19-23. 10. Hardwick N, Van Gelder LW, Van der Merwe CA and Van der Merwe MP, ‘Exogenous ochronosis: an epidemiological study’ British Journal of Dermatology, 120 (1989), 229-238. 11. Levitt J, (2007) ‘The safety of hydroquinone: a dermatologist’s response to the 2006 Federal Register’. Journal of American Academic Dermatology, 57(5), (2007), 854-72 12. Stone SP, ‘American Academy of Dermatology Association response to Docket No. 1978N-065 and RIN number 0910- AF53’, Skin bleaching drug products for OTC human use, 21 (2006), CFRE Part 310. 13. Levin CY, and Maibach H,‘Exogenous ochronosis. An update on clinical features, causative agents and treatment options’, American Journal of Clinical Dermatology 2 (2001), 213-217. 14. Tan SK, Sim CS, and Goh CL, ‘Hydroquinone-induced exogenous ochronosis in Chinese - two case reports and a review’, International Journal of Dermatology 47 (2008), 639-640.

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Attenuation of Acne Scars Using High Power Fractional Ablative Unipolar Radiofrequency and Ultrasound Mario A. Trelles, MD, PhD and Pedro A. Martı´nez-Carpio, MD, PhD; Instituto Medico Vilafortuny, Cambrils, Tarragona, Spain Published: Lasers Surg. Med. 2014 Wiley Periodicals, Inc. Background and Objective: to determine the efficacy and safety of a new method for treating acne scarring over a short term (two month) and long term (six month) period. Materials and Methods: treatment was carried out on six faces and 13 shoulders or backs of a total of 19 patients with varying degrees of acne scarring. A newly developed high power unipolar fractional ablative radiofrequency technology (iPixel™ RF from Alma Lasers) was used, with acoustic pressure ultrasound guided dermal injection of the PixelTreat Scars preparation (Alma Lasers), through RF Pixel fractionated microchannels. All patients underwent four treatment sessions at three-week intervals. Results: significant improvement was observed in scarring, both on the face and on the back and shoulders. After two months, the percentage of fading on total scarring was 57% on the face and 49% on the back and shoulders; after six months, the percentage increased to 62% on the face and 58% on the back and shoulders respectively. Conclusion: the bimodal procedure is safe and effective in reducing acne scarring. This represents a new therapeutic alternative of great interest to be used either as a monotherapy or in combination with other treatments. INTRODUCTION Acne is one of the most common dermatological conditions. The possible scarring resulting from it causes serious aesthetic and psychological problems in many patients. One of the main aims of acne treatment is to prevent scarring because once scars are formed, the treatments available are complex, insufficiently effective, and a combination is often required.1 Recent studies have shown that some radiofrequency technologies can significantly diminish acne scarring2–5, exhibiting results similar to those of CO2 fractional laser, and with fewer side-effects.5 The aim of this study is to determine the efficacy and safety of a new treatment method for acne scars that combines, in a single procedure, unipolar fractional ablative radiofrequency and ultrasonic dermal injection of bioactive compounds through perforated acoustic pressure microchannels. MATERIALS AND METHODS Patients A prospective study was carried out on 19 patients recruited from scheduled visits to the Instituto Medico Vilafortuny (Cambrils, 46

Tarragona, Spain). The study included 19 patients, of whom 14 were women and five were men (age range 22-53 years, mean age 35.2 years, and Fitzpatrick skin types II–IV). DEVICE AND TREATMENT PROTOCOL The Legato device (from Alma Lasers) was used for the study protocol. Legato is a new bimodal system that combines two technologies (fractional ablative microplasma radiofrequency (RF) and acoustic pressure ultrasound (US) to deliver drugs and bioactive compounds into the dermis. It includes new high power radiofrequency technology (iPixelTM RF), with different technical and application characteristics to those used to date.6,7 The device uses the Pixel RF to generate microchannels and provoke thermal damage and fractional ablation. Each microchannel is, on average, 80-120mm in diameter and has a depth of 100-150mm, depending on the RF power settings.7 After topical application of the preparation into the microchannels, the ultrasound generated by the ImpactTM module facilitates penetration into the dermis. The mode of operation is based on mechanical (acoustic) pressure and torques by propagation of the US wave via the sonotrode to the distal horn and the creation of a ‘hammering’ effect. This extracts the liquid from within the microchannels and forces the bioactive compounds to be enhanced under the epidermis–dermis junction through them. The Pixel RF and the US (Impact) handpiece are built into a console that also houses the software controlling the operation of both modules. The RF handpiece has a removable single-use wheel tip in which multiple needle-like electrodes are placed. The handpiece emits a unipolar RF, producing a high-density microplasma discharge which creates microscopic perforations on the skin. During the procedure, the wheel is rolled firmly over the skin and is controlled by the action of the hand piece trigger. When the rolling wheel is applied firmly to the skin, an electrical discharge occurs, passing to the interior of the skin, with most of the thermal effects taking place in the dermis. The electrical RF current passes through the dermis in search of the opposite electrode, according to the principles of RF mechanisms of action. When the electrical passage is interrupted the RF energy is absorbed, producing heating effects due to absorption.6 However, when the RF wheel tip is rolled over the skin without pressure, with minimal contact between the needles and the epidermis, microplasma sparks are produced. This microplasma causes subtle peeling of the superficial keratin layer covering the epidermis. Moreover, the microplasma effect is intended to create microchannels in the epidermis due to contact with the RF needle-like electrodes that discharge a high amount of electrical energy.

Aesthetics | July 2014

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1. BEL-DOF3-001_01. 2. Tran C et al. in vivo bio-integration of three Hyaluronic Acid fillers in human skin: a histological study. Dermatology DOI:10.1159/000354384. 3. Taufig A.Z. et al., J Ästhet Chir 2009 2:29 – 36. 4. Prager W et al. A Prospective, Split-Face, Randomized, Comparative Study of safety and 12-Month Longevity of Three Formulations of Hyaluronic Acid Dermal Filler for Treatment of Nasolabial Folds. Dermatol Surg 2012, 38: 1143 – 1150. 5. Buntrock H, Reuther T, Prager W, Kerscher M. Efficacy, safety, and patient satisfaction of a monophasic cohesive polydensified matrix versus a biphasic nonanimal stabilized hyaluronic acid filler after single injection in nasolabial folds. Dermatol Surg. 2013; 39(7):1097-105.

BEL092/0314/FS Date of preparation: April 2014

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During the treatment, two criss-cross passes of the wheel tip are performed, that is, four passes of the RF multiple unipolar electrodes, creating a multiple dense microperforation in the epidermis. After this action is completed, the bioactive compounds are applied, followed by application of the ultrasound module (Impact). The hammering effect produced by the sonotrode enables the transfer of the bioactive compounds to the area previously treated with the RF pixel roller, thus increasing the penetration of the compounds into the skin. The ultrasound is perpendicularly applied to the skin surface, in continuous contact, in a circular (concentric-eccentric) motion, both with and without pressure. The time allocated to the procedure is set according to the size of the area to be treated. Treatment is performed for a period of four to six minutes, depending on the size of the lesion, to enable the transepidermal penetration of the compounds. The RF Pixel was set at a power of 60 Watts. The Impact ultrasound device has a pulse modulation control that emits an output power of 40 Watts, with impacts ranging from 10% to 100% in intensity. The output frequency is 27.5kHz, with variables between 10 and 100Hz (acoustic pressure pulse vibration rate per second). The Impact US parameters on the console screen are expressed in intensity percentages (%) between 0% and 100%. The pulse rate is expressed in Hz (1/T). In the case of deep atrophic scar tissue, RF treatment was initiated by rolling the wheel tip, with four criss-cross passes firmly pressing the tissue, followed by another four criss-cross passes without pressure, to create microchannels in the epidermis. The first RF passes with pressure were intended to introduce electricity into the dermis, so that the current could have a stimulating effect on tissue and collagen formation. Collagen is developed during the healing of the microwounds formed by electricity absorption, which generates a thermal effect. When the treatment is finished, a soothing cream is applied to the treated areas as part of the protocol recommended by the manufacturers. The patients are then instructed to apply a moisturising cream to the treated areas twice a day as a maintenance treatment. Assessment of Results and Statistical Analysis All pre- and post-treatment evaluations were carried out on the basis of photographic images viewed on a computer screen. Front and profile photographs of the faces of six patients and images of the backs or shoulders of 13 patients were taken at three intervals. The resulting 75 photographs were submitted to three dermatologists not involved in the trial for evaluation. A blinded dermatologist (JAF) viewed the 75 photographs in a random order, while grading the severity of the scars on a six-point (0-5) scale based on their number and contrast. Three blinded dermatologists (JAF, ALP, and IAI) established a scar fading percentage (from 0% to 100%) at two and six months respectively, taking into account the number and intensity of the lesions, with particular consideration of atrophic and hypertrophic scars; for this the evaluators had the possibility to increase the size of each image. For facial treatments, 24 pairs of profile photographs were viewed and graded, of these, 12 pairs were taken before, and two months after treatment and 12 pairs were taken before, and six months after treatment in random order, with 48

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no knowledge of the time elapsed between them. Following the same procedure, 26 pairs of back or shoulder photographs were also viewed and graded. RESULTS Efficacy Results on the Face The average values on the six-point (0-5) grading scale were 3.64 before treatment and 1.89 at six months, showing significant reduction in scarring (P<0.0001). The average percentages of the evaluators (JAF, ALP, and IAI) were 58.3%, 55.0%, and 56.7% at two months, and 62.5%, 62.5%, and 61.7% at six months respectively. Therefore, an average attenuation of facial acne scarring of 56.7% at two months and 62.2% at six months can be established. Showing a trend for improvement at six months without reaching the predetermined statistical significance value (P=0.098). Out of six patients, one claimed to be ‘somewhat satisfied’, three ‘satisfied’, and two ‘very satisfied’. Efficacy Results on the Back/Shoulders The average values on the six-point (0-5) grading scale were 3.15 before treatment and 1.77 at six months, showing a significant reduction in scarring. The average percentages of the evaluators JAF, ALP, and IAI were 50.8%, 46.9%, and 50.0% at two months, and 56.9%, 60.0% and 58.4% at six months respectively. The average attenuation was 49.2% at two months and 58.4% at six months, showing a significant improvement at the sixth month in comparison to the second month (P=0.0022). Of the 13 patients, two claimed to be ‘somewhat satisfied’, seven ‘satisfied’, and four ‘very satisfied’. Adverse Effects and Complications At the end of the procedure and one hour later, erythema and edema with varying degrees of intensity depending on the case and the areas treated were observed, which for all patients persisted until the following day and had practically disappeared by the fourth day. During the application of ultrasound, cases of epidermal detachment were confirmed, which resulted in very thin scabs that were visible on the fourth day in five cases, and minimally persistent on the seventh day in two cases. At the third week, no adverse effects were observed in the treated areas. During the follow-ups, no cases of hyperpigmentation, hypopigmentation, atrophy or other long term side-effects were observed. DISCUSSION Reduction was observed in all types of scars. With regard to the intensity of the scars, that is, the contrast between the depth and elevation in relation to the surrounding skin, a higher reduction was observed in hypertrophic scars. However, a greater number of atrophic scars ceased to be visible in the comparative photographs. Among the atrophic subgroups, ice pick scars had a higher reduction percentage than box scars. For reasons that have yet to be determined, there was variable efficacy within the same types of scarring. The effect is achieved before two months, improving after six months. Although not complete, attenuation appears to be definite, with no signs of relapse of hypertrophic scars, at six months. The patients’ high level of satisfaction is due to

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the realistic expectations of success established prior to the start of the treatment, and the fact that they were shown the before/after photographic results. According to our information, this is the first study that evaluates the use of Pixel RF for the treatment of acne scars, and also the first to use the PixelTreat Scars formula recommended by the manufacturer. The procedure was well tolerated and no hypersensitivity reactions to the cosmetic preparation were observed. Literature on scar reduction using radiofrequency is relatively scarce on the Medline database; however, the information that can be found accords with its efficacy.2–5,7,8,13 Ablative laser resurfacing using CO2 or Er:YAG lasers are mentioned to have an efficacy of 25% to 90% when

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treating acne scars and considered the ‘gold’ standard.14 However, postoperative erythema, infection, scarring, and pigment disorders are not uncommon complications.14 Radiofrequency, especially in combination with other methods, can achieve aesthetic results which are presented as comparable to those achieved with ablative lasers2-5,7,8,13, without the limitations that the skin phototype involves and avoiding long standing erythema and post-inflammatory hyperpigmentation.14,15 The procedure, described in detail to help facilitate future research, represents an innovation of great clinical interest with regard to possible treatments for acne scarring. The efficacy/safety profile of the treatment itself is very positive, and it can also be useful as a complement to other treatments more specific for each type of scar.

Case Studies

Long-term evolution atrophic and hypertrophic scars (A), with average fading greater than 60% after 2 months (B), and 80% after 6 months (C).

B A

Treated areas corresponding to the shoulder and shoulder-blade regions. Atrophic and hypertrophic scarring can be observed (A), where the less pronounced scars disappear completely, and fading of the more severely pronounced scars occurs. Results at the end of the trial (6 months) (B).

Hypertrophic scarring, some of which, inflamed, was also treated (A). The improvement at 2 months is evident (B), with minimal residual atrophic scarring at 6 months (C).

REFERENCES 1. Fabbrocini G, Annunziata MC, D’Arco V, De Vita V, Lodi G, Mauriello MC, Pastore F, Monfrecola G. Acne scars: Pathogenesis, classification and treatment. Dermatol Res Pract 2010;2010:893080. Epub 2010 Oct 14. DOI: 10.1155/2010/893080. 2. Ramesh M, Gopal MG, Kumar S, Talwar A. Novel technology in the treatment of acne scars: The matrix-tunable radiofrequency technology. J Cutan Aesthet Surg 2010;3:97–101. 3. Gold MH, Biron JA. Treatment of acne scars by fractional bipolar radiofrequency energy. J Cosmet Laser Ther 2012;14:172–178. 4. Taub AF, Garretson CB. Treatment of acne scars of skin types II to V by sublative fractional bipolar radiofrequency and bipolar radiofrequency combined with diode laser. J Clin Aesthet Dermatol 2011;4:18–27. 5. Zhang Z, Fey Y, Chen X, Lu W, Chen J. Comparison of a fractional microplasma radiofrecuency technology and carbon dioxide fractional laser for the treatment of atrophic acne scars: A randomized split-face clinical study. Dermatol Surg 2013;39:559–566. 6. Trelles MA, Velez M, Allones I. “Easy Dressing”: An economical, transparent nonporous film for wound care after laser resurfacing. Arch Dermatol 2001;137:674–675. Fig. 5. Patients number 5, 8, and 10 (Table II). Treated areas corresponding to the shoulder and shoulder-blade regions. Atrophic and hypertrophic scarring can be observed (A), where the less pronounced scars disappear completely, and fading of the more severely pronounced scars occurs. Results at the end of the trial (6 months) (B). THE LEGATO DEVICE IN THE TREATMENT OF ACNE SCARS 7 7. Shin MK, Park JM, Lim HK, Choi JH, Baek JH, Kim HJ, Koh JS, Lee MH. Characterization of microthermal zones induced by fractional radiofrequency using reflectance confocal microscopy: A preliminary study. Lasers Surg Med 2013;45:503–508.

8. Krueger N, Sadick NS. New-generation radiofrequency technology. Cutis 2013;91:39–46. 9. Suh DH, Lee SJ, Lee JH, Kim HJ, Shin MK, Song KY. Treatment of striae distensae combined enhanced penetration platelet-rich plasma and ultrasound after plasma fractional radiofrequency. J Cosmet Laser Ther 2012;14: 272–276. 10. Issa MC, de Britto Pereira Kassuga LE, Chrevrand NS, do Nascimiento Barbosa L, Luiz RR, Pantelao L, Vilar EG, Rochael MC. Transepidermal retinoic acid delivery using ablative fractional radiofrequency associated with acoustic pressure ultrasound for stretch marks treatment. Lasers Surg Med 2013;45:81–88. 11. Issa MC, Kassuga LE, Chevrand NS, Pires MT. Topical delivery of triamcinolone via skin pretreated with ablative radiofrequency: A new method in hypertrophic scar treatment. Int J Dermatol 2013;52:367–370. 12. Trelles MA, Lecle`re FM, Martı´nez-Carpio PA. Fractional carbon dioxide laser and acoustic-pressure ultrasound for transepidermal delivery of cosmeceuticals: A novel method of facial rejuvenation. Aesthetic Plast Surg 2013;37:965–972. 13. Oh IY, Ko EJ, Kim H, Koh HJ, Park WS, Mun SK, Kim BJ, Kim MN. Facial scar treated with an intradermal radiofrequency device. J Cosmet Laser Ther 2013 Oct 17 [Epub ahead of print]. DOI: 10.3109/14764172.2013.854632 14. Asilian A, Salimi E, Faghihj G, Dehghani F, Tajmirriahi N, Hosseini SM. Comparison of Q-switched 1064nm Nd:YAG laser and fractional CO2 laser efficacies on improvement of atrophic facial acne scars. J Res Med Sci 2011;16: 1189–1195. 15. Lee SJ, Kang JM, Chung WS, Kim YK, Kim HS. Ablative nonfractional lasers for atrophic facial acne scars: A new modality of erbium:YAG laser resurfacing in Asians. Lasers Med Sci 2013; [Epub ahead of print]. DOI: 10.1007/s10103-013-1372-8 8 TRELLES AND MARTI´NEZ-CARPIO

Aesthetics | July 2014

R E S V E R AT R O L B E N I G H T C O N C E N T R AT E . I N N O V AT I V E F O R M U L AT I O N T O TA R G E T T H E V I S I B L E S I G N S O F S K I N A G E I N G .

HELPS TO INCREASE RADIANCE, ELASTICITY AND DENSITY MAXIMISED CONCENTRATION OF PURE RESVERATROL

For more information on SkinCeuticals contact our dedicated team on 0870 850 4338 www.skinceuticals.co.uk

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Aesthetics Journal

Aesthetics

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Advertorial SkinCeuticals

SKINCEUTICALS LAUNCH RESVERATROL B E INTRODUCING A NEW NIGHT-TIME ANTIOXIDANT FORMULATION Every day, our skin is exposed to a wide variety of free radical aggressors that contribute to the visible signs of skin ageing. This damage is largely considered to come from extrinsic sources like UV, smoke, pollution, and infrared radiation A. However, free radicals are also created internally by our own bodies, the by-products of normal bodily functions including metabolism, respiration, and inflammation. These intrinsic free radicals function in the same way as those generated from extrinsic sources, and continue to cause damage if they remain un-addressed in the skin’s cells. Whilst the skin is able to produce its own natural internal antioxidants to help defend the skin against this accumulated free radical damage, with age, and on-going environmental aggressions, the skin’s natural protective mechanisms can lose efficiency, rendering the skin vulnerable to the cumulative effects of free radical damage and the subsequent appearance of skin ageing. However, new science has shown that certain ingredients can work to influence and support these internal mechanisms. NIGHT-TIME PROTECTION SkinCeuticals has once again solidified its position as gold standard in the research of topical antioxidant formulations by introducing an innovative night-time ‘PREVENT’ formulation; Resveratrol B E. Formulated with a maximised concentration of 1.0% pure, stable Resveratrol – Resveratrol B E helps to support the skin’s natural defence system against free radical damage, to help repair the visible appearance of accumulated skin ageing. SkinCeuticals’ first nighttime ‘PREVENT’ formulation, Resveratrol B E helps to reinforce skin’s natural protection against age-accelerating internal free radicals. Resveratrol B E also helps to strengthen skin’s functionality to help diminish the visible signs of accumulated skin damage. Resveratrol is a potent polyphenol antioxidant found in grapes, various berries, nuts, and other plant sources. Over the past 10 years Resveratrol has garnered the reputation as the “longevity molecule,” owing to the role it has been found to play in determining species longevity and healthspan. Resveratrol B E combines our highest concentration of 1% pure, stable Resveratrol, one of the highest levels available in a skincare formulation on the market today. Known to be difficult to stabilise within an aqueous solution, Resveratrol B E has been formulated with hydrotopes to ensure optimum absorption of the active ingredient. This is then synergistically enhanced with 0.5% FEATURES AND BENEFITS • Scientifically proven to help improve the appearance of skin radiance, elasticity and density. • Helps to reinforce skin’s natural endogenous defence system against free radical damage, which can lose efficiency with age. • Maximised concentration of pure, stable Resveratrol. • SkinCeuticals first antioxidant night concentrate. • Complements daily SkinCeuticals Vitamin C formulations, such as C E Ferulic and Phloretin CF, for comprehensive skin protection.

Baicalin and 1% Alpha Tocopherol. The formulation helps to improve the visible appearance of skin radiance, elasticity, and density. Suitable for all skin types, Resveratrol B E should be applied at night after cleansing and is suitable to help target a wide variety of indications including signs of photodamage that have accumulated over time, overall loss of skin firmness and loss of skin radiance, poor elasticity and the appearance of fine lines and wrinkles. Resveratrol B E can also be recommended for use alongside invasive or non-invasive clinical treatments such as tightening and volumising procedures including radiofrequency or injectable treatments. DAYTIME PROTECTION Whilst Resveratrol has been shown to help reinforce skin’s internal antioxdiant processes, the skin’s natural external protection also requires continual supplementation. Often containing L-Ascorbic Acid, these formulations need to be applied in the morning to help reinforce the skin’s natural protection against external environmental sources; including UVA, UVB, infrared radiation, and pollution. However, as the skin cannot naturally produce or store Vitamin C alone this needs to be obtained from other sources to benefit the skin, such as applied topically through a broad-spectrum formulation. Over the past 17 years, topical Vitamin C formulations have changed the way people think about skincare protection and rejuvenation and have become an integral part of many recommended skincare regimens. The strict constraints that ensure adequate absorption revolve around having pure L-Ascorbic Acid, a high concentration of between 10-20% to provide meaningful levels of Vitamin C and crucially formulated at an acidic pH below 3.5. These rules are now the defined parameters for the strict Duke University patent, which all of the SkinCeuticals formulations conform to today. Today, the SkinCeuticals ‘PREVENT’ franchise provides a targeted solution for all patient profiles: • C E Ferulic [15.0% L-Ascorbic Acid, 1.0% Alpha Tocopherol and 0.5% Ferulic] optimum for lipid dry, mature skin showing signs of ageing. • Phloretin CF [10.0% L-Ascorbic Acid, 2.0% Phloretin and 0.5% Ferulic] designed for oilier, problematic skin, prone to hyperpigmentation or imperfections. • Phloretin CF Gel [10.0% L-Ascorbic Acid, 2.0% Phloretin and 0.5% Ferulic] suitable for male clients, patients with sensitive skin, or clients who prefer a hydrating gel texture. • AOX+ Eye Gel [5.0% L-Ascorbic Acid, 1.0% Phloretin and 0.5% Ferulic] our first formulation designed specifically for the finer skin around the delicate eye area • Serum 10 [10.0% L-Ascorbic Acid and 0.5% Ferulic] our introductory L-Ascorbic Acid formulation for younger clients new to Vitamin C skincare, or clients with sensitive skin. RESVERATROL B E IS AVAILABLE TO ORDER FROM SKINCEUTICALS NOW. FOR MORE INFORMATION ON THIS BREAKTHROUGH NEW PRODUCT, SPEAK TO A MEMBER OF THE SKINCEUTICALS TEAM ON 0870 850 4338 REFERENCES 1 Silvie T. et al (2012). Aging 4:146-158; Fontana, L. et al (2010); Science 328:321-326.

Aesthetics | July 2014

Clinical Practice Abstracts

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Aesthetics Journal

Aesthetics

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A summary of the latest clinical studies Title: A novel, volumising cosmetic formulation significantly improves the appearance of target glabellar lines, nasolabial folds, and crow’s feet in a double-blind, vehicle-controlled clinical trial Authors: Patricia K. Farris, Brenda L. Edison, Ronni L. Weinkauf, Barbara A. Green Published: Journal of Drugs in Dermatology, 2014 Jan Keywords: Topical, glabellar, nasolabial folds, crow’s feet Abstract: facial lines and wrinkles are caused by many factors including exposure to external elements and the dynamic nature of facial expression. Many cosmetic products and procedures provide global improvement to aging skin, whereas injectable therapies are frequently utilised to diminish specific wrinkles. However, some patients are unwilling to undergo injectables and would benefit from an effective topical option. A two-step formulation containing the cosmetic anti-aging ingredient N-acetyl tyrosinamide, was developed for use on wrinkle areas. The tolerability and efficacy of the serum plus cream were tested for 16 weeks in women with moderate facial photodamage on predetermined wrinkle areas (glabellar lines, nasolabial folds under eye lines, and lateral canthal wrinkles) in a single-center, randomised, double-blind, vehicle-controlled, clinical trial. Seventy women (47 Active group, 23 Vehicle group) completed the study. Digital photography, clinical grading, ultrasound and self-assessment scores confirmed improvement to wrinkle areas. The topical cosmetic formulation was statistically superior (P<0.05) to its vehicle in visually improving nasolabial folds, glabellar lines, crow’s feet, and under eye wrinkles and in reducing pinch recoil time. Title: A case of diffuse alveolar hemorrhage associated with hyaluronic acid dermal fillers Authors: Basor JF, Fernandez R, Gonzalez M, Adorno J Published: The American Journal of Case Reports, 2014 May Keywords: fillers, hemorrhage, HA Abstract: Hyaluronic acid injectable gels have been available for the general market since 2003 as cosmetic dermal fillers and skin boosters. Diffuse alveolar hemorrhage is an acute event that threatens the life of the patient and can lead to pulmonary fibrosis. Alveolar hemorrhage associated with hyaluronic acid dermal fillers is an entity that, to the best of our knowledge, has never been described in the medical literature. We describe a patient who presented with dyspnea and cough after a subcutaneous injection of hyaluronic acid, with radiographic abnormalities including ground glass opacities and consolidation. The patient underwent flexible bronchoscopy and was diagnosed with diffuse alveolar hemorrhage. It is generally believed that HA is a safe product with minimal adverse effects, usually involving the injection site. Diffuse alveolar hemorrhage associated with the non-approved use of cosmetic hyaluronic acid dermal filler raises concern about the safety of this easily accessible product. Physicians and other healthcare specialists must be vigilant for the misuse of these dermal fillers for cosmetics purposes and the possible risk of severe complications, including alveolar hemorrhage. Title: Intrinsic and Extrinsic Risk Factors for Sagging Eyelids Authors: Leonie C. Jacobs, Fan Liu, Isabel Bleyen, David A. Gunn, Albert Hofman, Caroline C. W. Klaver, André G. Uitterlinden, H. 52

A. Martino Neumann, Veronique Bataille, Timothy D. Spector, Manfred Kayser, Tamar Nijsten Published: JAMA Dermatology, 2014 May Keywords: dermatochalasis, genetics, risk factors Abstract: Our objective was to study nongenetic and genetic risk factors for sagging eyelids. Dermatochalasis was defined as the eyelid hanging over the eyelashes. Age, sex, skin color, tanning ability, hormonal status in women, current smoking, body mass index, and sun protection behavior were analyzed in a multivariable multinomial logistic regression model. Genetic predisposition was assessed using heritability analysis and a genome-wide association study. The study was performed in 2 independent population-based cohorts. The Rotterdam Study included older adults from one district in Rotterdam, and the UK Adult Twin Registry (TwinsUK) included twins from the United Kingdom. Participants were 5578 unrelated Dutch Europeans (mean age, 67.1 years; 44.0% male) from the Rotterdam Study and 2186 twins (mean age, 53.1 years; 10.4% male) from TwinsUK. 17.8% of individuals from the Rotterdam Study showed dermatochalasis. Significant and independent risk factors included age, male sex, lighter skin color, and higher body mass index. Current smoking was borderline significantly associated. Heritability of sagging eyelids was estimated to be 61% among 1052 twins (15.6% showed dermatochalasis). A meta-analysis of genome-wide association study results from 5578 Rotterdam Study and 1053 TwinsUK participants showed a genome-wide significant recessive protective effect of the C allele of rs11876749 (P = 1.7 × 10-8). This variant is located close to TGIF1, (an inducer of transforming growth factor β), which is a known gene associated with skin aging. Title: Facial allergic granulomatous reaction and systemic hypersensitivity associated with microneedle therapy for skin rejuvenation. Authors: Soltani-Arabshahi R, Wong JW, Duffy KL, Powell DL Published: JAMA Dermatology, 2014 Jan Keywords: microneedle, cosmeceuticals, hypersensitivity Abstract: In cosmetic practices, various cosmeceuticals are applied before microneedling to enhance the therapeutic effects. This results in intradermal tattooing of the topical product. Despite rapid increase in the use of microneedles in dermatology, there are few data about their safety. We describe 3 women, aged 40s to 60s, who developed facial granulomas following microneedle therapy for skin rejuvenation. Two had undergone microinjection of the same branded topical moisturizer. Biopsy in all cases showed foreign bodytype granulomas. Results of tissue cultures were negative. Chest radiography and serum angiotensin-converting enzyme findings were normal. The first 2 patients had a positive patch test reaction to the serum. Initial treatment with topical and oral corticosteroids was ineffective. Therapy with doxycycline hydrochloride and minocycline hydrochloride led to partial improvement in one case and resolution in another. Application of topical products prior to microneedling can introduce immunogenic particles into the dermis and potentiate local or systemic hypersensitivity reactions.

Aesthetics | July 2014

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Aesthetics Awards Special Focus

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Aesthetics Journal

Aesthetics

aestheticsjournal.com

The categories for The Aesthetics Awards 2014 are as follows: • Cosmeceutical Range/Product of the Year • Injectable Product of the Year • Treatment of the Year • Equipment Supplier of the Year • The Janeé Parsons Award for Sales Representative of the Year, supported by Healthxchange Pharmacy • Best Customer Service by a Manufacturer/Supplier • Distributor of the Year • The NeoCosmedix Award for Association/Industry Body of the Year With entries closing for The Aesthetics Awards 2014 on June 30, time is running out to enter the most prestigious awards in medical aesthetics. Don’t miss the opportunity to be recognised as a leader in the profession by entering yourself, or your company or client in the Awards, to be held on Saturday December 6 at the Park Plaza Hotel in Central London. The Aesthetics Awards bring together the best in medical aesthetics to highlight the achievements of the last 12 months with twenty-one select categories. Awards are presented to those who have demonstrated clinical excellence and who represent the highest standards in the profession, from clinics and individual practitioners to manufacturers and suppliers.

• The Pinnell Award for Product Innovation • Training Initiative of the Year • The 3D-lipomed Award for Best New Clinic, UK and Ireland • Best Clinic Scotland • The Church Pharmacy Award for Best Clinic North England • The Dermalux Award for Best Clinic South England • The Oxygenetix Award for Best Clinic London • Best Clinic Wales • Best Clinic Ireland

Closing date for entries Entries must be completed on The Aesthetics Awards website on or before 30 June 2014. If you have any questions please call our support team on 0203 096 1228 or email support@aestheticsawards.com

• The Institute Hyalual Award for Aesthetic Nurse Practitioner of the Year • The Merz Aesthetics Award for Aesthetic Medical Practitioner of the Year • Clinic Reception Team of the Year • The Aesthetic Source Award for Lifetime Achievement

How to Enter All entries must be made via the Aesthetics Awards website www.aestheticsawards.com. You can enter as many categories as you wish but you may only enter yourself, a company you work for as an employee, contractor or agency, an employee who works for your company or a product made or distributed by your company. Entries made on behalf of a third party will not be accepted. You should only enter each category once. Multiple entry forms for the same clinic, company, individual, treatment or product will be disregarded. All entries must be accompanied by the supporting evidence requested in the entry form. This information will be used to select the finalists and by the judges when deciding on the winners, highly commended and commended. The list of finalists will be announced in the September issue of Aesthetics Journal, after which the voting and final judging process will begin.

Aesthetics | July 2014

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Aesthetics Journal

Aesthetics

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Aesthetics Awards Special Focus

Here we feature more winners from The Aesthetics Awards 2013 as they tell us why they entered and how the award has supported and validated their hard work in medical aesthetics Aesthetic Practitioner of the Year

The Aesthetics Practitioner Award is sponsored by Merz Aesthetics

Dr Cheralyn Lumley was the winner of Aesthetic Practitioner of the Year award as chosen by both voters and our awards panel. Dr Lumley was quoted as “a credit to the profession and industry” by one of our readers, and a patient at her clinic commented, “Cheralyn’s impeccable professionalism and attention to detail is second to none.” Dr Lumley said, “It was a huge honour to win Aesthetic Practitioner of the year at The Aesthetics Awards 2013 and I am so grateful for the support from my patients and industry colleagues and for their choice and trust in me. As a single-handed practitioner with a small boutique clinic, I thought my chances of becoming a finalist were pretty slim. All of my patients were very excited and pleased for me when I was shortlisted alongside such talented others, and they were thrilled when they heard I had won. They feel that this is an endorsement of their choice of clinic and practitioner. This award has been such a benefit to my clinic, I have been able to be able to thank my patients for their support and loyalty, and local awareness through recent press and magazine editorials has led to a pleasing influx of new clients. I never thought I’d be in the spotlight. I only wish I’d bought a new frock and hadn’t ended up with panda eyes from the tears for the photo! The ceremony was a truly glamorous and enjoyable event, and I’m certainly looking forward to attending again this year.”

Dr Cheralyn Lumley

Association/Industry Body of the Year

This year the award for Association/Industry Body of the Year is sponsored by NeoCosmedix

The British Association of Cosmetic Nurses were presented with the award for Association or Industry Body for an amazing third consecutive year. The fantastic and tireless work of the BACN to raise standards within the industry and support aesthetic nurses was recognised by the voters with their clear win. “The BACN were honoured to have won the Aesthetics Awards Association of the Year 2013 for the third year running. It was a fantastic end to the year as the BACN committee, and members had worked incredibly hard on so many projects, particularly in Education and Training. We have made such positive progress in determining the future position for Cosmetic nurses in the UK, and being recognised and thanked for this work makes it worthwhile. This year the BACN is opening up a public section of the website to find a registered BACN practitioner. We are working with educationists, HEE and NMC, and will hold the biggest conference yet in October which is open to all medical professionals. If we are very lucky we might win Association of the Year 2014!!”

Sharon Bennett, Chair of BACN

Best New Product or Treatment Clinically proven to achieve rapid results for a range of skin concerns, Dermalux TriWave was the clear winner of Best New Product or Treatment. Voted by both readers and the judging panel, the award recognises new and dynamic treatments to the aesthetics industry. “We are very proud to have won the award for Best New Product or Treatment in 2013, especially as it was voted for by clinics who are using Dermalux and witnessing the efficacy and popularity of the treatment on a daily basis. Whilst LED Phototherapy has been around for a number of years, Dermalux is a relatively new but fast growing brand and the award has definitely helped awareness and recognition throughout the industry. Winning the award shows that all companies, no matter what their size, have a chance in The Aesthetic Awards, as the voting and judging process means that the results are genuine and respected within the industry. As a big supporter of independent clinics throughout the country, we are delighted to be sponsoring the award for the Best Clinic South England at this year’s awards ceremony and look forward to presenting the prize to the deserving winner.”

Louise Taylor, Dermalux Aesthetics | July 2014

Autumn Conference 2012 Royal Institute of British Architects, 66 Portland Place, London W1B 1AD

Until 1st July you can purchase a ticket to the British Aesthetic Medicine Main conference takesCollege placeofon: Conference 2014 from just £169.

•

The conference will be held at the Royal Institute of British Architects, London and will comprise a mixture of lectures and live demonstrations from fantastic international speakers in the main conference room. This year BCAM are also delighted to feature a parallel business programme for practice managers.

•

Saturday 15th September 2012 9am - 5pm followed by a gala dinner

nt ou w isc no d d ok bir Bo rly a r e ou r y fo

Conference 2014 - Saturday 20th September 2014

£199 per ticket for BCAM members, early bird offer £169 before 1st July (includes a fabulous lunch and coffee breaks) Tickets for guest attending business lectures £149 (includes lunch and coffee breaks)

• Tickets for non BCAM members are Venue: Celtic Manor Resort, Newport, Wales £225 as an early bird special offer and

Main conference speakers include Dr Russell Emerson,• The evening will feature a superb gala dinner on the Professor Alex Drrestaurant. Raj Acquilla more... RiverAnstey, Thames boat Ticketsand for this evening event are just £99 per ticket and will include a welcome drink, four course meal and live music. 7 x workshops by Healthxchange Pharmacy,

Wigmore Medical Ltd, Aesthetics and more... Invitation openMerz to all. Visit www.bcam.ac.uk/

£249 thereafter Don’t miss out on this year’s BCAM Autumn event, Saturday 20th September 2014... Register Now!

£30

www.bcam.ac.uk/ membership/events.asp

membership/events to find out how to register today!

Drinks reception & gala dinner on the Saturday evening

£390 (conference fee , Saturday dinner & accommodation) £250 (conference fee & Saturday dinner)

per pers per works

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Aesthetics Journal

In Practice Patient Retention

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Aesthetics

Holding power: the value of patient retention Gary Conroy explores how the interlinking aspects of your clinic can ensure long-term patient loyalty In recent years we have seen a huge influx of healthcare practitioners developing their skills and starting new businesses in medical aesthetics. While demand from patients also continues to increase, we may now be at a pivotal point in the market place when supply begins to outstrip demand. The global increase in sales of professional aesthetic products in 2012 over 2011 was 7.5%1, with average patient retention decay rates estimated at 10-30%, and an estimated doubling of healthcare professionals delivering services. 2 This is clearly evident with the continued and increasing number of businesses offering ‘wrinkle relaxing injections’ for prices such as £99. Whilst these adverts may be beneficial in recruiting patients they do not appear to show any evidence of recruiting ‘quality’ patients or developing patient loyalty. Because of this, companies such as these continue to require large advertising budgets in order to remain on the patient recruitment hamster wheel. It is necessary for all new businesses to attract new patients the key to any successful business is to keep them, maximising their value and ensuring that they refer new patients to you, from their network. Patient retention and referral is crucial in

ensuring a successful medical aesthetics practice. And as with all successful business journeys, change must start from within.

THE SERVICE-PROFIT CHAIN The service-profit chain, a concept originally developed in the nineties by a group of researchers from Harvard University Business School3, highlights the clear links between: • Profitability • Customer Loyalty • Employee satisfaction and empowerment • Employee loyalty and productivity Each part of the chain should be seen as individual service offerings, but a good understanding of how each offering is dependent on others is crucial to success. In essence, profit and growth are generated by the service offering, which in turn generates customer loyalty – will the customer return to purchase the product or service and will they recommend it to others? This customer loyalty is generated by the customer satisfaction with the service offered – did the product or service meet the customers’ expectations? Customer satisfaction is linked to the service offered, your treatments and the patient’s overall clinic experience, which is provided by employees. In order to achieve customer satisfaction and, in turn, keep patients coming back to your clinic, this service must be provided by satisfied, loyal and productive employees. To ensure this, you as a clinic manager should be asking, do the employees understand their role and feel empowered to contribute and deliver the company’s service offering? Understanding that employee satisfaction is created by the employer’s own service offering is vital. This comprises high quality support, a clear Diagram from ‘Putting the Service-Profit Chain to Work’, the article originally published in 1994 by a group of researchers from Harvard University

The Links in the Service-Profit Chain Operating Strategy and Service Delivery System

Revenue Growth

Employee Retention Intenal Service Quality

External Service Value

Employee Satisfaction

Customer Satisfaction

Customer Loyalty

Employee Productivity workplace design job design employee selection and development employee rewards and recognition tools for serving customers

Profitability service designed and delivered to meet targeted customers' needs service concept: results for customers

retention repeat business referral

Aesthetics | July 2014

In Practice Patient Retention

role description for the employee, and aiding the employee’s personal and professional development.4 It is clear from this business model that happy employees are more productive and deliver better service. This in turn leads to more satisfied patients and patient loyalty and referral, all resulting in growth and profitability for your clinic. To look in detail at the interlinking elements of the service-profit chain is to understand how deploying the use of this model can ensure patient retention:

INTERNAL SERVICE QUALITY To make sure employees are empowered to deliver the best external service proposition it is fundamental that the internal structure is optimal. This means ensuring the following are well understood, implemented and developed within your clinic: • An appropriate workplace for the service to be executed. It would be challenging to ask a marketing manager to run a social media campaign without a laptop, let alone expect them to recruit new patients without an intelligent database. As a manager, you must ensure that your employee works in the optimal environment to carry out their individual responsibilities. • Clearly defined roles. Responsibilities should be clearly understood and measured. As part of their roles, encourage staff to develop relationships with customers – the person answering the phone, responding to emails or delivering marketing communication needs to know what customers want. • Good recruitment. It is vital that the correct people are hired in the first instance, with both existing skill sets and a view to develop these skills to support the company strategy. It may seem like a great idea to hire a marketing manager who has previously worked in advertising sales, but how will they adapt their existing skills to achieve the company strategy? • Rewards structure. A transparent, fair reward and recognition policy within the workplace, which not only financially rewards successful behaviour and contributions, but also supports individual personal development goals, is necessary to maintain good staff moral.

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Aesthetics Journal

Aesthetics

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EMPLOYEE PRODUCTIVITY Employees who feel they belong, and are making a good, recognised contribution are far more productive in the workplace. Staff who feel like this will stick with you, delivering excellent customer service to your patients. To ensure optimal employee productivity, consider the following: • Embrace change. Out of date systems and processes may lead to frustration and impact productivity – encourage open dialogue and empower staff to improve systems. • Have a transparent business. Share company business performance reports, and nurture a culture in which employees take ownership of results. • Encourage self-reflection. Provide tools to allow employees to analyse their own productivity and contribution and encourage implementation of selfidentified areas for improvement. Developing empowered, loyal and motivated employees will allow you to properly implement your “External Service Value”.

EXTERNAL SERVICE VALUE When expectations are met, satisfaction is achieved. Your service proposition should aim to match or exceed patient expectations. • Value drives Customer Satisfaction Value is the direct correlation between the cost of a product or service and how that product or service meets with patient expectations. Therefore, if a patient’s expectations are surpassed at a competitive market price, patients will perceive the service or product as good value. To create high value it is necessary to understand what would surpass or delight your patients, and to do this you must have a deep understanding of their needs and desires through thorough market research. When developing an External Service Proposition for your business it is important to focus on what new and existing customers want to know. More often than not, this is that you care for them personally and that you can fix their problem. Quality patients – the kind that will return to your clinic and become loyal customers – are not looking for low cost wrinkle relaxing. Develop a customer relationship management system for your clinic. Soft data is as equally important as hard medical data when it comes to getting to know your customers. It is reasonable to have multiple external service propositions targeted at different segments within your patient population, or to geographically target marketing for patient recruitment. However beware of having multiple propositions within your main strapline, as this can cause confusion for patients. Pinpoint your patients’ needs by collecting data, and focus your marketing efforts accordingly.

CUSTOMER LOYALTY

Happy and satisfied employees do not look for new jobs elsewhere. Ensure staff know, embody and are involved in developing the company vision and strategy. Give them responsibility for delivering specific tactics relevant to their role. Support tailored packages for personal development and training, and work with your staff to understand their goals. For employees to excel in their roles, ensure they have the right business tools for the job. This may mean access to web developers, marketing agencies, the correct software to implement tactics, and readily available resources for all aspects of their work.

Highly profitable companies are experts in developing a high number of loyal customers, and these are the companies that will have clear strategies and measurement criteria of the customer flow from recruitment to retention to referral. These successful companies will be driven by an increase in repeat, as opposed to new, business. To ensure patient retention, profile all newly recruited customers during assessment. Redesign clinic questionnaires to capture soft data, The 4 R’s and ensure all data captured is stored and Recruitment, Retention, easily accessible. Customer contact and Repeat business and Referrals follow up after initial enquiry, regardless of Your competitor is only 1 mouse click away method, should be after three days, then again after 10 days, again after 14 days Recruitment and then every 30 days. All customers should receive at least four targeted Business & Referrals Retention communications per year following initial Repeat Business transaction – but no more than 12 as this can be overbearing. To gain quality Success: Profit Generated patients, avoid sampling or offering free or discounted offers. Only 3% of patients

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EMPLOYEE SATISFACTION

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will purchase following these offers and 30% will shop elsewhere.5 Increase value proposition through in-depth problem identification (skin analysis, case study examples) and solution-based selling.

CUSTOMER SATISFACTION Loyal patients are loyal because they are satisfied, because they perceive the service or treatments they have received to be of high value, the service has surpassed their expectations, and because their provider understands their needs well at an emotional level. Understanding patient expectation is key to success in your clinic. Involve and empower patients to take part in a journey to achieve goals. This may extend to offering lifestyle, fitness and nutrition advice, and should not be limited to only the services available in your clinic. Ask for feedback from your patients on a regular basis. Focus on one area of your business and ask one open question at a time. Encourage in depth responses and listen actively. Communicate transparently the feedback you have received and what you intend to do about it, celebrate the introduction of new or improved services

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and ask for feedback again.

PROFITABILITY AND REVENUE GROWTH This should be every company’s primary goal, and it is delivered by matching your service offerings to your patients’ needs.. To do this, profile your patients’ income, lifestyle, needs, budget, family circumstances, expectations, hobbies, and interests. Segment your patients based on the above information. Specifically target each segment with tailor-made marketing tactics. Rank your patients: identify your grade A customers – these customers are those which have been loyal longest (20% of customers will deliver 80% profit6) and will be most likely to refer new patients. Involve them in your business and continue to reward them. Loyal customers, loyal staff and referrals are the backbone to any businesses success. Patients are not necessarily looking for low-cost treatments but they certainly want good value from someone who understands them and cares for their needs. Businesses built on poor patient retention and high patient recruitment cannot offer the time and

HILOTHERAPY UK LTD The natural way to faster healing

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understanding required to deliver quality medical consultation and treatment. Successful medical businesses are built on value, quality and patient loyalty. Gary Conroy is co-founder and director at 5 Squirrels Ltd, a company that delivers services and products to meet the UK medical aesthetics requirements. Previously sales and marketing director at Ambicare Health, and head of aesthetic dermatology for Sanofi-Aventis, Gary has over 12 years of industry experience. REFERENCES 1. Kline blogs, Injectibles – The Pointy Edge of the Non-invasive Aesthetic Products Market, but Body Contouring is Shaping it, Feels Kline (http://blogs.klinegroup.com, 2013) < http://blogs. klinegroup.com/2013/10/09/injectibles-the-pointy-edge-of-the- non-invasive-aesthetic-products-market-but-body-contouring- is-shaping-it-feels-kline/> 2. Consulting Room. lorna@consultingroom.com. Market data. 28 Feb 2014. 3. Heskett, James L., Sasser, W. Earl Jr., and Schlesinger, Leonard A., The Service Profit Chain: How Leading Companies Link Profit and Growth to Loyalty, Satisfaction, and Value, The Free Press (New York, 1997) 4. James L. Heskett, Thomas O. Jones, Gary W. Loveman, W. Earl Sasser, Jr., and Leonard A. Schlesinger, Putting the Service-Profit Chain to Work (hbr.org, 2008) < http:// hbr.org/2008/07/putting-the-service-profit-chain-to-work/ar/1> 5. Marsh D. ‘10 pathways to marketing success in challenging times’, Hearing Review, (6(6), 2009), pp. 32-34 6. Newman, MEJ, ‘Power laws, Pareto Distributions, and Zipf’s law’, (arxiv.org, 2006) <http://arxiv.org/PS_cache/cond-mat/ pdf/0412/0412004v3.pdf> [Accessed10 April 2011] (p. 11)

‘Hilotherapy was the best aid to my recovery’ ‘It was a godsend in terms of relief and diminishing the bruised areas’ ‘I believe this has helped to reduce the swelling to my face majorly and also helped with the pain. I would highly recommend it to anyone.’ • Hilotherapy is the simple, clinically tested system that provides natural pain relief and faster recovery post treatment for your clients • This product is now available through our new popular Homecare rental service • Clinics are able to offer the service direct to their clients through our referral programme

Please contact us for more information: 02476 323 372 or homecare@hilotherapyuk.com

In Practice Patient Relations

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Statistics show that the majority of aesthetics patients are female, yet there are still far more male doctors treating them. Learning the nuances of how to connect and engage with women is essential, argues Wendy Lewis

WHAT WOMEN WANT 6 ways to reach female patients Ploughing through the rigours of medical school, followed by years of clinical training prepares physicians with the diagnostic skills and techniques required to treat patients effectively. Regrettably, one thing the process is not programmed to tackle is how to actually deal with real patients. In fact, some physicians have limited insight into how they come across when talking with patients, and little opportunity for formal feedback. While most doctors really are invested in their patients and in making the right decisions for their circumstances, there are still some who lack the skills to show that they care.1 I can recall one of my earliest visits to London to interview plastic surgeons and patients for my first book, The Lowdown on Facelifts and Other Wrinkle Remedies. I met with one businesswoman who had received a facelift that she described as an excruciating experience. I asked if the doctor had given her pain medication – she said that he did but when she asked what it was, he responded, “My dear, just take this pretty pink pill and let me worry about that.” Fast-forward to 2014, and I highly doubt that any woman in the UK would put up with that kind of arrogance from a doctor. So what has changed? Patients want to be treated with respect and care. They demand more than a cursory ten-minute consultation and an attitude of, “I know what’s best for you.” The age-old DoctorGod complex is outdated and, in aesthetics, patients will not put up with it when they have many choices of clinics and practitioners. We all know that men and women differ in their behavioral traits, and this fact should be at the forefront of every practitioner’s approach to dealing with patients, new and existing. Here are six factors that are important to consider when looking to improve and enhance your interactions with female patients:

COMMUNICATION IS A TWO-WAY PROCESS

WOMEN WANT TO FEEL CONNECTED Build a rapport with the patient from the initial encounter. When you first meet her, look her right in the eyes and extend your hand. “Hello, I’m Dr. Black. It’s nice to meet you…” It is vital to establish that personal connection as early as possible in the relationship, so the dialogue and the relationship will flow more freely going forward. Fostering good doctor-patient communications helps to instill trust, encourages patients to be honest and disclose more information, and aids in managing patient expectations and outcomes. Particularly in the field of medical aesthetics, where we are not treating diseases, being a “nice doctor” that female patients have rapport with goes a long way.

BE EMPATHETIC Women need to feel empowered by their relationships with healthcare practitioners. A caring attitude will contribute to a female patient’s comfort in your clinic. A female 60

patient isn’t looking for you to talk her into anything, or solve all of her problems: often she just wants you to listen and empathise, without being judgmental. Try to understand patients’ beliefs, fears, and social and cultural backgrounds. Don’t jump into an analytic, problem-solving mode right away. If you’re not sure what the patient’s goals really are, ask her. You might say, “It sounds like you have some very reasonable questions. Tell me about your priorities, and I will make some suggestions.” Be sensitive to issues from the past as well as to your female patient’s frame of mind. Did she have a bad previous experience with a cosmetic treatment? Is her partner or family not supportive of her desire to have something done? Perhaps this is the first time she has ever considered an anti-ageing treatment and is feeling guilty for spending money on herself. Sensitivity among male doctors is typically judged by female standards, whereas assertiveness is often judged by male standards. Some doctors may become uncomfortable and stern if they feel a patient is trying to control them. This kind of behaviour can be what causes female patients to complain about doctors’ insensitivity.

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Look at the doctor-patient connection as an invitation to keep on talking, listening, and eventually to make a decision as a team. Remember that you are on the same side; this is not an adversarial relationship. Arrive at a plan together so the patient doesn’t feel like she is being talked or persuaded into anything. As men and women communicate with each other differently, it is only natural for men and women to interface with patients of the opposite sex in a different way. You may not even be aware you are doing it. A study conducted in 1970 by Dr. Ray Birdwhistell the founder of Kinesics (also known as body language) at the University of Pennsylvania concluded that 93%

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of human communication occurs non-verbally.2 For example, women are more prone to smiling during an interaction, whereas men tend to be more cautious about smiling, and think of it as more of an emotional (or feminine) expression. Alpha males are also known to point more than women do, which portrays a more dominant role. Opening your hands means that you are ready and willing to act; whereas closing your hands shows an unwillingness. Undoubtedly, doctor-patient communication is going to be affected by gender, even if it is subliminal. The world famous professor of linguistics, Deborah Tannen of Georgetown University in Washington D.C, explored the differences between men and women in her best selling book, You Just Don’t Understand: Women and Men in Conversation.3 She wrote, “For women, as for girls, intimacy is the fabric of relationships, and talk is the thread from which it is woven. Little girls create and maintain friendships by exchanging secrets; similarly, women regard conversation as the cornerstone of friendship.” This should give you some insight as to where female patients are coming from when connecting with an aesthetic doctor. What is important is not the individual topics that are discussed, but the sense of closeness that emerges when she shares her thoughts and impressions. Women want and need to believe that the doctor actually cares about them and that they have formed some sort of bond.

BODY LANGUAGE AND EYE CONTACT It is important to pay attention to non-verbal cues as well as verbal cues. Non-verbal communication is a powerful thing. Your body language speaks to the patient, and this is of course universal, not restricted to gender. Maintain eye contact as much as possible during interactions and stay attentive. Speaking in a professional yet friendly manner will be well received. Never seem distracted or glance at your assistant while the patient is talking. This can make the patient feel that she is not being taken seriously, and sets the wrong tone. Never look at your watch or smartphone, take a call, or walk out of the room unless there is an emergency that requires your immediate attention. Some female patients, especially women in their 50s and over, may feel uncomfortable getting undressed in front of a man, even if he happens to be wearing a white coat and is called “doctor.” To make your female patient feel at ease, be respectful of a woman’s modesty and privacy. Bedside manner is of vital importance in medical aesthetics. During the course of daily practice, verbal and nonverbal communication styles vary, and aesthetic patients have been known to continue or discontinue treatment because of these differences. I would add that it is partially for this reason that aesthetic nurses have done so well in the UK. Due to their training and experience, nurses tend to have a more empathetic ear and their demeanor is less threatening, meaning female patients can relate to them easily.

AVOID A CONDESCENDING TONE If a patient asks what a word means, be aware of the tone you use to further explain details – you don’t want to make the patient feel stupid. If you need to use a highly complex word or phrase, ask whether its meaning is clear. Your tone of voice should be calm and understanding. Every patient deserves to have all their questions answered – no matter how many and how detailed they are. Not answering pertinent questions or making patients feel that they should not be asking you affects the informed consent process that is at the cornerstone of medical practice. For both ethical and legal reasons, patients must be given enough information to be fully informed before deciding to undergo a treatment. The way that the

In Practice Patient Relations

“For women, as for girls, intimacy is the fabric of relationships, and talk is the thread from which it is woven. Little girls create and maintain friendships by exchanging secrets; similarly, women regard conversation as the cornerstone of friendship.” physician explains things can result in disconnect with the patient. Female patients may be nervous and anxious when they are in your clinic talking about such personal issues as wrinkles, fatty bulges, and acne, especially if it is for the first time. Your job is to break down those barriers so they feel comfortable and more relaxed. Speak slowly, deliberately, and unambiguously. Provide information in small bits, without overwhelming patients with lengthy explanations and complicated details, unless asked. Where appropriate, use an iPad, photographs, or diagrams to illustrate the theme you want to convey. Some of the most successful doctors I know use brilliant analogies to describe medical concepts and techniques that resonate well with female patients. For example, the “rock in a sock” analogy for placing oversized implants in a saggy breast. In this instance, the patient knows immediately what you are describing.

LISTEN MORE, TALK LESS Be an active listener. Ask open-ended questions that will engage your patient in conversation. Female patients often complain that doctors do not let them fully explain what they think or feel about their condition. Whilst certain situations warrant a doctor interrupting a patient, it should be done with tact and sensitivity. This is particularly important when a doctor interrupts a patient’s list of concerns or symptoms. Guard yourself against changing the topic or imposing your opinion on the patient while she is still talking. Instead of showing your concern just by giving your opinion and offering solutions, ask questions to probe more deeply into what makes your female patient tick. Be more understanding and congenial, rather than merely offering advice and your opinion. It would behoove all doctors to alter their style in favour of a more feminine or nurturing approach where possible, to adopt a more cooperative form of doctor-patient communication. Every female patient wants more than just to be heard; she wants to be understood in terms of her thoughts, feelings, and fears. Despite all the marketing tactics you may employ to promote your clinic, word-ofmouth referrals, from one patient to another, is still the most successful approach to attracting new patients, and currently, the majority of these new patients will be female. Learning how to speak to your majority audience is therefore essential to secure a thriving practice. Wendy Lewis is president of Wendy Lewis & Co Ltd, Global Aesthetics Consultancy, the author of 11 books on anti-ageing and cosmetic surgery, and founder/editor in chief of Beautyinthebag.com. She is an international presenter and lecturer and has written over 500 articles for medical journals and consumer publications. REFERENCES 1. Gillian Timothy and Sekeres, Mikkael, ‘Can Doctors be Taught How to Talk to Patients?’ (The New York Times, 2014) <http://well.blogs.nytimes.com/2014/02/27/can-doctors-be-taught-how-to-talk-to- patients/?_php=true&_type=blogs&_r=0> 2. Ray L. Birdwhistell, Kinesics and Context, (Philadelphia: University of Pennsylvania Press, 1970), p. 80. 3. Tannen, Deborah, You Just Don’t Understand: Women and Men in Conversation (William Morrow Paperbacks, 2007)

Aesthetics | July 2014

In Practice Treatment Menu

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Tailoring your treatment menu Dr Rita Rakus on how to ensure you are offering the treatments your patients want Getting your clinic treatment menu just right is vital in order to maximise the results for your patients and maintain safety. You need to think of your menu as one of the first steps in your customer satisfaction programme but it is most certainly a twopronged approach. You must find both the treatments that attract new clients and those that keep existing clients coming back for more great results. It is essential that you are at the front of cutting edge technology and keep up to date with the latest innovative treatments. Get to know your customer It is important to get to know your client base and those that live in your area to ensure that not only is your pricing spot on, but also that your offering is in tune with

what they need and/or want. If your offering is compelling enough you can become a ‘destination clinic’ that patients will make the effort to travel to for its unique offering or reputation. We are lucky enough to have both categories in our client database, with some travelling from far-flung countries to see us. To start with, price speaks volumes – too cheap can incite an element of distrust and high price points can obviously also be off-putting if they do not seem to be justified. But the terms ‘cheap’ and ‘expensive’ are subjective as it really depends on your audience. One thing is for sure, bargain basement treatment prices can sound incredulous and many package deals, offers and discounts are unethical and certainly don’t inspire confidence in

Price speaks volumes – too cheap can incite an element of distrust and high price points can obviously also be offputting if they do not seem to be justified. 62

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customers. Put simply, if it’s not safe or effective, good customers will not part with their hard earned cash no matter how much it costs. If customers aren’t absolutely sure the treatment will get the desired effect, it’s a no go. During my time in the aesthetics industry, I’ve learnt that media interest, celebrities and other people in the public eye create interest amongst consumers. We all want to know what the A-listers are opting for and we like the latest and most efficacious options. Don’t be fooled though, celebrity sparkle doesn’t mean that you can name your price; the treatment has to work and be within your patient’s budget. What to offer It’s a good idea to have something for every skincare complaint, including retail home-use options so that patients can carry on the good work and care for their skin post-treatment. We are lucky enough to be able to offer some really potent products that can’t be bought in high street stores. Customers can rely on us to give them the very best in the market when a clinician isn’t available. Face and body treatments can complement each other; more often than not if a client is looking neck-up to solve skin issues then it’s likely that they will look neck-down once those are corrected. Establish trust and you may find there are lots of other issues to tackle, which makes this patient a valuable long-term customer. Most non-surgical clinics today need a combination of modalities e.g. lasers, radio frequency, ultrasound, peels, skincare and fat busters, and combining packages to maximise results can be very effective. Most manufacturers will offer PR support and when treatments appear in the press, lots of new patients contact the clinic asking for these specifically. It’s a good idea to check what kind of promotion the brand does before you purchase their machine – you don’t want to be left with an expensive piece of equipment in your clinic that nobody’s interested in. Tracking Success This sounds very obvious but you would be surprised how many clinics don’t bother tracking how successful each of the treatments they offer are with their customers, and how much new interest they generate. Once you know something is working well for you, take action to make the most of this. Do you need two therapists trained to provide the treatment instead of just the one? Is it a good idea to invest in

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another piece of equipment to double up appointments? Is there a complementary treatment that you can bolt on before or after to enhance the results or tackle a neighbouring area that needs work? Are there any windows of time that you can fill with a facial or a peel to maximise the client’s end result before they leave your clinic? You have a finite period of time with each patient to achieve the desired result and impress them so much that they want to come back. Competition The worst possible thing you can do is try to replicate what a local clinic is doing nearby – you can aim to offer something similar, but your treatment and service has to be better. Ensure that you are aware of your competition and monitor what they are doing, and not doing, in order to set yourself apart. When speaking to suppliers and distributors, don’t be afraid to ask where they stand on exclusivity. Enquire whether if you buy their machine, they could guarantee that nobody in the surrounding area will have the exact same offering.

In Practice Treatment Menu

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Find Your Niche What are you and your staff interested in predominantly? You’ll find that those treatments are the ones that they excel in and this will come across to your clients. It may be worthwhile to address what skills your team is lacking when you make your next hire. If you only have one laser specialist, the chances are that you are not maximising a business opportunity. If you find yourself without an expert for a specific treatment then start your search for the perfect fit for your clinic fast and watch your numbers grow. Quality Control Your treatment offering has to be the best and the minute something new and improved is launched and widely publicised, your clients will want to try it. Keep an eye on consumer magazines and newspapers to know what people are going to be talking about and what patients might request. You should read clinical publications and studies and collaborate with your peers to find out

what treatments are seeing particularly positive results. I visit experts all around the world to know what is happening outside of London. If you ever find that your equipment isn’t performing as well as it once was then you can be sure that by the time you’ve noticed it, 10 of your customers have. Don’t be complacent – you are only as good as your last patient result. You shouldn’t try to stop your clinic evolving; the industry is changing all the time and so must you. If you are completely replacing one treatment for another, just be sure to communicate why to your regular customers and show them why it’s better for them. Don’t expect them not to notice. Dr Rita Rakus has over 20 years of experience specialising in non-invasive cosmetic solutions for face and body rejuvenation, dubbed by the media as ‘The London Lip Queen’. Dr Rakus is a fellow of British College of Aesthetic Medicine, and is involved in training within the field. She has a clinic in Knightsbridge.

EXCITING CAREER OPPORTUNITY REGISTERED GENERAL NURSE Due to continued expansion an exciting opportunity has arisen for a dynamic, self-motivated qualified nurse to join our busy aesthetic non-surgical clinic at the prestigious Knightsbridge centre.

EXPERIENCE OF WORKING WITHIN THE PRIVATE HEALTH SECTOR IS ESSENTIAL EXPERIENCE IN AESTHETIC TREATMENTS IS DESIRABLE, BUT FULL TRAINING WILL BE GIVEN

This unique role combines practical nursing skills with day-to-day administrative duties. Specific responsibilities include, but are not limited to:

• • • •

• • • • • • • •

Assisting doctor with Thermage, Fraxel, LipoSonix, Pelleve, IPL, IntraCel, BodyJet, Ulthera and other non-surgical treatments Pre and post treatment care of patients Pre and post treatment photography General office duties Maintenance of the computerised patient database Filing and record keeping Interface with patients to ensure that the highest customer service standards are maintained Willingness to perform any other duties as specified by the Clinic Manager to ensure the high standards of the clinic are maintained

Essential qualities are: Excellent telephone manner • Ability to work well under pressure Excellent communication skills • Reliability and trustworthiness Computer literacy • Self-motivation, but a committed Flexible approach to hours of work team player hours • Discretion and confidentiality • Interest in skin care and designing patient treatment programmes The Rewards:

•

• Excellent remuneration package • Friendly working environment • Flexible hours of work 25 days annual holiday plus bank holidays

If you are interested in applying for the above position please e-mail your c.v. plus a covering letter outlining why you feel you should be considered for the position together with a current photograph of yourself to Barbara Deakin, Clinic Manager at drrita@drritarakus.com

In Practice Leadership

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What makes a successful leader? Business specialist Alan Rajah shares his advice on how to be a successful business leader in medical aesthetics I imagine that at some point this year you may take a step back to reflect on your current career position. This, of course, will be different for everyone as we all have personal aspirations and goals. Many of you may have been in practice for some time and are looking for your next career move, for others, you may have reached the pinnacle of your career and be in the process of identifying a successor to take over your practice, and looking to establish long-term goals. Each of us has all the characteristics of a successful business leader, but it is up to you to explore or enhance your individual skills. Here, I will provide eight key insights that will help you to lead your business forward successfully. Utilise your team In order for an aesthetic medical association, society or organisation to thrive, you and your colleagues/employees should have a common goal – to be as successful as possible. In this fast-moving and complex industry, no-one will have the ability to effectively plan and achieve organisational goals entirely on their own. Collaboration with a variety of people with specialist knowledge, skills and expertise is essential in obtaining unique insights and perspectives. Encouraging open communication and involving colleagues in the decision making process is key to future success and progression as a team. Accept responsibility for your failures Where there are ups, there are also likely to be some downs. When the latter happens, the sign of a true leader is one that accepts responsibility for these failures. This may be anything from a patient complaint to disappointing profit margins. Blaming others does not solve problems and can potentially create a culture of mistrust with fellow colleagues. Use these experiences as a learning curve for yourself and your business as a whole. What can you do in future to avoid this happening again? 64

Have a positive attitude Positivity is contagious and it is a fact that when people are happier they tend to be more focused and successful. If a person exudes anger, it can have a negative impact on everyone around them. Adopt a positive attitude to motivate your team. If a particularly difficult patient is being rude to staff, assure employees that they should not take this personally and politely address the situation with the patient. Embrace change To be successful, you must not fear or deny change but tackle it head-on. As one of the fastest growing industries, medical aesthetics will continue to be subject to remarkable change and sometimes embracing this is one of the hardest and scariest things to do. Keeping up to date with the latest trends, consumer demands and competitor behaviours will ultimately force you to do things differently. Having the courage to experiment is not always easy; it requires personal courage and a strong sense of determination. But whatever the outcome, you will know that it was worth trying, and valuable lessons will be learnt in the process.

most successful business leaders in any field. There’s no time like the present for getting goals down on paper. These could be anything from increasing your patient numbers, to winning an achievement award for your clinic. Give credit to others for their hard work Teamwork is the key to success. When working with other practitioners or therapists, always acknowledge the great work they have done. Letting others have their own victories and moments to shine will motivate them to perform to a much higher standard and improve their skills. Admitting that your associates may have come up with a better idea than you demonstrates a willingness to look at all points of view and treat others as joint collaborators. In the long term, this could earn you a great reputation as a manager.

Focus on new and exciting ideas Successful people engage with those around them to discuss ideas and welcome new points of view that challenge their own. This creates a positive and inclusive atmosphere, where everyone within the business is in the pursuit of a common goal. Your colleague or business partner may want to try offering a new product or treatment. Discuss both your preferences in depth and come to a decision based on what would be best for your patients, and thus your business.

Share information and data Sharing knowledge is another key ingredient to success. When you share information and data with others, it can reveal insights and allow you to create a vision for your practice or organisation. It could also help avoid stagnation and influence competiveness within your industry. Keeping information to yourself is counter-productive and is only likely to aid small, short-term gains. Often, those working in aesthetics are in a unique position, having trained in areas removed from the typical leadership or management disciplines. This training could be beneficial, offering a wealth of innovative insights. Utilise your experience in order to maximise your business’ potential within the aesthetic market, and establish your reputation as a forward-thinking aesthetic leader.

Set goals and plan ahead To become successful you need to know where you are heading. Whether it’s compiling a daily goal list, annual strategic plan, three-year forecast or a ten-year plan, all of these are useful tools used by the

Alan Rajah is a business specialist at Lawrence Grant Chartered Accountants. He has specialist knowledge of clients in the medical profession and deals with the specialist tax and compliance issues facing doctors, consultants and other medical professions.

Aesthetics | July 2014

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In Practice In Profile

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“Every milestone is a proud moment” Dr Tapan Patel is founder and director of Viva and PHI clinic. A leading cosmetic doctor in the UK and KOL for numerous aesthetic companies, Dr Patel details his journey into aesthetic medicine Whilst training in hospital medicine and just starting his GP career, a conversation with an old friend encouraged Dr Tapan Patel to re-think his medical speciality. In 2000, he met up with Dr Mike Comins, president of the British Association of Cosmetic Doctors and a close friend of Dr Patel. “We were having a chat and he told me about Botox – I have to admit I didn’t even know what Botox was at that point – other than something we used in hospitals for treating muscle spasm,” he says. When Dr Comins explained he was using it for cosmetic procedures, Dr Patel admits he found this a little strange. “I didn’t anticipate there would be a market for this, so he encouraged me to do a training course.” He found the half-day, hands-on botulinum toxin course fairly basic and unstructured, but for the next five years, Dr Patel continued his training – learning how to inject collagen and hyaluronic acid, whilst building his patient database by renting rooms in various clinics. His reputation was gaining traction and soon Dr Patel was receiving calls from friends of patients who had recommended him. “At that time I was running my clinic with a mobile phone and a paper diary,” he explains. “I was my own receptionist, my own bookkeeper and I ordered my own stock.” In 2005 Dr Patel took a lease on a clinic in Golders Green, with just two treatment rooms and a shared reception. He bought his first laser and focused on skin resurfacing, hair removal and injectables. By 2008 he had bought a second clinic and was expanding the treatment menu. “Around that time I found I was getting busier and busier. The growth from 2008 to 2011 was just huge,” he says. Dr Patel’s public profile had also begun to grow, and he found himself frequently asked to give training courses and speak at industry events. “I absolutely adore speaking and travelling,” he says. “I thrive on it.” But in 2012, with over 40 trips abroad, he admits it got 66

excessive. “It was a great experience but I realised I had to cut back to concentrate on developing the clinic.” Dr Patel classes the opening of his PHI clinic in Harley Street earlier this year as one of his biggest achievements to date. “But every milestone is a proud moment,” he says. “Injecting my first patient, purchasing my first device, speaking on a podium for the first time were all huge milestones for me.” There are lots of positives and opportunities for practitioners starting off in the aesthetics industry today, notes Dr Patel. “The advance in technology and communication means they don’t have to do the same donkey work that we had to do back then. We would sometimes learn a technique only to find a few months later that it wasn’t as good as we thought and have to discard it.” But looking back, Dr Patel says he wouldn’t have done anything differently. “Every time you make a mistake you learn from it. Everything shapes what you do in the future.” He advises newcomers to have patience learning new skills, and believes an appreciation for art and beauty is essential in medical aesthetics. “I think there’s not a successful practitioner in the industry that doesn’t have an eye for beauty,” he says. For Dr Patel, drawing helps him study and gives him a better idea of the proportions and anatomy of the body. “What we do is a hybrid of art, science and commerciality but it is important not to lose sight of the fact that it is a field of medicine,” he says. “I do believe that the consumers are patients not clients, I believe that we are medical practitioners first and foremost and not simply technicians.” After a busy few years, Dr Patel is focusing on sustaining his clinic, pursuing excellence and contributing as much as he can to training practitioners. “In terms of the clinic, getting it up and running is one thing, but making sure that it can be a centre of excellence is something that takes years to achieve.” Aesthetics | July 2014

Q&A What treatment do you enjoy giving the most?

Volumising the face with hyaluronic acid fillers – it’s something I feel I’ve honed my skills on. There’s definitely an art to it. What’s your favourite tool?

I use a lot, more than 35 devices. One thing I couldn’t do without is a small gauge needle. Perfectly put, it’s an extension of my arm. What’s the best piece of advice anyone has given you?

Dream big, don’t limit yourself, you’ve got to stretch yourself. My father said that. What is your number one pethate of the industry?

Practitioners who have a reluctance to share their skills or expertise. I’ve always found that I have the greatest respect for those people who are good at what they do, but also have the generosity to share that with new practitioners. What aspect of the industry do you enjoy the most?

Seeing it expand over the years – that feeling that I was in it at an early stage. Now you could argue it’s been around for hundreds of years or a couple of years, but it’s really ballooned with the popularisation of botulinum toxin, that’s something I’ve really enjoyed. Do you have an ethos you practise by?

No compromise on quality or excellence. I like to feel that I’m constantly in a pursuit of excellence.

“The day with Mr Dalvi Humzah was fantastic. I learned so much and came away buzzing! I hope the other teaching days are of this standard - you’ve set the bar high!” First year student

School of Medicine and Dentistry

MSc Non-Surgical Facial Aesthetics (NSFA) for Registered Healthcare Professionals (3 Years Part-time) Taught online and with face-to-face study days that fit around your working life.

Supervised clinical work on patients takes place at our state-of-the-art, on-campus clinical facility. A unique, evidence based programme of study, offering a valuable educational and clinical experience. Topics include: • Anatomy for non-surgical facial aesthetics • Foundation Dermatology for facial aesthetic practitioners • The ageing process • Patient assessment and treatment planning • Consent and medico legal issues • Science and pharmacology of toxins and fillers

• Injectable therapies • Laser and light based therapies • Physical and chemical rejuvenation • Adjunctive therapies • Medical emergencies • Clinical practice in non-surgical facial aesthetics

www.uclan.ac.uk/nsfa cenquiries@uclan.ac.uk • 01772 892400 Course starts January: Apply now Find out more at one of our Advice Events taking place in October, November and December 2014 www.uclan.ac.uk/med-dent

In Practice The Last Word

@aestheticsgroup

Aesthetics Journal

The last word Clinical nurse specialist Sharron Brown argues that patient education must be a priority for all practitioners in medical aesthetics

Ageing is an unavoidable fact of life. However, with such easy access to information via the media and internet, is it any wonder that patients’ expectations have become more unrealistic regarding what is and isn’t achievable to slow down the appearance of ageing? In today’s modern world, with the emphasis on remaining ever youthful, we live in a consumerist society where instant gratification is the norm. Media messages through advertising, makeover programmes and beauty pages influence patients before they walk through the clinic door and I find that increasingly, patients will bring their own sourced information to the consultation. As professionals it is unethical of us to merely grant the patient’s desires without educating them first on procedures and products available to enhance, treat or correct the issues concerning them. The challenge for us as practitioners is reduce the potential harm caused by erroneous information, available to patients via multimedia. One of the key areas of patient education is informed consent. The consent form should act as an aide-memoire; a check-list of important information and a description of the benefits and risks provided to the patient before they are expected to make the decision to go ahead with the treatment. The consultation process and consent form should provide the patient with everything that they need in order to know exactly what is involved in the treatment that you are recommending, realistic outcomes for them, what complications might occur and information about other options they could consider. Furnishing the patient with clear and relevant knowledge means giving them the autonomy to make more informed choices rather than risk being swayed by outside influences such as friends, partners, 68

advertising or society at large. Unlike other medical pathways which are accessed via the NHS, often by referral from another healthcare provider, our patients are also consumers. Therefore effective communication is crucial because the individual seeking non-surgical cosmetic treatment is usually medically healthy and may not associate the chosen treatment or procedure as having a medical basis or be aware that there will be unavoidable risks such as swelling or bruising. The treatments we do are medically based with clearly documented positive and negative outcomes that must be made clear to our patients. An article in the Gallup Business Journal in 20101 stated that all that patients want is the fulfilment of four psychological elements; Confidence reflects the belief that the patient can trust you or your clinic to deliver on its promise. Integrity reflects the belief patients will be treated fairly and that any problems that might occur will be resolved, or an acceptable resolution reached. Pride reflects the degree to which a patient feels good about using you or your services and how using those services reflects on them. Passion reflects the belief that your practice is irreplaceable and an integral part of the patient’s life. Patients want to be treated by someone who embodies all of these characteristics and who takes personal responsibility in delivering clinical excellence. By fulfilling these four emotional needs, you have the basic requirements for a good service and overall medical care, which goes a long way towards creating a positive patient experience. Engaged and informed patients tend to have better experiences because their journey to achieving a realistic Aesthetics | July 2014

Aesthetics

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result is one that is physically, psychologically and emotionally rewarding. Globally we are living longer, and as medical professionals we should be educating our patients on how to preserve and maintain the health of the body’s largest organ. As nurses and doctors working within this specialty we should have the appropriate training and education to identify risk factors, along with early detection of skin disease. It is our duty to encourage the patient to adopt lifestyle changes that, over time, will improve skin integrity and reduce risk factors to their health. The anti-ageing industry should not just be about ameliorating lines and wrinkles, instead a holistic approach should be taken to preventative medicine and our patient’s health. In this respect, an evidence-based approach is vital. Evidence based medicine does not limit choice, in fact it increases and complements our clinical expertise, which in turn allows us to extend that to the people who we treat. When applied to individual patient care, it takes into account desires, concerns, biology, anatomy, resources, skills and experience. Treatments and techniques supported by robust evidence only improve the art and science of cosmetic treatments and the overall care of our patients. Developing patient reported measures, by questionnaires or an interview regarding final outcomes, along with pre- and postprocedure photographs, goes some way to quantifying these subjective endpoints. Patient education is paramount. Assessing motivations and expectations during the consultation period, and being honest and transparent in the information that we share with our patients, leads to realistic outcomes and patients who are able to make better choices regarding the available treatments. This will not only provide a better experience for the customer but will also instil loyalty in our patients who will see that we are ethical practitioners, concerned with their emotional and physical well-being. Sharron Brown works in the NHS for Pan London Facial Lipoatrophy Service as a specialist nurse correcting HIV related facial lipoatrophy. She is also an independent aesthetic nurse and sits on the membership board as secretary of the BACN. She has been involved in research and writing papers and is on the Sculptra Advisory Board. REFERENCES 1. Jennifer Robison, What is the “Patient Experience”? (Gallup Business Journal, 2010) http://businessjournal.gallup.com/ content/143258/Patient-Experience.aspx [accessed 09/06/14].

International Faculty already includes: Dr Patrick Tonnard, Dr Lorne Rosenfield, Dr Patrick Trevidic, Dr Foad Nahai, Dr Alain Fogli, Prof Wolfgang Gubisch, Dr Malcom Paul, Dr Raj Acquilla, Dr Raina Adami, Dr Nick Lowe Non-Surgical and Surgical Conferences Insight and expertise from a world-class speaker line-up NEW Dermatology Lab The science behind skin and skincare NEW Surgical Training Dome Interactive, hands-on learning for trainee consultants Live Demonstration Theatre Non-Surgical technology and techniques in action Injectables Masterclass Live, close-up expertise The Business Hub Advice to improve business outcomes Surgical & Non-Surgical Technology Workshops Preview the latest tools and technology Great Live Debate Theatre Controversy, opinions and insights aired Networking Drinks The key industry social Major Scale Exhibition 200 exhibiting companies CPD Accredited Content

SURGICAL & NON-SURGICAL. TWO WORLDS, ONE EVENT. CCR Expo is a major scale showcase for aesthetic medicine professionals, packed with CPD accredited content and featuring over 200 exhibitors and 4,000 visitors. From scalpel to syringe CCR Expo provides a professional platform for the exchange of ideas, the pursuit of best practice and the sharing of knowledge, insight and expertise.

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References: 1. Galderma Restylane fillers Data on File (4). 2. Galderma Restylane fillers Data on File (5). RES/018/0514 Date of preparation May 2014