Aesthetics March 2015 by Aesthetics & CCR

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We weigh up the pros and cons and uncover the latest developments in vitamin infusion

Dr Hilary Allan highlights the best method of perfecting the patient experience

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Contents • March 2015 06 News The latest product and industry news 14 On the Scene Out and about in the industry this month 16 Conference Report We report on the International Master Course on Aging Skin (IMCAS) conference in Paris

Special Feature Treating an Aesthetic Patient Page 21

18 News Special A final preview of the highly anticipated ACE 2015

CLINICAL PRACTICE 21 Special Feature: How to treat an aesthetic patient We ask three aesthetic practitioners to assess the same patient and share their individual approaches 27 CPD Clinical Article In a two-part weight loss special, Dr Sotirios Foutsizoglou gives an introduction to managing obesity 34 Spotlight On: Plexr Soft Surgery We look at the latest advancements in non-ablative technology 39 The Vitamin Drip Debate Allie Anderson investigates the growing trend for vitamin infusion 42 Anatomy of the Eye Dr Sabrina Shah-Desai provides an overview of periorbital anatomy 47 Patient Satisfaction Dr Beatriz Molina outlines her role in recent research on measuring patient satisfaction 48 Hair Transplant Techniques Dr Greg Williams on current treatments to restore hair and reconstruct previous procedures 52 Advertorial: SkinCeuticals SkinCeuticals invite you to discover their Vitamin C antioxidant range 53 Abstracts A round-up and summary of useful clinical papers

IN PRACTICE 54 The Patient Journey Dr Hilary Allan on the factors that create the perfect patient experience 56 The Art of Sharing Knowledge D Kieren Bong details the best methods of sharing knowledge 60 Hiring Staff Victoria Vilas explains how to pick the right candidate for the job 63 Partnership Agreements Shubha Nath outlines the key points to keep in mind when working with a business partner 65 The Mobile Revolution Tracey Prior on why your practice should be mobile-ready 66 In Profile: Emma Davies We talk to aesthetic nurse Emma Davies about her successful journey into the world of aesthetics 68 The Last Word: Training in Dermatology Dr Paul Charlson argues the importance of dermatological training for aesthetic practitioners

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Patient Experience The Patient Journey Page 54

Clinical Contributors Dr Sotirios Foutsizoglou specialises in minor cosmetic surgery and aesthetic medicine. He is founder and medical director of SF Medica, and has lectured and presented on various topics both nationally and internationally. Dr Tapan Patel is the founder and medical director of VIVA and PHI Clinic. With more than 14 years of clinical experience, he is passionate about standards in aesthetic medicine and regularly participates in active learning. Mr Adrian Richards is a plastic and cosmetic surgeon. He is the clinical director of both Aurora Clinics and Cosmetic Courses, the largest non-surgical training provider in the British Isles. Dr Tamara Griffiths is a consultant dermatologist and honorary lecture at the University of Manchester. She is also clinical research lead and director of the MSc in Skin Ageing and Aesthetic Medicine. Dr Sabrina Shah-Desai is an oculoplastic surgeon specialising in eyelid lifts, ptosis, and revision eyelid surgery. She is highly experienced in non-surgical periorbital rejuvenation. Dr Beatriz Molina is a member of the British College of Aesthetic Medicine (BCAM) and founder of the Medikas Medispa Clinic. She also teaches techniques for botulinum toxin administration. Dr Greg Williams is a hair transplant surgeon and member of the British Association of Aesthetic Plastic Surgeons (BAAPS). He has more than 10 years of experience in hair restoration procedures.

NEXT MONTH

• IN FOCUS: Smile • Managing Obesity • Treating the Lips • Advances in Laser

Aesthetics Conference and Exhibition 7-8 March 2015 www.aestheticsconference.com

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

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Editor’s letter One fundamental truth of the aesthetics industry is that without patients we have no business, and no working practice. This means that the work of nurturing a patient, and taking care of their experience from start to finish is essential in ensuring continued practice, and Amanda Cameron continued success. Every patient is different, Editor and the approach to each individual must be customised as such in order to fully embrace the notion of the ‘patient journey’ – a term often used but not nearly so often fully considered and accommodated for. This issue is dedicated to the idea of the patient experience. The factors that contribute to this, and how they should be exercised in order to ensure patients feel cared for and satisfied. Dr Hilary Allan leads the exploration in In Practice by addressing the in-clinic elements that together create a positive and long-lasting impression on your patients – from reception comforts to members of staff with dedicated roles for patient care (p.54). Dr Beatriz Molina underlines the importance of documenting and measuring patient satisfaction in aesthetic research (p. 47), and our In Profile practitioner, nurse independent prescriber Emma Davies, stresses the importance of a measured and thorough approach to patient care – warning against

a ‘factory’ type approach to consultation and treatment (p.66). For our Special Feature this month (p.21) we asked a surgeon, dermatologist and cosmetic doctor to share their individual approaches to treating the same patient. Their answers are illuminating, and express the wide breadth of our practice. March sees all our ACE 2015 planning come to fruition, after months of hard work and incredible contribution from leading names in the aesthetics speciality. The first weekend of March will see top names – the latest of these being renowned aesthetic pioneer Dr Arthur Swift – engage in interactive and educational sessions and ground-breaking debate at the Business Design Centre in central London. We are extremely proud to present the four key sessions that comprise the conference’s Main Agenda; including body image and fat treatment, injectables to treat the upper and lower face, and dermatology with a focus on the patient. For those attending – be prepared to brush up on your anatomy! New technology this year allows for audience participation, enabling you to vote on aesthetic issues whilst observing treatment from all angles with the aid of a three-screen stage. There is still time to register; visit www. aestheticsconference.com now. In the meantime, we love to hear your feedback issue by issue, so make sure to send us your thoughts @aestheticsgroup or email us at editorial@aestheticsjournal.com

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

Dr Raj Acquilla is a cosmetic dermatologist with over 11 years

British 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.

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 Dalvi Humzah is a consultant plastic, reconstructive and

Dr Tapan Patel is the founder and medical director of VIVA

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.

and PHI Clinic. He has over 14 years of clinical experience and has been performing aesthetic treatments for ten years. Dr Patel is passionate about standards in aesthetic medicine and still participates in active learning and gives presentations at conferences worldwide.

Sharon Bennett is chair of the British Association of

Mr Adrian Richards is a plastic and cosmetic surgeon with

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).

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.

Dr Christopher Rowland Payne is a consultant

Dr Sarah Tonks is an aesthetic doctor and previous

dermatologist and internationally recognised expert in cosmetic dermatology. As well as being a co-founder of the European Society for Cosmetic and Aesthetic Dermatology (ESCAD), he was also the founding editor of the Journal of Cosmetic Dermatology and has authored numerous scientific papers and studies.

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

PUBLISHED BY EDITORIAL Chris Edmonds • Managing Director T: 0203 096 1228 | 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 • Assistant Editor 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 Hazel Murray • Journalist T: 0207 148 1292 hazel@aestheticsjournal.com

ADVERTISING Hollie Dunwell • Business Development Manager T: 0203 096 1228 | M: 07557 359 257 hollie@aestheticsjournal.com Sadia Rahman • Customer Support Executive T: 0203 096 1228 | support@aestheticsjournal.com MARKETING Marta Cabiddu • Marketing Manager T: 0207 148 1292 | marta@aestheticsjournal.com EVENTS Helen Batten • Events Manager T: 0203 096 1228 | helen@synaptiqgroup.com Kirsty West • Assistant Events Manager T: 0203 096 1228 | kirsty@synaptiqgroup.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 Sadia Rahman; support@aestheticsjournal.com © Copyright 2015 Aesthetics. All rights reserved. Aesthetics Journal is published by Synaptiq Ltd, which is registered as a limited company in England; No 3766240

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Talk Aesthetics #PatientEducation BAAPS Press Office/@BAAPSMedia BAAPS Prez Michael Cadier: “[Patients] are doing their research, taking their time and coming to us with realistic expectations.” #Finally #USA Dr. Harold Lancer/@DrLancerRx What happens in Vegas never stays in Vegas! Happy to be at @nordstromlv today sharing the Method & how to #getyounger #FaceOff Dr Vidhya Maheswaran/@DrVidhyaM @aestheticsgroup I am seriously looking forward to ACE 2015! ‘Face off’ & ‘Getting into the zones’ is on my agenda. #Ambition Dr Tapan Patel/@drtapanp When Alexander saw the breadth of his domain, he wept for there were no more worlds to conquer. What are your goals? #ambition #motivation #ACE2015 The Banwell Clinic/@banwellclinic The Banwell Clinic is proud to share that Paul Banwell FRCS (Plastic) will be a Key Speaker at ACE 2105 (7/8th March). @aestheticsgroup. #Journal Look & Feel Younger/@DrTerryLoong @LornaBowes great article on the role of moisturisers in @aestheticsgroup magazine. #Training Facial Anatomy/@facialanatomy @pdsurgery Busy year ahead for bespoke Facial Anatomy Teaching! Exciting plans ahead! #awardwinning

To share your thoughts follow us on Twitter @aestheticsgroup, or email us at editorial@aestheticsjournal.com Psoriasis

Cosentyx approved for psoriasis treatment in US and Europe Consentyx has become the first interleukin-17 prohibitor to be approved for use in the treatment of psoriasis, both by the FDA and the European Commission. Cosentyx is also the first biologic agent to be cleared for front-line use in the EU. Trials indicated that Cosentyx had 100% or 90% clearance on the psoriasis area and severity index, in 70% or more of treated patients within 16 months of starting treatment. Head of Novartis Pharmaceuticals David Epstein said the approval marks “a turning point for psoriasis patients, who can now benefit from the first and only approved treatment targeting the IL-17 pathway, proven to play a key role in the development of plaque psoriasis.”

Aesthetics Journal

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ACE

Dr Arthur Swift to present at Merz Live Demonstration Zone as part of ACE 2015 It has been confirmed that renowned practitioner and trainer Dr Arthur Swift will be joining the line-up at the Merz Live Demonstration Zone, as part of the Aesthetics Conference and Exhibition (ACE) weekend in March. Dr Swift will be launching Belotero+ Volume and joining a panel of specialists to discuss safety in the industry. The renowned practitioner will also be joining the Main Agenda at the highly anticipated conference, where the main programme will include leading practitioners Dr Raj Acquilla, Dr Tapan Patel and Mr Dalvi Humzah presenting on stage together for the first time. Joining Saturday afternoon’s ‘Face Off’ module, Dr Swift will be aiding the trio to present the best and most innovative techniques in facial rejuvenation today. Dr Raj Acquilla said, “I am delighted to welcome my dear friend and colleague Dr Arthur Swift to the ACE faculty. We are honoured to have him join us for our first live injection symposium where he will showcase his unique approach to creating the Beautiful Upper Face using a S.A.F.E. anatomical technique.” He added, “This will be a true masterclass in facial aesthetics and a great learning experience not to be missed for injectors of all levels.” ACE 2015 will take place on March 7 and 8 in Central London. For full information and to register visit www.aestheticsconference.com Industry

GMC considers action against individuals involved with private practice cash referrals Following the exposure of six-figure incentive packages to doctors for patient referrals to private hospitals, the UK General Medical Council (GMC) have condemned the practise as wrong. The news comes in lieu of the revelation published by the British Medical Journal (BMJ) that, allegedly, private hospital chains have been ‘buying’ referrals to their facilities; by offering practitioners up to £100,000 in rewards and incentive packages. Though the Competitions and Marketing Authority (CMA) had ruled that rewards and cash incentives for patient referrals must end in April last year, since being formally exposed in 2011, it was found that the practise had not ceased while the inquiry was on-going. The BMJ reported that one surgeon had recently approached them claiming he had been offered a six-figure package for patient referrals after the CMA had ruled that such practise was detrimental to patient welfare. The BMJ further reported that independent practices, including ones in Harley Street, were offered free rents in return for referrals to the private hospitals. In a statement from the GMC, chief executive Niall Dickson said, “The GMC takes very seriously the issue of conflicts of interests. That is why we have clear and unambiguous guidance in Good Medical Practice that doctors must be honest in financial and commercial dealings. Our guidance states that doctors ‘must not allow any interests you have to affect the way you prescribe for, treat, refer or commission services for patients.’” The GMC are now completing an internal review of the CMA that highlights the potential for conflicts of interest to arise when doctors refer patients for medical treatment. “When that is complete, we will be writing to all independent healthcare providers and their Responsible Officers seeking assurances from them that they have responded to the report and that they are not operating any schemes that could place their doctors in a position where they could be acting outside our guidance,” said Dickson.

Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015

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Surgical

Aesthetics Technology

Popularity of cosmetic surgery declines The British Association of Aesthetic Plastic Surgeons (BAAPS), has announced that the demand for cosmetic surgeries has dropped by 9% since 2013. According to BAAPS, the top ten surgical procedures performed on both men and women in 2014 totalled 45,406, compared to 50,122 in 2013, and their order of popularity has shifted for the first time in five years. Although breast augmentation procedures remain the most popular cosmetic surgery choice in the UK, demand for the procedures dropped by 23% in 2014. Breast reduction surgery, however, increased by 3% in women and 1% overall. Rhinoplasty procedures fell dramatically from 2013 with 24% less people opting for the surgery in 2014, whilst abdominoplasty procedures declined by 20% overall. Liposuction procedures, however, moved from the 6th to 5th most popular cosmetic surgery procedure in the UK, with 7% more people opting to have the surgery in 2014. Face and neck lifts in women were the only other procedures to increase in popularity, with a rise of 1%. BAAPS has suggested that these findings show that aesthetic patients are considering surgery with more caution and rationality than in previous years. According to former BAAPS president and consultant plastic surgeon Mr Rajiv Grover, the results have reflected a ‘more educated’ Britain. He said, “The difference between 2013 and 2014 may seem surprising, but the dramatic double-digit rise last year [2013] was very clearly a post-austerity ‘boom’, and figures are simply now returning to a more rational level.” Consultant plastic surgeon and BAAPS president Michael Cadier said, “The message to the aesthetic sector is clear: patients want subtle and understated and, most refreshingly, they are doing their research, taking their time and coming to us with realistic expectations.” Grover added, “It might seem counterintuitive that as plastic surgeons we could possibly welcome such a change, but we are pleased that the public are now so much more thoughtful, cautious and educated in their approach to cosmetic surgery.” Botulinum toxin

Study shows changing pH in botulinum toxin B can reduce injection pain A study, published in Dermatologic Surgery, has found that injection pain can be reduced without compromising results by changing the pH level in the acidic solution of botulinum toxin type B (BTX-B). Two patients who had developed acquired resistance to botulinum toxin type A were injected with two different dilutions of BTX-B, following confirmation of their resistance. BTX-B usually has a pH of 5.6, but researchers diluted a dose with sodium bicarbonate in the syringe, immediately prior to injection, to normalise the pH to 7.5. Pain assessments were carried out on the patients to compare the two dilutions. Researchers found that the BTX-B formula changed to pH 7.5 significantly reducing pain in the injection site, with retained efficacy over a ten-week period.

Study finds app improves sun protection usage Users of a mobile app have reported using more sun protection after following the advice on their phone. The Solar Cell app provides real-time sun protection advice, based on UV Index forecasts and personal information from the user. The app also sends alerts to users informing them as to when they need to apply or reapply sunscreen. A randomised clinical study on Solar Cell’s influence was conducted, enrolling 604 participants. Complete data from the first-phase study results was available on 454 individuals (222 in the treatment group and 232 in a control group), and found that 41% of participants in the treatment group reported spending more time in the shade, compared to 33.7% in the control group. More participants in the control group, however, (34.5%) reported using sunscreen than those in the treatment group (28.6%). A second randomised trial showed increased improvement in the use of sun protection. At the seven-week follow-up, researchers found that 23.8% of participants who utilised the app deployed the use of wide-brimmed hats more frequently, compared to those in the control study who did not utilise the app (17.4%). Results indicated that 46.4% of women and 43.3% of men made more use of combined sun protection (sunscreen, protective clothing and shade) after using the mobile app. The authors said, “The Solar Cell mobile app seemed to promote sun protection practices, especially when it was used. Specifically, it increased use of shade. Shade can substantially reduce exposure to solar UV radiation, but it needs to be available for it to be used.” Solar Cell was developed by Klein Buendel under a contract with the National Cancer Institute in the US. Surgical

‘Aesthetic Surgery Services’ is published as European Standard The European Committee for Standardisation (CEN) and British Standards Institution (BSI) have announced that the ‘Aesthetic Surgery Services’ has now been published. After four years of development, the document (EN 16372) was approved for publication in June 2014, however procedural issues halted the process until the New Year. Quoting from the National Foreword of the published standard, Mike Regan, chair of the BSI Committee, said, members agree that the document provides a valuable framework to work by for those employed in the aesthetics sector. He also said that the committee believe it offers useful guidelines for those seeking aesthetic treatment. Topics covered in ‘Aesthetic Surgery Services’ include general requirements and recommendations for procedure rooms and operating theatres, hygiene standards, continuous professional development (CPD) and continuous medical education (CME). The document does not address dentistry, reconstructive surgery or non-surgical aesthetic procedures. A two-month European public consultation for non-surgical aesthetic procedures began in late February 2015, and will be led and administered by the BSI.

Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015

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Skincare

New speakers announced for ACE 2015

Harley Street doctor launches new skincare product using stem cell abstracts

New speakers have been announced for the Aesthetics Conference and Exhibition (ACE) 2015, taking place on March 7 and 8. With an already extensive number of speakers set to take to the floor at ACE 2015 to speak on a variety of topics, new speakers have been added to all four agendas to offer attendees an even higher quality learning experience. Renowned aesthetic practitioner Dr Rita Rakus will take part in the highly anticipated ‘Getting into the Zones’ session with aesthetic experts Mr Dalvi Humzah, Dr Raj Acquilla and Dr Tapan Patel. Often referred to as the ‘London Lip Queen’, Dr Rakus will offer delegates her expertise on lip enhancement during the injectables module on Sunday morning. It has been confirmed that the main agenda will include input from Dr Samira Yousefi, aesthetic doctor and author of upcoming book Diet Peace, and plastic surgeon Mr Adrian Richards, who has specialist experience with fat treatments. Dr Yousefi and Mr Adrian Richards will be joining Mr Taimur Shoaib and Dr Thuvaraka Vetpillai on the specialist panel for Saturday morning’s ‘The role of FAT in medical aesthetics’ module. This will be a dynamic session exploring case studies and discussing treatments within aesthetics for achieving weight loss. The Business Track will see Mark Lainchbury, managing director and founder of e-clinic, discuss the use of technology to attract new patients, offering expert guidance on how to increase patient retention rates. Eddie Hooker, managing director of insurance provider Hamilton Fraser, will also be contributing his expertise to the Business Track programme, advising delegates on the most effective ways to protect business from litigation. Dr Sherif Wakil, aesthetic doctor and hair transplant surgeon, will join the Expert Clinics agenda to demonstrate non-surgical blepharoplasty. This session, sponsored by Fusion GT, will introduce Plexr, a new soft surgery technique for blepharoplasty. Institute Hyalual has confirmed that Dr Maryam Borumand, a scientist from Rederm, will present their sponsored Masterclass on skin rejuvenation with combination treatments using hyaluronic acid and succinic acid. For more information on speakers and the ACE agenda visit www.aestheticsconference.com.

Aesthetic practitioner Dr Vincent Wong has launched a new revitalising cream, using stem cell abstracts with a combination of antioxidants and vitamins, as the first product in his Vivify skincare range. The Stem Cell Revitalising Cream is an organic, non-fragrant cream that is free from parabens and sulphate. It aims to promote healthy skin by using ingredients that synergistically work together to speed up cell turnover, protect the skin from free radical damage and boost the development of collagen production. Dr Wong said, “I’m so excited to be introducing my first skin care product, Vivify Stem Cell Revitalising Cream. This product is a unique formula that combines a number of potent, plant-based ingredients that work synergistically. I’ve had many patients looking for a face cream that really makes a difference and I hope this will be the answer they’ve been looking for.” The launch of this new skincare product coincides with Dr Wong’s release of cosmetic safety campaign film Life is Beauty-Full. and will be available from April. During the film premiere he was also awarded the Sinclair IS Pharma Practitioner of the Year Award.

Weight loss

Distribution

New statistics reveal one in five would consider ‘quick fix’ weight loss treatments A new study by Mintel has found that one in five people in the UK would consider undergoing cosmetic weight loss procedures. The study, undertaken in light of the UK’s growing obesity rate, showed that 22% of people would consider having excess skin removed, while 19% would consider liposuction in the future. Three in ten (27%) who had previously undergone treatment, or would consider doing so, said they would undergo cosmetic surgery as what is dubbed a ‘quick fix’ to an area of their body they disliked. Mintel’s consumer lifestyle analyst, Jack Duckett, said, “The high level of pressure from the Government and health organisations on consumers to lose weight is likely to continue to intensify over the coming years as an increasingly obese population continues to put strain on NHS resources. “This could present the UK cosmetic surgery market with a greater number of opportunities to assist adults with rapid weight loss, or provide excess skin removal for those that have lost weight themselves.”

Unique Skin to distribute Clinical Resolution products Aesthetics distributor Unique Skin has announced that it is now the exclusive UK distributor for Clinical Resolution products. Clinical Resolution offers, amongst others, the Microneedle Therapy System (MTS) Roller. This non-surgical, non-ablative device can be used to treat a variety of skin conditions, including wrinkles, scarring and hyperpigmentation. According to the manufacturers, clinical studies have shown MTS to be more effective than ablative treatments such as laser resurfacing, microdermabrasion and chemical peels. Julian McGlynn, director of Unique Skin, said, “We are very proud to have reached an exclusive agreement for the distribution of the entire range of products, which are all now available and ready for dispatch to both existing and new customers.”

Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015

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Survey

Study suggests almost a third of acne sufferers receive unsatisfactory treatment A new survey by the British Skin Foundation has found that almost a third of acne sufferers who had sought treatment for the condition were left unsatisfied by medical professionals. With more than 2,000 responses, the survey provided an insight into the lives of acne sufferers, highlighting the emotional impact of acne on mental health. It further revealed that 56.78% had experienced verbal abuse from friends, family and acquaintances due to the condition, while a fifth of respondents claimed that the disease had caused a relationship to end. While it was revealed that almost a third of patients had not received satisfactory treatment from a medical professional, consultant dermatologist and British Skin Foundation spokesperson Dr Anjali Mahto said, “A good dermatologist can offer a large number of potential treatments that can be tailored to the individual. Unfortunately, the skin is such a visible organ, that it’s only natural that self-esteem is so closely tied to it.” She added, “I think these results highlight that acne should be taken far more seriously.” Cosmeceuticals

Lifestyle Aesthetics to distribute Teoxane Cosmeceutical Range Aesthetic distributor Lifestyle Aesthetics has added Teoxane Cosmeceuticals to their product portfolio. Coinciding with their 10th anniversary, the distribution company has taken on the distribution of Swiss manufacturer’s Teoxane Cosmeceutical Range, which claims to strengthen, protect and plump the skin. Comprising Resilient Hyaluronic Acid (RHA) technology, Teoxane asserts that their cosmeceutical range offers additional benefits to traditional hyaluronic-based skincare products. The RHA Serum, which has the highest concentration of the range’s core ingredients, showed promising results after an independent lab study with 31 participants. It was found that the serum made the complexion 94% brighter, and the skin 91% more resistant. FDA

FDA highlights differences between cosmetics and drugs

Aesthetics

Vital Statistics

Keratosis pilaris aﬀects around 40% of adults (www.patient.co.uk)

In 2014, facelifts, browlifts, and blepharoplasty were most performed on adults over the age of 55 (American Academy of Facial Plastic and Reconstructive Surgery)

The popularity of liposuction increased by 7% in 2014 (British Association of Aesthetic Plastic Surgeons)

A study found that less than 1% of non-invasive treatments conducted across the US result in adverse events

(Northwestern University, US)

of people with melasma are men (American Academy of Dermatology)

The demand for lip reduction increased by 135% in the last quarter of 2014 (WhatClinic.com)

US-based companies have received letters from the Food and Drugs Administration (FDA) detailing the differences between cosmetics and drugs. According to the FDA, clarification on their differences is needed as firms sometimes illegally market cosmetics with a drug claim or a drug as though it were a cosmetic. In the letters, the FDA emphasises that the Federal Food, Drug and Cosmetic Act (FD&C Act) does not recognise ‘cosmeceutical’ as a category. The Act explains that although a product can be a combination of a drug and a cosmetic, the term ‘cosmeceutical’ has no meaning under the law.

Most people who experience psoriasis in their lifetime will have it by the age of 40 (American Academy of Dermatology)

Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015

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Events diary 7 - 8 March 2015 The Aesthetics Conference and Exhibition 2015, London www.aestheticsconference.com th

26th - 28th March 2015 13th Anti-Aging Medicine World Congress, Monte Carlo www.euromedicom.com/amwc-2015/ index.html 27th - 25th June British Association of Plastic, Reconstructive and Aesthetic Surgeons Summer Scientific Meeting 2015, Bruges www.bapras.org.uk 7th - 9th July 2015 British Association of Dermatologists Annual Meeting 2015, Manchester www.bad.org.uk

Business

Allergan profits exceed expectations Botox-maker Allergan has revealed that their fourth-quarter profits have beaten expectations. Reaching $537.2 million, Allergan reported that this was a two million dollar increase on the same period last year, which sat at $312.9 million. The pharmaceutical company also noted that product sales rose 13.8%, reaching nearly $1.9 million, while specialty pharmaceuticals net sales further rose 12.4% compared to the last quarter of 2013. The recorded profit for the year reached $1.5 billion based on $7.2 billion in revenue. Allergan chief executive David Pyott, who recently revealed that he will be leaving the company once the Actavis acquisition is complete in a few months, said, “Allergan yet again recorded in the fourth quarter the strongest increase in absolute dollar sales in any quarter in our history, driven by exceptional performance across all of our businesses and geographic regions. This is a tribute to the focus of our employees during the unsolicited acquisition attempt.”

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RCS recommends introduction of approved register of surgeons The Royal College of Surgeons (RCS) has announced that patients having cosmetic surgery should be able to check their surgeon is on an approved register. Under the recommendations set out by the Cosmetic Surgery Interspecialty Committee (CSIC), created by RCS in 2013 in response to the Keogh Review, surgeons working in the private sector will have to prove they meet new standards of training to be certified and included on a register. The suggestion was made in the Cosmetic Surgery Interspeciality Committee Consultation Document, which aims to improve the quality of care to patients undergoing cosmetic procedures. Chair of the CSIC and vice president of the RCS Mr Stephen Cannon said, “We are determined to ensure there are the same rigorous standards for patients undergoing cosmetic surgery in the UK as other types of surgery.” The RCS hope to make the register publically available to employers and patients so they can make informed decisions when considering cosmetic surgery, and have access to clear, unbiased and credible information about their surgeon. To obtain certification, surgeons will have to be on the GMC’s specialist register in the area of training that covers the operation they wish to perform. They will be required to have the appropriate professional skills to undertake cosmetic surgery and must be able to provide evidence of the quality of their surgical outcomes. In addition, surgeons will also have to have undertaken a minimum number of procedures within the relevant region of the body, in a facility recognised by the health regulator, to be listed on the register. According to the RCS, certification will only permit surgeons working in the private sector to undertake cosmetic surgery on the areas of the body that relate to the speciality they trained in. Cannon said, “This consultation provides the next step in establishing clear and high standards for training and practice so that all surgeons in the UK are certified to the same level, irrespective of where they trained.” Patients, surgeons and providers of cosmetic surgery are encouraged to respond to the consultation by Friday 6 March. Skin Technology

Lumenis launches ResurFX system International energy-based medical company Lumenis has announced the launch of its new non-ablative fractional skin resurfacing device, ResurFX. The device is a stand-alone desktop system, which made its debut at this year’s IMCAS meeting in Paris. It uses Lumenis’ CoolScan technology to provide continuous contact cooling, and offers practitioners the opportunity to customise their treatments, with more than 600 different options for shape and size of treatment area, as well as density and energy delivery. “We have seen such a dramatic rise in fractional non-ablative skin resurfacing because the procedure provides excellent results, without the long downtime associated with other cosmetic procedures,” said Dr Matteo Tretti Clementoni of Istituto Dermatologico Europeo. “ResurFX is the leading solution in this space because it provides the best balance of efficacy and patient convenience – some of my patients are even coming in for ResurFX treatment as a ‘lunch-time’ skin rejuvenation procedure.”

Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015

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Industry

BACN announces revision to its membership requirements The British Association of Cosmetic Nurses (BACN) has announced a revision to its membership requirements. The amendment will allow General Medical Council (GMC) and General Dental Council (GDC) registered doctors and dentists to become affiliated BACN members. Once affiliated, they can access various BACN services, including the Annual Conference, training programmes and information resources. They may further join the Regional Network, allowing exchange of best practice and industry discussion – though voting will remain limited to nurses only. The BACN will also see their membership structure reorganised, creating a stronger emphasis on education, training, revalidation and CPD, based on the developing standards from Health Education England, with membership available internationally. BACN chair Sharon Bennett said, “The introduction of an Affiliated Member category will enable a number of highly qualified aesthetic practitioners to become part of the BACN family and will cement the already existing processes of joint working and learning.” Experts

AestheticSource invite you to ‘Meet the Experts’ at ACE 2015 AestheticSource, aesthetic distribution company and headline sponsors of the Aesthetics Conference and Exhibition (ACE), will be providing access for delegates to ‘Meet the Experts’ at ACE 2015. On Saturday 7 March at 2:35pm, plastic surgeon Miss Rozina Ali, dermatologist Dr Sandeep Cliff and cosmetic doctor Dr Raina Zarb-Adami, will come together at the AestheticSource stand (49) to allow ACE delegates the chance to learn from their wealth of experience. As experts in skincare, the trio will offer invaluable advice on skin health and clinically-effective skincare regimens in order to help delegates retain patient loyalty and enhance their clinical practice. Dr Maria Gonzalez and AestheticSource director Lorna Bowes will also be on hand to talk to delegates at the stand, following their Expert Clinic on Sunday 8 March. They will use their expertise and experience with chemical peel technology to advise delegates on the best ways to combine peels with other aesthetic treatments, in order to boost patient satisfaction. Each AestheticSource Expert Clinic aims to offer a range of top advice from these respected aesthetic professionals, whilst giving their guidance on the best ways to utilise skincare and chemical peels. To register FREE visit www.aestheticsconference.com Fillers

Adare Aesthetics to distribute Luminera Crystalys Aesthetic distributor Adare Aesthetics has added a new dermal filler to its product portfolio. Available now, Luminera Crystalys is a calcium hydroxyapatite injectable facial implant that can be used for filling deep lines and wrinkles, as well as for general facial restoration. Director of Adare Aesthetics Dr Naomi Mackle said, “Patients should expect an improvement to the area treated with Luminera for six to 12 months. So far we have had excellent results with very high patient satisfaction.” Adare Aesthetics also claims that the risk of granulomas is reduced as Luminera Crystalys is uniformly and homogeneously arranged.

Lorna Bowes, director of AestheticSource What brought you to aesthetics? I have had a real passion for skin since my first NHS dermatology staff nurse role in 1987, which led me to take my personal study of the skin, skin health, and pharmaceutical/cosmetic ingredients further. I have now been in the aesthetics field for well over 20 years. I’ve had a wonderful journey, from teaching dermal fillers (collagen to start with, then later HAs) to running and successfully selling The Bowes Clinics with a team of nurses around the UK, as well as teaching ‘all things aesthetic’ with Wigmore Medical from 2008. I have experienced various industry roles, including editing the Journal of Aesthetic Nursing in its first couple of years. My passion for skin grows more each year. Who are AestheticSource? AestheticSource was set up in 2011. Our mission is to deliver clinically proven dermatologistled skin fitness solutions to the aesthetic and beauty markets. We have grown and are now a team of aesthetic nurses, therapists and highly experienced industry professionals with a wealth of experience in brand and clinic development, training and customer service. We were thrilled to be finalists and even more so to receive Commended in the Aesthetics Awards just before Christmas; we are a small company that puts our customers first and foremost, so to be publicly acknowledged for this is a great honour. What does the future hold? In the world of cosmeceuticals (or rather, cosmetics), having published clinical data in international peer-reviewed medical journals is rare. The cost and time implications of performing the randomised double blind placebo or vehicle controlled studies that we are used to in the medical field does not translate well to the cosmetic market. At AestheticSource we work with leading experts including dermatologists, dermatopharmacologists, plastic surgeons and aesthetic practitioners in the UK and around the world to source and understand brands with a heritage of evidence-based practice. Finding brands to match the medical heritage of NeoStrata Co has proved a challenge, but we have some very exciting developments in the pipeline that complement our current portfolio. This column is written and supported by

Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015

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News in Brief SkinCeuticals to introduce Mineral Eye UV Defense SPF 30 SkinCeuticals has announced that it is to launch a new product, Mineral Eye UV Defense SPF 30, in April 2015. Designed to protect the delicate skin around the eyes from the sun, Mineral Eye UV Defense offers SPF 30 UVA and UVB protection. SkinCeuticals claims the product will also enhance skin tone and optimise make-up application. Evosyal receive FDA approval for phase 3 study protocol Alphaeon Corporation has announced that the FDA has approved its phase 3 study protocol for the use of the botulinum toxin Type A neuromodulator, Evosyal, in the treatment of glabellar lines. Alphaeon Corporation acquired exclusive US rights to Evosyal through its takeover of Evolus last year. Over the past 12 months, the company has submitted an investigational new drug application for Evolus, and completed enrollment for the phase 2 clinical trial. Phase 3 enrollment will commence soon. Aesthetic Response launches telephone message-taking service Clinic support company Aesthetic Response (AR) has launched a message-taking service for aesthetic practices. According to AR’s founder Jo Fisher, calls will be answered promptly and professionally for up to 66 hours a week. The company aims to ensure aesthetic practices never miss a patient call or valuable enquiry, enabling them to provide excellent customer service and capitalise on new business opportunities. Environ launches Super Moisturiser+ Environ has launched a new moisturising product which it claims will assist in regulating the skin’s natural moisture levels. Containing moisturising agents Pentavitin and Revidrate, both of which have been clinically proven to enhance epidermis moisturisation, Super Moisturiser+ promises to leave skin richly nourished.

Aesthetics Journal

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Training

New Skin Restoration training course to launch at ACE The Academy of Advanced Aesthetics will launch ‘Advanced Skin Restoration’ at the Aesthetics Conference and Exhibition (ACE) 2015. The training course aims to teach trainees how to prepare the skin for invasive therapies and explain the effects of skin regeneration technology. It will also aim to detail the importance of balancing the skin’s biological functions for improved treatment outcome. Founder of the Academy Barbara Freytag said, “The course concentrates on offering specialist advice to familiarise aesthetic practitioners with the treatments and their effect on the skin, rather than mere machine operation.” She notes that detailed education on preparing the skin prior to treatment is beneficial to practitioners as it can aid faster post-treatment healing, decrease the possibility of complications, and provide improved aesthetic results. Visit stands 84 and 86 at ACE 2015 to find out more. Topical

Sepai launches Vitamin C boosting serums Barcelona-based skincare manufacturer Sepai has launched four serums that each contain 5% Vitamin C, to aid in protecting skin cells and preventing premature ageing. Comprising two eye and two face serums, Sepai claim the products have been specifically formulated to target under eye circles, puffiness, dehydration, dark spots, wrinkles, open pores and dull skin. Dr Lisa Zdinak, a New York-based aesthetic practitioner who stocks the products, said, “Sepai delivers bioactives that impact directly on the skin cell control centres so that they behave more like younger, fresher skin cells.” Each product comes with a Vitamin C booster, which can be added to the serum and applied directly to the skin. The skincare line is available to clinics in the UK now. Business

‘Aesthetic Business Network’ aims to provide creative and effective business solutions A group of aesthetic business experts have established an ‘Aesthetic Business Network’ with the aim of providing unique advice to industry professionals. Created by Richard Crawford-Small, founder of iConsult software, the group will hold regional business workshops offering insight, training and knowledge on topical business issues within aesthetics. Crawford Small said, “The aim of the Aesthetic Business Network is to ‘disrupt’ the UK aesthetic marketplace in a positive and innovative way by helping aesthetic business owners to find creative and effective solutions to their business issues.” Members of the Expert Network include founder of Aesthetic Business Transformations Pam Underdown, who has developed the concept alongside Crawford-Small, Mark Bugg, founder of the Web Marketing Clinic, and branding expert, Russ Turner. Also offering their wealth of experience are owners of Aesthetic Response Gilly Dickons and Jo Fisher, founder of Vantage Professional Risks Martin Swann, and founder of the Wright Initiative and PaPPS, Norman Wright. Underdown said, “The group will provide the richest source of knowledge, valuable free resources, networking and interview opportunities to ensure that they not only add value, but ultimately help every UK aesthetic business owner grow their business with a network of trusted and reliable providers.” The first business workshop will be held in the Midlands on June 16.

Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015

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‘Life is Beauty-Full’ Launch, London

Aesthetic practitioner Dr Vincent Wong launched his documentary, ‘Life is Beauty-Full’, on January 28. Guests were welcomed with a champagne and canapé reception at the Bulgari Hotel, Knightsbridge, before being seated in the hotel’s private cinema room for the viewing. Directed by Dr Wong in conjunction with awareness campaign Safety in Beauty, the documentary targets consumers, with the aim of encouraging them to be more safety-conscious when choosing an aesthetic treatment. The film also featured a soundtrack written by Dr Wong himself. Of the evening, Dr Wong said, “The journey itself has been challenging – it is the first time I have produced a documentary, and written a song, but I hope viewers will find it innovative and at the same time entertaining.”

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SkinCeuticals Integrated Strategies Summit, London Aesthetic doctors, dermatologists and plastic surgeons attended an evening discussion on the future of integrated skincare and aesthetics on 2 February. Held at the Royal Society of Medicine in Chandos House, London, the SkinCeuticals event featured talks from facial cosmetic surgeon Dr Steven Dayan, and assistant vice president of Global Education at SkinCeuticals Nicole Simpson. Dr Dayan delivered a presentation entitled, ‘The Future of Aesthetics: Are You Ready?’ where he discussed the popularity of cosmetic surgery in Asia, and noted how the UK and the US are falling behind in terms of treatments per capita. Simpson gave attendees an insight into marketing strategies and methods of incorporating skincare into a medical setting. Her interactive session also touched on ways clinics can improve their retails sales and retention rates. Guests included Dr Rita Rakus, Dr Raina Zarb Adami, Dr Tapan Patel, Mr Christopher Inglefield and Dr Raj Acquilla. Dr Acquilla said, “My friend Steven Dayan was eloquent and entertaining as ever, combining sublime content with charisma and perfect timing. The incorporation of cosmeceuticals into your aesthetic practice seems common sense, but the SkinCeutical range seems a natural compliment for what I do.”

Specialist insurance for cosmetic practitioners

Clinic Insurance for Medical Professionals Whether you run one cosmetic clinic or a chain of clinics, it is important to make sure you have adequate insurance in place should the unexpected happen. We can provide tailor made insurance to protect your cosmetic clinic, drugs and equipment against loss or damage caused by insured events such as storm, flood, escape of water and theft.

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Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015

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We report on the highlights from Paris’ international aesthetics conference

IMCAS 2015, Paris Aesthetic professionals from around the world descended on Paris for the 17th International Master Course on Aging Skin (IMCAS) between January 29 and February 1, 2015. More than 5,500 nurses, doctors, surgeons, exhibitors and manufacturers from 84 countries met at the Palais Des Congrés in Paris for four days of knowledge-sharing, educating and learning about the latest developments in our multifaceted industry. The varied and engaging agenda comprised 155 scientific sessions, presented by 420 Key Opinion Leaders from around the world. Themes covered included body contouring, skin rejuvenation, hair removal and practical anatomy workshops using cadavers. One clear trend appearing on numerous agendas, however, was vulvo-vaginal rejuvenation. Thursday saw three sessions that covered the fundamentals of treatment, surgical techniques and treatment using lights, radiofrequency and laser. Experts discussed the anatomy of the vulvo-vaginal area, G-spot enhancements, genital beautification and CO2 laser treatment for vaginal atrophy in postmenopausal women. Chair of session one Dr Nicolas Berreni noted that enquiries for vulvo-vaginal rejuvenation treatments are growing year on year – a fact supported by the American Society for Aesthetic Plastic Surgeons (ASPS), which recorded more than 5,000 procedures in 2013; a 44% increase on 2012.1 Other well-received presentations included neck and décolleté rejuvenation and lip restoration. Dr Thomas Rappl detailed the anatomy of the neck and décolleté, whilst the lip restoration session, presented by facial plastic surgeon Dr Frank Rosengaus, taught delegates ‘the happy face treatment’, in which he outlined how best ways to treat commissures and marionette lines. Cosmetic doctor Dr Raj Acquilla also contributed to the segment, presenting his 6-point injection protocol for lip and perioral rejuvenation. Audience member and aesthetic practitioner Dr Catherine Stone said, “Raj Acquilla always stands out. I love his techniques and he always manages to make everything incredibly simple.” Dr Stone has been attending IMCAS for three years and travels from New Zealand, where she is based, in order to attend

Aesthetics Journal

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the congress each year. She added, “It’s been interesting to see the transition in the injectable space from mainly botulinum toxin procedures to vulva-vaginal rejuvenation. It’s been a fascinating conference and really awesome to meet so many new people.” Other highlights of the annual conference included the ‘Facial rejuvenation surgery vs. medicine’ sessions, which took place on the Friday afternoon. The four debates, which centred on different treatment methods for each area of the face, had delegates squeezing into the lecture room and queuing for entry outside. Topics discussed included: the efficacy, safety and financial implications of periorbital rejuvenation, when and how to lift the eyebrows, eyelid lipofilling, mid-face volume addition, refinements of the nose using HA fillers or surgery and surgical enhancement of the jaw-neck complex. Dermatologist Dr Heidi Waldorf presented during the ‘nose – mouth – chin complex’ debate, and highlighted the appropriate methods of evaluating and rejuvenating the perioral complex. In her talk she suggested that practitioners should strive to achieve a ‘more cohesive look’ when treating the face, arguing that just treating ‘segmental areas’ would not create the most attractive face for the patient. After the session, Dr Waldorf said of the conference, “IMCAS Paris is on my calendar every year and will continue to be so. It brings great speakers from around the world, although, sometimes, I learn even more from the hallway conversations than the lectures.” This year IMCAS housed 165 exhibition stands, which delivered a plethora of displays from basic clinical equipment such as surgical scissors, to the latest innovations in laser equipment. Medical aesthetic business consultant Richard Crawford-Small noted that there was an increase in Far Eastern companies exhibiting their new technology and products, which reflected international statistics discussed in the conference’s Industry Tribune. He shared his predictions on the effect of this development, noting, “The repercussions of this could result in the existing manufacturers who build the kit in Europe and the US coming under an increasing amount of pressure in coming years.” The three-hour long Industry Tribune, on Friday afternoon, saw market experts take to the stage in the main conference room to share statistics and predictions for the ever-growing aesthetics specialty. It was well attended by delegates, who learnt that the global facial aesthetics market was valued at 2.7 billion USD in 2014. Medical industry analyst Michael Moretti also told the audience that this figure is predicted to rise to more than 4 billion USD by 2019. Attendees also learnt that the Asian aesthetic market overtook its European counterpart in terms of revenue in 2014, and is expected to expand even more over the next four years. The US, however, is predicted to retain its global market share of

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RESOLVE 44% within the same time frame. According to the statistics presented, the value of the cosmeceutical industry is set to take over from the breast implant industry this year, and body contouring and energy devices are predicted to become even more sought after, with their popularity predicted to increase by 9.9% annually over the next five years. After Moretti’s presentation, industry leaders from Allergan, Galderma, Merz, Syneron and Lumenis took to the stage to put forward their marketing strategies, and this was followed by an industry vs. doctors round table debate. This proved an insightful opportunity to learn from experts on both sides of the working field, and provided invaluable information on the direction that the aesthetics specialty is headed in 2015.

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The value of the cosmeceutical industry is set to take over from the breast implant industry this year Speaking after the Tribune, IMCAS course director Benjamin Asher said, “Feedback on the congress so far seems to be what we were expecting – the degree of satisfaction is high. We have reached our target and are now the number one medical aesthetic meeting in Europe.” Adding, “But, of course, we have to improve and get better each year.” Following the Tribune, delegates and exhibitors enjoyed a cocktail networking reception in the Palais Des Congrés, before gearing up for La Nuit des IMCAS Awards 2015 on the Saturday evening, in support of Breast Cancer Research. Feedback was positive; with dermatologist Dr Anne Le Pillouer Prost commenting that it was a “great evening as usual”. The much-anticipated event drew to a close on Sunday 1 February, after a morning of ‘Meet the Expert’ series, along with Research and Development sessions. Topics covered included 3D technology, the role of botulinum toxin for treating depression, liquid tissue in a syringe, and myth vs. reality of collagen stick formulation by injectable fillers. Overall the congress was well received by attendees; Richard CrawfordSmall said, “I’ll definitely be back. If you want to know where the market’s going and how it’s developing then you need to attend these industry events.” Dr Raj Acquilla added, “IMCAS has surpassed my expectations of a global major congress. It’s been a pleasure to be here sharing knowledge, skills and techniques with colleagues and friends from around the world.” REFERENCES 1. The American Society for Aesthetic Plastic Surgeons, 2013 Cosmetic Surgery National Data Bank Statistics, (US: ASAPS, 2013) <http://www.surgery.org/ sites/default/files/Stats2013_4.pdf>

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With only one week left until the Aesthetics Conference and Exhibition 2015, we detail why this is an event not to be missed

Last look: ACE 2015 Next week, the Aesthetics Conference and Exhibition (ACE) 2015 will provide more than 2,000 industry professionals with access to a multitude of interactive learning and networking opportunities at the Business Design Centre in Islington, central London. With one week left to register, join numerous aesthetic professionals on March 7 and 8 as they learn how to enhance their business and expand their clinical knowledge. At the UK’s first industry conference of the year, attendees can secure vital connections and be the first to discover the latest product and service innovations, with access to more than 100 leading exhibitors. Based on feedback from last year’s delegates, our brand new Conference format, created on an interactive agenda, is unlike anything seen before in the UK’s aesthetic industry. This agenda will provide delegates with engaging, premium content presentations and demonstrations, and up to 50 CPD points are available across all programmes throughout the weekend.

Agendas Complementing registration for the free exhibition pass, which includes access to the Business Track, Expert Clinics and Masterclasses, delegates can book main agenda sessions that are relevant to their area of practise or interest – with no obligation to book all four modules. For just £95 a session, including VAT, those opting for this flexible pass will receive discounts with each learning module chosen. Each individual module will demonstrate entire patient journeys, from consultation through to follow-up care, outlining exact patient treatment to achieve optimum outcomes. See leading aesthetic practitioners Dr Arthur Swift, Mr Dalvi Humzah, Dr Tapan Patel and Dr Raj Acquilla present on stage together for the first time in this year’s ‘Face Off’ and ‘Getting into the Zones’ facial injectables sessions. Utilising state of the art technology, these sessions will use multiple screens for optimal viewing and learning, incorporating live treatment demonstrations, anatomy dissection exploration and audience participation. Mr Taimur Shoaib will chair a panel of specialists, including Dr T Vetpillai and Dr Samira Yousefi, during Saturday morning’s session, ‘The Role of FAT’, on weight management and body sculpting. The panel will present and examine

Aesthetics Journal

Aesthetics aestheticsjournal.com

case studies on fat reduction treatments, discussing the journey from consultation and treatment to post-procedure advice. Sunday afternoon will see leading dermatologists Dr Christopher Rowland Payne and Dr Stefanie Williams host ‘The Aesthetic Dermatology Clinic’, featuring guidance on differential diagnosis with key insight from dermatologist Dr Daron Seukeran and aesthetic nurses Anna Baker and Lorna Bowes. With this year’s comprehensive Business Track, sponsored by Church Pharmacy, delegates can maximise the opportunity to develop their clinic by attending as a whole practice, in order to learn about the non-clinical aspects of running a successful aesthetics business. Expert Clinic and Masterclass live demonstrations will show how successful practitioners use the best products to achieve top results, providing invaluable advice on techniques and avoiding and managing complications. Topics covered in the Expert Clinics will include advanced injectables, bio-generative skin rejuvenation and non-ablative soft surgery, while the dynamic Masterclasses, led by word-class professionals, will offer invaluable learning and practical advice on specific products. Saturday evening’s Question Time event will be a unique session, hosted by former BBC presenter Peter Sissons, addressing questions asked by you, our readers, to stimulate debate between industry leaders. Panel members will include professional body chairs Dr Paul Charlson and Sharon Bennett, international business specialist Wendy Lewis, Health Education England (HEE) performance and delivery manager Carol Jollie and respected surgeons Mr Dalvi Humzah and Mr Paul Banwell. Within the exhibition, the Merz Aesthetics Live Demonstration Zone will feature a presentation from world-renowned aesthetic surgeon Dr Arthur Swift as he introduces Belotero+ Volume. Amongst taking part in a range of demonstrations, he will also join a panel of specialists who will share their expertise on safe practice within the industry.

Valuable experience Of more than 1,600 attendees last year, 92% said they will return to ACE in 2015. Among the praise received regarding last year’s event, one delegate reflected that, “Talking to the exhibitors helped me because they provided practical material and supplies, and also information I can actually use in my practice.” Headline sponsors, AestheticSource, will be present at the exhibition to provide information for their customers, as well as new delegates. Lorna Bowes, director of AestheticSource, said, “AestheticSource are looking forward to another successful ACE Conference and Exhibition. We love the educational content that the various parts of the programme provide, with a diverse group of speakers stimulating thought and discussion.” The esteemed ACE Steering Committee, led by Mr Dalvi Humzah, will guarantee that the education and speakers featured are of the highest quality, giving attendees the most beneficial and valuable experience possible and making this an essential event on the aesthetics calendar. Don’t miss your chance to attend ACE 2015. Register today at www.astheticsconference.com WITH THANKS TO OUR SPONSORS

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How to treat an aesthetic patient We asked three practitioners to share their individual approaches to treating a hypothetical aesthetic patient. After assessing the images, our surgeon, dermatologist and cosmetic doctor share their thoughts

Dr Tapan Patel, cosmetic doctor This patient is attractive, with good facial balance and does not have any major treatment indications. Ideally I would prefer to assess this particular patient with a headband so that we could clearly examine the upper third of her head. The first intervention I would suggest concerns the condition of her skin. She displays some degree of mottled hyperpigmentation, and there is also some suggestion of erythema. These conditions, which are exacerbated by sun exposure, make her suitable for photo rejuvenation with, for example, an IPL system. She might also be a candidate for fractional resurfacing with the use of a C02 Laser. This would not only improve the tone, but also the texture of her skin. Additionally, we could use more aggressive parameters around her eyes to reduce the static periorbital rhytides. Without animation it is not possible to see to what level she has dynamic lines of expression. She certainly seems to have a prominent platysmal band on the right side, which could be treated with botulinum toxin. The lower aspect of her face suggests she may have some degree of masseter hypertrophy, and this gives her a slightly square look. I would consider treating this region with some botulinum toxin to contour the jawline. Finally, the chin shows signs of cobblestone appearance. If this is the case when she activates mentalis, this can be softened with botulinum toxin.

Despite her hair being down, it would appear she has some degree of bi-temporal recession. Over Treatment List time this will deepen and lead to drooping of the tail • IPL of the eyebrow. This can • Botulinum toxin be rectified by the use of • Radiofrequency a volumising filler, injected • C02 laser deeply into the temporal • HA filler fossa. Overall she seems to have good volume, especially in the mid face and in the chin. Because she has good projection of her cheeks, nose and chin, it does make her lips appear a little undersized, especially in the lower lip. With this in mind, she may indeed benefit from very subtle injections of the lips with the use of a hyaluronic acid filler. There is a suggestion of mild infraorbital hollowing, especially on the left side medially. This can be softened with a direct tear trough injection. It would be important to examine the lower eyelid skin to ensure it is not too flaccid prior to this intervention. I suspect this patient would benefit from skin tightening, especially on the neck, perhaps even on the full face. This could be achieved with a system such as a radiofrequency device, ideally delivered using a needle system. Finally, I would recommend a skin care regime comprising of a wash, exfoliating agent, anti-oxidant, retinoid and sun protection.

Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015

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Mr Adrian Richards, surgeon In order to analyse this patient’s ageing process, I would ask her, as part of the initial consultation, to bring in photographs of herself taken in each decade of her life. This is important in order to understand how a patient’s face has aged, in order to attempt to reverse this process. It is also important at this stage to understand the patient’s motivation for treatment: how much downtime can they afford and what change they would like to see? For some, the motivation behind their decision may be the desire to look ‘refreshed’, for others it may be the desire to look like they did 10 years ago. I tell all of my patients, that in my hands, 10 years younger is the maximum that can be achieved whilst still maintaining a natural appearance. In order to achieve natural looking and long-lasting rejuvenation, the four aspects of facial ageing need to be addressed: gravity, volume loss, skin quality and active lines. To correct one or two of these without addressing the others can produce a disjointed and unnatural appearance. Firstly, as with any patient, I look at the changes in gravity. In this patient, this includes a heavier upper eyelid fold on the right, softening of the jaw line in the jowl areas and platysmal banding and loss of the neck angle, which again, is more severe on the right side. For me as a practitioner, the only way to reverse gravity changes effectively is surgery. For this patient I would recommend an upper blepharoplasty and short scar MACS facelift. I would not advise her to have a lower blepharoplasty, as she does not have puffy lower eyelids or significant skin

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excess in this area. Next, I would consider Treatment List her volume issues. She has slightly more • Upper natural volume in the blepharoplasty left side of her face, • Sho rt scar MACS which appears more fac elif t youthful, but overall • Fat gra ft she has lost volume • Ch em ica l Peel from both cheeks, the • Bo tuli num toxin nasolabial folds, oral commissure, marionette lines and lips. During surgery I would use 2030mls of the patient’s own fat, removed from her inner knee region. I find that this site produces the most reliable and longlasting fat for transfer. I would harvest the fat using the closed PureGraft system and restore the youthful contours of the face using a multi-layered spot graft technique. Skin quality is often the most overlooked aspect of the four factors of facial ageing. It is, however, crucial to achieving a balanced and natural appearance. I would consider using a peel at the time of surgery, paying particular attention to the mixed pigmentation areas with brown sun-spots on her cheeks. Following surgery, I would emphasise the importance of prophylactic skin protection from UV radiation and recommend an on-going skin treatment programme. Skin lesions are representations of ageing and inevitably enlarge with time. I would therefore recommend removal of the small intradermal naevi on the side of her chin and both cheeks. Finally, I would address the fourth aspect of facial ageing: active lines and areas over active muscles activity. Our patient does have some residual active lines on her forehead, glabella, crow’s feet and lateral nose region. I would treat these with botulinum toxin treatments before, during or after surgery. Toxin treatment would also be helpful in treating her central playtsmal bands, which are again more pronounced on the right side. In my opinion, toxin relaxation combined with surgical tightening of the neck would produce the most natural rejuvenation of this region.

In order to achieve natural looking and long-lasting rejuvenation, the four aspects of facial ageing need to be addressed: gravity, volume loss, skin quality and active lines Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015

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Dr Tamara Griffiths, dermatologist Achieving successful facial rejuvenation is dependent on several factors. These include, an understanding of the complex events that occur at multiple anatomical levels associated with facial ageing; a thorough consultation with the patient, including an accurate assessment combined with good aesthetic judgement; and technical skill involving a variety of evidencebased rejuvenation modalities. These together provide a safe, effective and balanced approach to aesthetic treatment. My first step when meeting with the patient in question would be to discuss what bothers her the most. This is required to better understand the patient’s needs and to establish realistic expectations. Body dysmorphic disorder and other psychological issues need to be addressed and supported. The term “courageous restraint” has been coined to reflect the practitioner’s need to use sound, rational judgement, whilst understanding that in some cases not treating the patient is the best option. When analysing this relatively young female patient, the feature that strikes me the most is her sun- or photo-damaged skin. She has numerous pigmented actinic lentigenes on her cheeks, which could be treated with cryotherapy, light-based treatments such as IPL, or a range of chemical peeling agents. The key message to communicate to the patient would be the need to use broadspectrum (UVA and UVB) sunscreen on a regular basis – I usually recommend that this is applied three seasons out of four in the UK – and to give correct advice on the amount and frequency of use (eg. SPF 15 in foundation makeup is inadequate). If she likes the ‘sun-kissed’ look, then false tan is her best option, and as part of the consultation I would emphasise good ‘sun smart’ behaviour. I would recommend the use of a topical retinoid such as 0.025% tretinoin, and combine this with advice and guidance on use (frequency of application etc), in order to reduce the risks of irritation. Tretinoin provides short-term effects with increased epidermal thickening over the first three months, but I would advise the patient that the repair of collagen and elastin will take at least three months. Tretinoin will also help to lighten the actinic lentigenes. Recommendation of a cosmeceutical with a hydrophilic

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effect, such as hyaluronic acid (HA), will keep her skin hydrated, and a stable antioxidant Treatment List will add further photoprotection. • Cryotherapy Further analysis • IPL demonstrates a slight • Chemical Peel asymmetry in her facial • Tretinoin fat pad distribution. The • Hyaluronic acid light reflects off her • Botulinum toxin left cheek differently compared with the right, suggesting flattening or increased volume loss on the left. This could be corrected with a deep injection of a volume-replacing HA filler; my preference here would be the “pillar” technique, placing a deep periosteal injection on the left. This is a highly advanced technique due to the vascularisation of this region, with potential risk of blindness due to retrograde spread of the filler. Another option would be to use a microcannula

The key message to communicate to the patient would be the need to use broad-spectrum (UVA and UVB) sunscreen on a regular basis technique to the left malar region. HA filler would also be beneficial to a subtle degree in the melomental area; here I would use a microcannula and again the key is a subtle approach to minimise any kind of unnatural, ‘puffy’ look. When assessing the patient, it is critical to touch and squeeze/compress affected areas to accurately determine volume depletion. Asking the patient to move and animate their face is also important, particularly prior to the use of neuromodulators or botulinum toxins. It appears this patient’s right brow is slightly lower and more horizontal compared with the left. She would need slightly more toxin in the right brow depressor complex and less in the elevator complex to give a symmetrical and attractive brow lift. I would also most likely recommend m. orbicularis oculi injections bilaterally which would not only reduce crow’s feet wrinkles but widen the aperture of the eye. She would benefit from injections in the chin (m. mentalis) to reduce the mental crease and minimise pebbling with speaking/animation. She could also benefit from injection into m. depressor anguli oris and platysma in the anterior neck for the subtle cords, and more lateral injections into platysma for a slight tightening of the jaw line (referred to as the ‘Nefertiti lift’). Depending on the patient, it is likely these procedures would be performed over a few visits. My approach is to achieve a gradual, natural transformation deploying a holistic view of facial ageing and rejuvenation.

Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015

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one point

Managing Obesity: An Introduction In the first of a two-part weight special, Dr Sotirios Foutsizoglou explores the physiology and role of fat against the backdrop of current trends in obesity rates Introduction The laws of thermodynamics require that overall energy balance should be constantly maintained in living organisms during periods of stable weight. Weight gain results from an imbalance between energy intake and expenditure. Correlation of energy intake and expenditure with energy stores is a complex process, controlled in the hypothalamus and involving numerous amine and peptide neurotransmitters and neuromodulators. The hypothalamus senses adipose tissue mass (energy stores) by reception of leptin, a circulating signal generated in adipose cells. Obesity can result from an altered set point of energy stores, from unregulated caloric intake, decreased energy use or resistance to the action of leptin.1 Leptin and ghrelin are two hormones that have been recognised to have a major influence on energy balance. Leptin is a mediator of long-term regulation of energy balance, suppressing food intake and thereby inducing weight loss. Ghrelin, on the other hand, is a fast-acting hormone, playing a role in meal initiation. As a growing number of people suffer from obesity, understanding the mechanisms by which various hormones and neurotransmitters have influence on energy balance has been a subject of intensive research. In obese subjects the circulating level of the anorexigenic hormone, leptin, is increased, whereas surprisingly, the level of the orexigenic hormone, ghrelin, is decreased. It is now established that obese patients are leptin-

resistant.2 However, despite research, the manner in which both the leptin and ghrelin systems contribute to the development or maintenance of obesity is, as yet, not clear. Obesity is not just a cosmetic problem. It is a complex and chronic disease associated with a multitude of complications and life-threatening conditions (see Table 1). Health risks such as cardiovascular disease, cancer, diabetes, osteoarthritis, and chronic kidney disease increase when a person’s Body Mass Index (BMI) exceeds 23. In 2010, obesity and being overweight were estimated to have caused 3.4 million deaths worldwide, most of which were from cardiovascular causes. Research indicates that if left unchecked, the rise in obesity could lead to future declines in life expectancy.3 It is difficult to give an exact definition of obesity. From my experience, I would define obesity as the accumulation of excess body fat to the extent that it can be associated with reduced life expectancy and a negative impact on the individual’s health. The most common measure of obesity is the BMI. A person is considered overweight if their BMI is between 25 and 29.9, or obese if their BMI is 30 or above. Obesity can be subclassified into hyperplastic (referring to increased fat cell number) or hypertrophic (referring to increased fat cell size). Childhood-onset obesity is hyperplastic, whereas adult-onset obesity is characterised by hypertrophic changes. There are

Table 1. Diseases and conditions associated with obesity Relative risk (RR)

Associated with metabolic consequences

Associated with excess weight

Greatly increased RR > 3

Type 2 diabetes Gall bladder disease Hypertension Dyslipidaemia Insulin resistance Non-alcoholic fatty liver Atherosclerosis

Sleep apnoea Breathlessness Asthma Social isolation and depression Daytime sleepiness and fatigue

Moderately increased RR 2-3

Coronary heart disease Stroke Gout/hyperuricaemia

Osteoarthritis Respiratory disease Hernia Psychological problems

Slightly increased RR 1-2

Cancer* Reproductive abnormalities/impaired fertility Polycystic ovaries Skin complications Cataract

Varicose veins Musculoskeletal problems Bad back Stress incontinence Oedema/cellulitis

Breast, endometrial, colon, oesophageal and others.

Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015

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INDICATION

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Now approved for crow’s feet lines Bocouture® 50 Abbreviated Prescribing Information Please refer to the Summary of Product Characteristics (SmPC) before prescribing. 1162/BOC/AUG/2014/PU Presentation 50 LD50 units of Botulinum toxin type A (150 kD), free from complexing proteins as a powder for solution for injection. Indications Temporary improvement in the appearance of moderate to severe vertical lines between the eyebrows seen at frown (glabellar frown lines) and lateral periorbital lines seen at maximum smile (crow’s feet lines) in adults under 65 years of age when the severity of these lines has an important psychological impact for the patient. Dosage and administration Unit doses recommended for Bocouture are not interchangeable with those for other preparations of Botulinum toxin. Reconstitute with 0.9% sodium chloride. Glabellar Frown Lines: Intramuscular injection (50 units/1.25 ml). Standard dosing is 20 units; 0.1 ml (4 units): 2 injections in each corrugator muscle and 1x procerus muscle. May be increased to up to 30 units. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. Crow’s Feet lines: Intramuscular injection (50units/1.25mL). Standard dosing is 12 units per side (overall total dose: 24 units); 0.1mL (4 units) injected bilaterally into each of the 3 injection sites. Injections too close to the Zygomaticus major muscle should be avoided to prevent lip ptosis. Not recommended for use in patients over 65 years or under 18 years. Contraindications Hypersensitivity to Botulinum neurotoxin type A or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, Lambert-Eaton syndrome). Presence of infection or inflammation at the proposed injection site. Special warnings and precautions. Should not be injected into a blood vessel. Not recommended for patients with a history of dysphagia and aspiration. Adrenaline and other medical aids for treating anaphylaxis should be available. Caution in patients receiving anticoagulant therapy or taking other substances in anticoagulant doses. Caution in patients suffering from amyotrophic lateral sclerosis or other diseases which result in peripheral neuromuscular dysfunction. Too frequent or too high dosing of Botulinum toxin type A may increase the risk of antibodies forming. Should not be used during pregnancy unless clearly necessary. Should not be used during breastfeeding. Interactions Concomitant use with aminoglycosides or spectinomycin requires special care. Peripheral muscle relaxants should be used with caution. 4-aminoquinolines may reduce the effect. Undesirable effects Usually observed within the first week after treatment. Localised muscle weakness, blepharoptosis, localised pain, tenderness, itching, swelling and/or haematoma can occur in conjunction with the injection. Temporary vasovagal reactions associated with pre-injection anxiety, such as syncope, circulatory problems, nausea or tinnitus, may occur. Frequency defined as follows: very common (≥ 1/10); common (≥ 1/100, < 1/10); uncommon (≥ 1/1000, < 1/100); rare (≥ 1/10,000, < 1/1000); very rare (< 1/10,000). Glabellar Frown Lines: Infections and infestations; Uncommon: bronchitis, nasopharyngitis, influenza infection. Psychiatric disorders; Uncommon: depression, insomnia. Nervous system disorders; Common: headache. Uncommon: facial paresis (brow ptosis), vasovagal syncope, paraesthesia, dizziness. Eye disorders; Uncommon: eyelid oedema, eyelid ptosis, blurred vision, blepharitis, eye pain. Ear and Labyrinth disorders; Uncommon: tinnitus. Gastrointestinal disorders; Uncommon: nausea, dry mouth. Skin and subcutaneous tissue disorders; Uncommon: pruritus, skin nodule, photosensitivity, dry skin. Musculoskeletal and connective tissue disorders; Common: muscle disorders (elevation of eyebrow), sensation of heaviness. Uncommon: muscle twitching, muscle cramps. General disorders and administration site conditions; Uncommon: injection site reactions (bruising, pruritis), tenderness, Influenza like illness, fatigue (tiredness). Crow’s Feet Lines: Eye disorders; Common: eyelid oedema,

dry eye. General disorders and administration site conditions; Common: injection site haemotoma. Post-Marketing Experience; Flu-like symptoms and hypersensitivity reactions like swelling, oedema (also apart from injection site), erythema, pruritus, rash (local and generalised) and breathlessness have been reported. Overdose May result in pronounced neuromuscular paralysis distant from the injection site. Symptoms are not immediately apparent post-injection. Bocouture® may only be used by physicians with suitable qualiﬁcations and proven experience in the application of Botulinum toxin. Legal Category: POM. List Price 50 U/vial £72.00 Product Licence Number: PL 29978/0002 Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer Landstraße 100, 60318 Frankfurt/Main, Germany. Date of revision of text: August 2014. Further information available from: Merz Pharma UK Ltd., 260 Centennial Park, Elstree Hill South, Elstree, Hertfordshire WD6 3SR.Tel: +44 (0) 333 200 4143 Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard Adverse events should also be reported to Merz Pharma UK Ltd at the address above or by email to medical.information@merz.com or on +44 (0) 333 200 4143. 1. Bocouture 50U Summary of Product Characteristics. Bocouture SPC 2014 August available from: URL: http://www.medicines. org.uk/emc/medicine/23251. 2. Prager, W et al. Onset, longevity, and patient satisfaction with incobotulinumtoxinA for the treatment of glabellar frown lines: a single-arm prospective clinical study. Clin. Interventions in Aging 2013; 8: 449-456. 3. Sattler, G et al. Noninferiority of IncobotulinumtoxinA, free from complexing proteins, compared with another botulinum toxin type A in the treatment of glabelllar frown lines. Dermatol Surg 2010; 36: 2146-2154. 4. Prager W, et al. Botulinum toxin type A treatment to the upper face: retrospective analysis of daily practice. Clin. Cosmetic Invest Dermatol 2012; 4: 53-58. 5. Data on File: BOC-DOF-11-001_01 Bocouture® is a registered trademark of Merz Pharma GmbH & Co, KGaA. 1180/BOC/OCT/2014/LD Date of preparation: October 2014

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Botulinum toxin type A free from complexing proteins

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gender differences in fat distribution. The male or android distribution is characterised by increased subcutaneous fat in the upper body as well as central visceral fat deposits. The female or gynecoid distribution refers to fat accumulation in peripheral stores, in particular the femoral and gluteal areas. Central obesity is more metabolically active, changes with diet, and correlates with the risk of disease. Peripheral fat, on the other hand, is less metabolically active and is not significantly affected by diet restriction.4 Abdominal obesity carries a strong risk factor in terms of the development of cardiovascular disease, atherosclerosis, hypertension, and possibly some female cancers (breast, endometrial, ovarian).5 The visceral fat cells are of particular importance because of their relationship to the portal circulation. The breakdown products of lipolysis from visceral adipocytes drain directly into the portal circulation and can overcrowd the liver with a high concentration of free fatty acids, leading to hypertriglyceridaemia.6 Visceral obesity is also strongly associated with insulin resistance and impaired glucose tolerance, which are precursors of diabetes type 2.7 Physiology and Function of Adipose Tissue The primary function of adipose tissue is to insulate and cushion the body, to store free fatty acids (FFAs) after food intake and to release FFAs during the fasting state to ensure sufficient energy status. During the postprandial phase, FFAs are taken up from the blood in adipose tissue after hydrolysis of triglycerides (TG) from triglyceride-rich lipoproteins (very low-density lipoproteincholesterol (VLDL-c), chylomicrons and their remnants) by lipoprotein lipase (LPL). Mobilisation of this reserve occurs by hydrolysis of adipocyte TG by hormone sensitive lipase (HSL). Insulin is the main regulator of adipocyte fat content, since it is both a potent inhibitor of HSL and an important activator of LPL, thereby enhancing FFA uptake and triglyceride synthesis in adipocytes. Fat is an exocrine, endocrine, and apocrine organ and plays a role in immunity. Fat cells produce hormones such as leptin, which is normally released after a meal and dampens appetite. They also produce the hormone adiponectin, which is thought to influence the response of cells to insulin.8 Although scientists are still deciphering the roles of individual hormones, it is becoming clear that excess body fat, especially abdominal fat, disrupts the normal balance and functioning of these hormones.8 Adipose tissue consists of adipocytes, fibrous trabeculae, and blood vessels. Mammals have two different types of adipose tissue; white adipose tissue and brown adipose tissue. White adipose, the most common type, provides insulation, serves as a reservoir of energy, and provides insulation and protection against physical injury. Brown adipose, found mainly in newborn and hibernating animals, generates heat and actually consumes energy. In humans, the percentage of brown adipose found in the body decreases with age. Its colour and heat-generating properties are imparted by the abundance of iron containing mitochondria found in brown fat cells which utilise fuels to produce energy in the form of ATP.9 The chief chemical constituents of adipocytes are triglycerides, which are esters made up of a glycerol and one or more fatty acids, such as stearic, oleic, or palmitic acids. Enzymes contained in adipose cells specialise in the hydrolysis of triglycerides in order to generate fatty acids and glycerol for physiological processes. The fat stored in these cells partly comes directly from the fats eaten, or is manufactured within the body from fats and

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Recent studies have revealed that adipose tissue is a dynamic tissue with multiple functions carbohydrates in food, sometimes protein. The main reservoir of fat in the body is the adipose tissue beneath the skin, called the panniculus adiposus. There are also deposits of fat between the muscles, among the intestines and in their mesentery, around the heart, between abdominal organs, and in our cells (e.g liver cells).9 Adipocytes appear packed between the vasculature. This is because they are compressed by colloid osmotic pressure, generated by soluble proteins in the interstitial space, with the most important adipocytes being albumin, globulin, and fibrinogen. The shape of a fat-laden mature adipocyte is that of a cygnet ring, as the central lipid accumulation pushes the nucleus to the periphery. Every adipocyte is surrounded by capillaries, which are highly sensitive to epinephrine, causing vasoconstriction. Liposuction performed with the use of Klineâ&#x20AC;&#x2122;s tumescent anaesthesia takes advantage of the above in order to produce a relatively bloodless procedure.10 Recent studies have revealed that adipose tissue is a dynamic tissue with multiple functions. Adult stem cells are abundant within the adipocytes, and in the case of excess calorie intake, these stem cells are recruited to form new lipocytes.11, 12, 13 Zuk reported isolation of a population of stem cells from human adipose tissue, where the cells were obtained from a liposuction aspirate, and were then determined to be mesenchymal and mesodermal in origin. In vitro these cells could differentiate into adipogenic in the presence of proper induction factors.14 This study indicates that the removal of fat by liposuction does not necessarily equate to a permanent reduction in the absolute lipocyte number, a common misconception in aesthetics. Gross Anatomy of Adipose Tissue Subcutaneous fat is the layer of subcutaneous tissue that is most widely distributed. It is composed of adipocytes, which are grouped together in lobules separated by connective tissue. Subcutaneous fat is found just beneath the skin, as opposed to visceral fat, which is found in the peritoneal cavity. Visceral fat has been linked to metabolic disturbances and increased risk for cardiovascular disease and type 2 diabetes. In women, it is also associated with breast cancer and the need for gallbladder surgery.15 One reason excess visceral fat is so harmful could be its location near the portal vein, which carries blood from the intestinal area to the liver. Substances released by visceral fat, including free fatty acids, enter the portal vein and travel to the liver, where they can influence the production of blood lipids.16 Visceral fat is directly linked with higher total cholesterol and LDL cholesterol, lower HDL cholesterol, and insulin resistance.16 Most of the remaining nonvisceral fat is found in the hypodermis and

Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015

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can be divided into three layers: apical, mantle and deep. Apical Layer This most superficial layer of subcutaneous fat is just beneath the reticular dermis and surrounds sweat glands and hair follicles. It also surrounds vascular and lymphatic vessels. This layer is rich in carotenoids and tends to be yellow in appearance. Mantle Layer This layer is composed of columnar-shaped lipocytes and is separated from the deep layer of fat by a fascia-like layer of fibrous tissue. The mantle is absent in eyelids, nail beds, bridge of the nose, and penis.10 This layer significantly contributes to the skin’s ability to resist trauma. It causes external pressure to be distributed across a larger field; much like a box-spring mattress absorbs sitting pressure. Deep Layer This layer extends from the under-surface of the mantle layer to the muscle fascia below. Its shape and thickness depend on the sex, genes and diet of the individual. In this layer fat cells are arranged in pearls, and the pearls are gathered into globules. These globules are then packaged like eggs in an egg crate between septa, and arranged between tangential and oblique fibrous planes. Oblique planes are thinner and interconnect the tangential fibrous layers. They also play a role in the formation of cellulite.10 The apical and mantle layers formerly represented the ‘no go zone’ in liposuction, due to their proximity with nerves and vessels, disruption of which could lead to seroma, pigment disorders and full thickness skin necrosis. Nowadays, however, with the use of much thinner cannulae, we are able to treat superficially to the deep subcutaneous layer during a liposuction procedure. Nutrition and Metabolism Everything we eat contains carbohydrates, fats and proteins in varying amounts. Dr Sam Robson, medical director of Temple Medical, says “Sugars are ready made fuels. Carbohydrates can be turned into sugars relatively fast, but fats are stored in the fatty tissue for future needs, because turning fat into fuel requires more energy. If the body cannot use the amount of fuel (sugars and carbohydrates) immediately, these sugars and carbohydrates, as well as proteins, will be stored in the form of fats.” Stored fat is mobilised during calorie restriction through the activation of triglyceride lipase. The hormonal signal to activate triglyceride lipase is glucagon and, to some extent, epinephrine. When the insulin-glucagon ratio is in favour of insulin, fat cannot be mobilised. Insulin is secreted in response to circulating glucose levels. Thus, a meal that raises glucose will cause insulin secretion, the magnitude of which depends on the carbohydrate load. Fat is stored as triglycerides, it is deposited in the adipocyte by lipoprotein lipase (lipogenesis), and is released by hormone sensitive lipase (lipolysis). Over a two to three week period, all of the stored triglycerides are either catabolised for energy production or broken down into free fatty acids. The liver is also involved in fat metabolism. The liver can utilise fatty acids for energy production, synthesise triglycerides from carbohydrates and, to a lesser extent, from proteins,

Fats serve important structural and metabolic functions

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and esterify fatty acids to form other lipid compounds such as phospholipids. After carbohydrate consumption, the amount in excess of that used for energy, or stored as glycogen, is converted by the liver into triglycerides, which are then stored in adipocytes.17 Exogenous dietary fats are hydrolysed in the gut and then packed into chylomicrons by the intestinal cells, which are finally released into the lymphatics and the blood stream. Endogenous fatty acids are synthesised by the liver from carbohydrates and, to a smaller extent, from proteins. These fatty acids are then metabolised into triglycerides, packed as the very low-density lipoproteins and released into the circulation. Lipolysis is under the influence of the hormone-sensitive lipase. It can be activated by epinephrine, norepinephrine, corticotrophin, glucocorticoids, growth hormone, thyroid hormone, and a decrease in plasma insulin. Catecholamines also stimulate lipolysis acting on β- adrenergic receptors. Regarding lipogenesis, the action of lipoprotein lipase is the rate-limiting step that mediates the uptake of free fatty acids into the adipocyte. An integral part of the formation of triglycerides is the formation of αglycerolphosphate from glucose in the fat cells. Glucose transport is facilitated by insulin receptors on adipocytes.17 Fat is one of the three main macronutrients along with protein and carbohydrate. As we know, ‘fat’ does not necessarily make us fat and should be included in our diet. As Eva Escofet, a nutritional therapist with more than 10 years of clinical experience, says, “Restrictive diets are generally shown to offer short term resolutions only, which are not sustainable.” Foods that are naturally low-fat (like fruits and vegetables) are beneficial, but processed foods with ‘low-fat’ on the label can sometimes be loaded with unhealthy ingredients, such as high fructose corn syrup and partially hydrogenated soya bean oil which contains trans fat, rendering them more damaging to our health.18 Fats serve important structural and metabolic functions. A large amount of the daily metabolic energy requirement comes from fat metabolism. There are two metabolic functions of adipose tissue. First, it provides storage of triglycerides as long-term energy reserve and, second, it has a very dynamic pattern of metabolism, which responds, on a minute-to-minute basis, to the energy requirements by modulating the supply of lipid energy released to the rest of the body in the form of non-esterified fatty acids.19 On the other hand, I strongly believe that trans fat and refined oils should be kept to a minimum due to their strong link with cardiovascular disease.20 Animal-based fats were once the only trans fats consumed, but by far the largest amount of trans fat consumed today is created by the processed food industry21 as a side effect of partially hydrogenating unsaturated plant fats (generally vegetable oils). These partially hydrogenated fats have displaced natural solid fats and liquid oils in many areas, the most notable ones being in the fast food, snack food, fried food, and baked goods industries. Consumption of trans fats has shown to increase the risk of coronary heart disease in part by raising levels of the lipoprotein LDL (so-called ‘bad cholesterol’), lowering levels of the lipoprotein HDL (‘good cholesterol’), increasing triglycerides in the bloodstream and promoting systemic inflammation. Refined vegetable oils such as soybean, corn and canola oils, contain large amounts of Omega-6 fatty acids, which are biologically active and can cause oxidative stress and make the LDL lipoproteins in the body become oxidised, potentially contributing to heart disease.22 The AMP-activated protein kinase (AMPK) is an important integrator of signals managing energy balance. It has been shown that dysregulation of AMPK activity underlies the pathogenesis of metabolic syndrome. A strong correlation between low activation state of AMPK and metabolic disorders associated with insulin resistance,

Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015

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obesity and sedentary activities has been established.23 A high fat diet causes dysregulation of AMPK, associated with impaired AMPK phosphorylation and protein expression in skeletal muscle, heart, liver, aortic endothelium and hypothalamus. AMPK inhibition can also be caused by inflammatory signals (i.e. pro-inflammatory cytokines). AMPK is implicated in energy production by the cell through phosphorylation on threonine residue 172 (Thr-172), thus inhibition of AMPK will also have a negative effect on cellular metabolism.24 Trends in overweight and obesity rates “Obesity is an issue affecting people of all ages and incomes, everywhere,” says Dr Christopher Murray, director of Institute for Health Metrics and Evaluation (IHME) and a co-founder of the Global Burden of Disease (GBD) study. “In the last three decades, not one country has achieved success in reducing obesity rates, and we expect obesity to rise steadily as incomes rise in lowand middle-income countries in particular, unless urgent steps are taken to address this public health crisis.” In terms of statistics, China and India together represent 15% of the world’s obese population.25 The highest proportion of obese people in the world (13%) live in the United States. Nationally representative estimates from 2009 to 2010 indicate that 35.5% of the adult population in the US is obese (defined as BMI >30). About 15.5% of the US adult population has a BMI of 35 or Figure 1: BMI Chart

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Weight (kilograms) Figure 2: Trend in adult prevalence of obesity in the UK (BMI≥30kg/m2) – percentage of the adult population assessed as obese in the UK and Ireland, 1995 – 2011. (Public Health England 2014)

Obesity prevelance (%)

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more, and 6.3% are severely obese (BMI >40).25 Despite increased spending on medical and surgical interventions, rates of obesity continue to increase inexorably. The prevalence of obesity in England has more than doubled in the last 25 years.26 In 2010, it was estimated that about 46% of men in England and 32% of women are overweight (a body mass index of 25-30 kg/m2), and an additional 17% of men and 21% of women are obese (a body mass index of more than 30 kg/m2).27 In 2012 a health survey of England showed that 1.7% of men and 3.1% of women had a BMI of 40 or more (morbidly obese).28 Obesity rates continue to increase in all countries within the British Isles and Ireland, and Scotland continues to have the highest prevalence of obesity.29 In 2010, 65% of Scottish adults aged 16 and over were overweight or obese (BMI≥25).30

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Conclusion Obesity is a complex condition, one with serious social and psychological dimensions, that affects virtually all age and socioeconomic groups and threatens to overwhelm both developed and developing countries. Its health consequences range from increased risk of premature death to serious chronic conditions that reduce overall quality of life. The classical perception of adipose tissue as a storage depot of FFAs has now been replaced by the notion that adipose tissue is an active endocrine organ playing a central role in lipid and glucose metabolism, and produces a large number of hormones and cytokines involved in the development of metabolic syndrome, diabetes mellitus, and vascular disease. Better understanding of the physiology and role of the adipocyte may provide the pathophysiological framework within which the relationship between obesity and its associated detrimental metabolic consequences can be found. Weight reduction and increasing physical activity are effective interventions for improving adipose tissue function. It has been shown that after three months of restricted caloric intake and increased exercise TNF-a, leptin, and IL-6 levels decrease. On the other hand, anti-inflammatory cytokines (adiponectin and IL-10) are significantly increased in obese subjects with metabolic risk factors. Insulin sensitivity

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improves and adiponectin plasma levels increase, suggesting that adipocyte function improves, as low adiponectin levels are generally associated with adipocyte dysfunction.31 Further knowledge of the underpinnings of adipose tissue dysfunction may provide new targets for drug development for the management of obesity, along with better approaches to halt the epidemic proportions of obesity before it is too late. REFERENCES 1. Berne R M, Levy M N, Physiology, 4th Ed., (St Louis: Mosby 1998) 2. Klok MD, Jakobsdottir S, Drent ML. ‘The role of leptin and ghrelin in the regulation of food intake and body weight in humans: a review’, Obesity Reviews, Jan;8(1) (2007) 21-34 3. Marie Ng et al., ‘Global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013: a systematic analysis for the Global Burden of Disease Study 2013’, The Lancet, Vol 384, Issue 9945 (2014), pp. 766 – 781 4. Larsson B, ‘Regional obesity as a health hazard in men. Prospective studies’, Acta Med Scand Suppl, 723 (1988) p.121-134. 5. Schapira DV, Kumar NB, Lyman GH, and Cox CE, ‘Abdominal Obesity and Breast Cancer Risk’, Annals of Internal Medicine, (1990) 6. Klein S, ‘The case of visceral fat: argument for the defense’, J Clin Invest, 113(11) (2004), pp. 1530–1532 7. Kissebah AH and Evans DJ, ‘Mechanisms associating body fat distribution to glucose intolerance and diabetes mellitus’, Acta Med Scand, 723 (1988) p.79-89 8. Ukkola O, Santaniemi M., ‘Adiponectin: a link between excess adiposity and associated comorbidities?’, J. Mol. Med. 80 (11) (2002), pp. 696–702. 9. Encyclopaedia Britannica, Adipose Tissue (US: Encyclopaedia Britannica, 2014) <http://www. britannica.com/EBchecked/topic/5948/adipose-tissue> [Accessed February 9] 10. Shiffman M and Di Giuseppe A., Liposuction: Principles and Practice. (Germany, Springer, 2006) 11. Cheng AYM, Deitel M, Roncar DAK, ‘The biochemistry and molecular biology of human adipocyte’, Int J Obes (2004). 12. Van RLR et al. ‘Complete differentiation of adipocyte precursors’. Cell tissue Research 195 (2012) 317-39 13. Lott KE, Awad HA, Gimble JM, Guilak F, ‘Clonal Analysis of multipotent Differentiation of Human Adipose- Derived Adult stem Cells’, Duke Med News March 12 (2013) 14. Zuk PA, Zhu M, Mizuno H, Huang JBS, Katz AJ. ‘Multilineage Cells from Human Adipose Tissue: Implications for Cell-Based Therapies’ Tissue Eng 7:211-24 (2001) 15. Kissebah, AH, et al. ‘Relation of body fat distribution to metabolic complications of obesity’, J. Clin. Endocrinol. Meta, 54 (1982), pp. 254-260. 16. Harvard Medical School, ‘Abdominal fat and what to do about it’, Harvard Health Publications, February 2007 update (2007)

Dr Sotirios Foutsizoglou specialises in minor cosmetic surgery and aesthetic medicine. He is the founder and medical director of SFMedica, based on Harley Street in London. In addition to his MBBS he also holds a BSc(Hons) in mathematics from the University of Athens and a MSc in Biostatistics and Epidemiology from the Harvard School of Public Health.

17. Frayn KN, ‘Adipose tissue metabolism’, Clin Dermatol, 17 (1989), p.49-61 18. Thomas LH, Jones PR, Winter JA, Smith H, ‘Hydrogenated oils and fats: the presence of chemically-modified fatty acids in human adipose tissue’, American Journal of Clinical Nutrition 34 (1981) 877-86 19. Guyton AC, Lipid and protein metabolism. Human Physiology and Mechanisms of Disease (Philadelphia: WB Saunders, 1992) p.520-25 20. Mozaffarian D, Katan MB, Ascherio A, Stampfer MJ, Willett WC. ‘Trans fatty acids and cardiovascular disease’, New England Journal of Medicine, Apr 13;354(15) (2006) 1601-13 21. Casimir C. et al. Food lipids: chemistry, nutrition, and biotechnology. (New York: M. Dekker 2002), pp. 1–2 22. Westerterp-Plantenga MS, Nieuwenhuizen A, Tome D, Soenen S, Westerterp KR, ‘Dietary protein, weight loss, and weight maintenance’, Annu Rev Nutr, 29 (2009), p.21-41 23. Kelly M, Keller C, Avilucea PR, Keller P, Luo Z, Xiang X, Giralt M, Hidalgo J, Saha AK, Pedersen BK, ‘Interleukin-6 regulation of AMP-activated protein kinase. Potential role in the systemic response to exercise and prevention of the metabolic syndrome’, Diabetes Dec;55 Suppl 2 (2006) 48-54 24. Lee WJ, Lee IK, Kim HS, Kim YM, Koh EH, Won JC, Han SM, Kim MS, Jo I, Oh GT, Park IS, Youn JH, Park, ‘Alpha-lipoic acid prevents endothelial dysfunction in obese rats via activation of AMP-activated protein kinase’, Arterioscler Thromb Vasc Biol 25 (2005) 2488–2494. 25. Cynthia L et al, ‘Prevalence of Childhood and Adult Obesity in the United States’, JAMA 311:8 (2014), 2011-2012 26. Public Health England, UK and Ireland prevalence and trends (England: Public Health England, 2015) <www.noo.org.uk/NOO_about_obesity/adult_obesity/UK_prevalence_and_trends> 27. Health Survey for England – 2010: Trend Tables. The NHS Information Centre, 2011. 28. Public Health England, Severe Obesity (England: Public Health England, 2014) <http:// www.noo.org.uk/NOO_about_obesity/severe_obesity> 29. Public Health England, International Comparisons (England: Public Health England, 2015) <http:// www.noo.org.uk/NOO_about_obesity/adult_obesity/international> 30. Bromley, Catherine et al, The Scottish Health Survey: Volume 1: Main Report Bromley, (Scotland: scotland.gov.uk, 2011) < http://www.scotland.gov.uk/Publications/2011/09/27084018/0> 31. Hajer GR, van Haeften TW, Visseren FL, ‘Adipose tissue dysfunction in obesity, diabetes, and vascular diseases’, Eur Heart J 29(24) (2008), pp. 2959-2971

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Spotlight On: Plexr Soft Surgery

Aesthetics explores the latest development in non-ablative technology equivalent to those achieved through surgery Patient demand for faster treatment with minimum downtime is increasing year on year. Aesthetic practitioners are being continually challenged to offer non-surgical procedures that provide results. In response to this demand, Professor Giorgio Fippi, president of the Italian Society for Aesthetic Medicine, has developed an innovative tool that uses plasma to treat an array of aesthetic concerns. The Plexr (which stands for Plasma Exeresis) comprises three handheld wireless devices (white, green and red) that each offer varying degrees of treatment. The device , which has received CE approval, works through the non-ablative process of sublimation. Plasma is formed through the ionisation of atmospheric gas, which works to stimulate the contraction, shortening and tightening of skin fibres, thus resulting in the reduction of the skin surface. The amount of plasma generated depends on which Plexr device is used, air exchange in the ionisation area, and the emission of atmospheric

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gases in the treatment area. Plexr can also be used for mole removals, stretch mark treatment, excess skin removal, keloid scar removal, hyperpigmentation treatment, acne scarring and as an active acne treatment. As Plexr does not directly touch the skin, the manufacturers claim using the device for aesthetic concerns significantly reduces the risk of complications occurring. Studies into the efficacy of Plexr for the treatment of excess skin on the upper eyelid, perioral rhytides and acne have been conducted, with positive results.1,2,3 Dr Sherif Wakil, president of the International Association of Soft Surgery and lead Plexr Soft Surgery trainer in the UK, uses the device as an alternative to blepharoplasty. He explains, “Plexr works on a completely different mechanism of action compared to laser or cryogenics. By generating plasma, Plexr maintains the vitality of the tissue much better than other methods of skin tightening or rejuvenation, as demonstrated in a histological comparison between Plexr and radio-surgical methods.”1 “Extra skin on the eyelid is a very common patient complaint in my clinic,” says Dr Wakil. “With surgery, there is a standard procedure which can allow one eye to be more corrected than the other. Plexr allows the practitioner to sculpt each patient’s upper eyelid and individualise treatment to each line or piece of skin. As it is a very small tool, it’s very easy to manoeuvre and target the most hidden areas to achieve the best results.” He adds, “This procedure has less complications than surgery for blepharoplasty – no anesthesia, reduced down-time and the expense is much lower. You find a lot of patients are boasting that they’ve had an effective procedure without a knife touching their face.” Plexr can also be used for dermabrasion. The study, ‘Treatment of Perioral Rhytides with Voltaic Arc Dermoabrasion’, comprised 15 patients (11 female and four male) who were aged between 30 and 65 years. The majority (90%) had class II and III wrinkle scores within the perioral area. After undergoing treatment with Plexr, the study’s authors concluded that, “Fine rhytides, particularly in the perioral areas may be completely eradicated with voltaic arc resurfacing; deeper creases are also improved, probably secondary to a general tightening effect.” A second study, ‘Plexr in Acne Treatment’, treated 30 patients with acne (10 male, 20 female) aged between 14-45 years. Of the 30 patients, 23 had already tried to treat their acne with both local and systemic treatment, with little effect. The remaining seven patients had not undergone any treatment prior to Plexr. The authors found no relapse in any of the patients, and no side effects such as dyschromia, scars, hyperpigmentation or hypopigmentation, which can occur as a result of laser and peel treatments. They concluded, “Plexr is an alternative way of treating acne without

Treatment case studies Before Eyelid treatment with Plexr

Before Periorbital treatment with Plexr

After Eyelid treatment with Plexr

Immediatly after Perioribtal treatment with Plexr

Before mole removal with Plexr

After Mole removal with Plexr

Images courtesy of Dr Sherif Wakil

Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015

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the need of systemic medication.” Depending on the indication, practitioners can adopt two techniques for effective treatment results, known as ‘spraying’ and ‘spotting’. The first is more commonly used for pigment treatments, whilst the second is used to aid skin tightening. “Each technique has its own treatment protocol,” explains Dr Wakil. “Practitioners are given patterns to follow for ‘spraying’ and are taught how to target treatment areas whilst ‘spotting’.” Dr Wakil explains that the Plexr should be held 1-2mm away from the skin during treatment, and says, if the device touches the skin, it will immediately switch off, preventing the risk of injury. Once treated, the skin will develop a crust-like protective layer, which will fall off approximately five-seven days post procedure. The new skin, often referred to as similar to ‘baby skin’ by Dr Wakil’s patients, will be very thin and soft, and pink in colour. Patients can conceal it with makeup until it develops to match their natural skin colour. Plexr treatments usually take approximately 20-30 minutes, depending on the area being treated and the severity of each case. For practitioners using the Plexr as an alternative to blepharoplasty, Dr Wakil advises practitioners offer patients two to three treatments, before the final aesthetic results equate to those achieved through surgery. “When you are starting out, it’s better to do it bit by bit,” he says, adding, “Don’t be aggressive and make sure you take your time.” Dr Wakil says that there are no contraindications for the use of Plexr, and explains it can treat aesthetic concerns not achievable through laser treatment. “You can not use lasers to treat Herpes Simplex, however Plexr allows you to treat the viral disease, as well as the blisters that could accompany it.” He says he has not yet

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seen any complications following treatment with Plexr, and notes that the procedure is suitable for most patients with all Fitzpatrick skin types. After cleansing the skin and applying the numbing cream, practitioners should wait around 20 minutes before administering treatment. Dr Wakil explains that you can then position the patient appropriately and begin using the Plexr. He says, “Patients can open and close their eyes during the procedure, allowing practitioners to target each area effectively.” Once the procedure is complete, Dr Wakil says he then applies a concealer to the treated area, which patients can take home. Healing time for patients with higher Fitzpatrick skin types can take four/five weeks, compared to the usual two/three weeks for patients with lighter skin. He suggests that practitioners should advise patients to protect their skin from the sun and apply ice to the swollen treated area, which, according to the doctor, usually goes down after approximately two days. Dr Wakil also gives patients eye drops to take home, for the rare occasion that patients develop any redness or infection. Whilst Dr Wakil reports no complications, he does note that problems could arise if a practitioner does not receive appropriate training for the use of Plexr. Adding to the already varied indications Plexr can treat, research is currently underway for its effectiveness as an alternative treatment to labiaplasty. REFERENCES 1. Scarano A et al, ‘Skin lesions induced from the radiosurgical unit and voltaic arc dermoabrasion: A rabbit model’, European Journal of Inflammation, 9 (2011), p.89-94. 2. Scarano A et al, ‘Treatment of perioral rhytides with voltaic arc dermoabrasion’, European Journal of Inflammation, 10 (2012), p.25-29. 3. Stamatina G et al, ‘Plexr in acne treatment’, Pinnacle Medicine & Medical Sciences, 2 (2015), p.482-486.

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THE FUTURE OF WELLNESS HAS ARRIVED LONDON / 7-8 MAR 2015

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“Fatigue, lack of energy and weight gain are amongst the commonest symptoms I see. Reviv with its high concentration vitamin and mineral intravenous therapy, might just be the answer. Safe and effective, its set to become the go-to treatment for everyone in the UK who likes to work hard and play hard.” Dr Hillary Jones

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notes that there are some contraindications to treatment, such as “potassium issues, certain cardiac problems or those taking specific medications”, adding that around 1% of patients presenting are unsuitable for IVMT. Post-treatment, patients feel more relaxed and energised with enhanced skin and wellbeing, although these benefits are anecdotal. At Reviv clinics, patients can have IV infusions and booster shots containing a mix of nutrients. Former GP, TV doctor and Reviv’s chief medical adviser, Dr Hilary Jones, explains that the IV and intramuscular treatments are designed to combat fatigue, dehydration, sickness, common cold, dry skin and much more. “On average, most people report a benefit within two hours,” Dr Jones says. “Your body will be fully hydrated; individuals report increased energy levels for four to seven days and, from a preventative health perspective, no longer suffer from the common cold and flu. A high percentage see a significant difference in their skin and nail condition.”

The Vitamin Drip Debate Allie Anderson examines the arguments for and against this growing aesthetic trend Background Intravenous micronutrient therapy (IVMT) has enjoyed a surge in popularity in recent years, perhaps thanks to a string of celebrity endorsements. The practice was pioneered decades ago by US physician Dr John Myers, who routinely gave intravenous infusions containing a mixture of vitamins and nutrients to patients with a range of ailments. After his death in 1984, Dr Alan Gaby continued treating some of Myers’ patients with an adapted version of what has become known as ‘Myers’ cocktail’ – which is said to have contained magnesium chloride, calcium gluconate, thiamine, vitamins B6 and B12, calcium panthothenate, vitamins C and B complex and diluted hydrochloric acid.1 Dr Gaby expanded the use of IVMT and it gained in prominence throughout the United States and, soon after, internationally. The treatment is now widely available in a variety of settings, most commonly in cosmetic clinics and medispas, but it can also be administered in offices and in the comfort of the individual’s home. Reported effects According to Esther Fieldgrass, aesthetic practitioner and founder of London’s EF Medispa, IVMT is potentially suitable for anyone with dehydration, fatigue and nutrient deficiency. “Our patient profiles cover a wide variety of people: those who lead very active lives, frequent travellers suffering jet lag, people in high-stress jobs and some who consider themselves prone to minor ailments,” she says. IV infusions are individually formulated, based on an extensive patient history and questionnaire, which are reviewed by a doctor or nurse. “The practitioner may request specific tests – such as urine, saliva and blood – if the patient presents with any health concerns.” Fieldgrass

The evidence Many studies have been conducted into the efficacy of IVMT, most of which examine its use in particular cohorts of patients with specific conditions. In a 2002 review of evidence, Dr Gaby reported that his modified version of Myers’ cocktail “had been found to be effective against acute asthma attacks, migraines, fatigue, fibromyalgia, acute muscle spasm, upper respiratory tract infections, chronic sinusitis, seasonal allergic rhinitis, cardiovascular disease, and other disorders”.1 He concluded that Myers’ cocktail (or variations thereof) was safe and effective, but that “most of the evidence is anecdotal”. Fieldgrass and Dr Jones both cite studies of the use of IV magnesium in treating acute asthma.2,3,4 In a 2000 review of literature describing the effects of IV magnesium sulphate for acute asthma, scientists concluded that although routine use of the therapy in asthma patients presenting to emergency departments was not supported, the treatment appears to be safe and beneficial for others with severe acute asthma.4 Similar studies claim to demonstrate that IVMT is beneficial for people with fibromyalgia,5,6 but a later, randomised placebo-controlled trial found no statistically significant differences between patients treated with IVMT and those given a placebo.7 Dianne Bedford, practitioner at the Lasky Aesthetics and Laser Center in California, administers IVMT to a range of patients. “Individuals not only want to look good, but feel good as well,” she explains. “IV vitamin infusions are a way to deliver beneficial nutrients into the cell to help remedy a variety of concerns and improve overall wellbeing.” Bedford describes the majority of her patients as those seeking to boost their immune system and optimise their general health. She says there are benefits to supplementary nutrients because many people don’t absorb them sufficiently when they are ingested. “Many factors are needed for optimal absorption and delivery of nutrients, such as optimal gut health, healthy liver function and healthy cell membranes,” Bedford comments. “Most patients have some type of gut complaint, such as poor digestion, acid reflux, food intolerance or allergies, thereby decreasing their ability to breakdown and absorb any supplement.” In addition, Bedford suggests that certain nutrients are only beneficial to our bodies at higher concentrations. “Vitamin C has been known to have an antiviral effect at serum concentrations of 10-15mg/dl [micrograms per decilitre]. These levels are not attainable with oral intake of vitamin C. Most people take 500mg to 1gm of vitamin C daily, [but] a dose of 2.5gm of vitamin C would raise the serum concentration to about 1.2 to 1.5mg/dl.”

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A 1990 study indeed found that vitamin C at high concentrations (10 to 15mg/dl) had antiviral properties.8 However, the study specifically examined suppression of the human immunodeficiency virus (HIV) in vitro rather than as a therapy on real-life patients. A more recent study reviewed and compared placebo-controlled trials involving more than 11,000 participants, and found that regular supplementation of vitamin C failed to reduce the incidence of colds, but was successful in reducing the duration and severity of colds.9 The study neither stated the upper vitamin C dose limit of the reviewed trials, nor distinguished between the effects of different doses; but it stated that the trials tested doses of at least 0.2g (200mg) per day of vitamin C – the amount available in an average, over-the-counter oral supplement.

that’s without sufficient evidence to prove its efficacy. “I don’t like the fact that we can trivialise things that shouldn’t be trivialised. A vitamin drip to improve the quality of your skin seems, to me, a step too far. I feel there’s an element of the emperor’s new clothes about this.” For Duckett, the answer to achieving the health benefits that IVMT purports to deliver is simple: “Get enough sleep, get enough exercise and eat a healthy diet.” Dr Quinn highlights a potentially more significant problem. “When someone has an intravenous drip there is always a risk of severe allergic reaction or even anaphylactic shock,” he says. “There’s a very strong argument that anyone having an IV infusion should be in hospital, and not in an aesthetic clinic – so there is a safety issue here as well.”

Opposition Much of the dispute against IVMT centres on the argument that we ought to get all the nutrients we need from our diet. The recommended daily intake of vitamin C in the US is 90mg for adult males and 75mg for adult females,10 and in the UK it’s 40g for all adults.11 Vitamin C – like many of the others used in IVMT, such as B1, B2, B3, B6 and B12 – are water-soluble, simply meaning that rather than storing them in our cells, our bodies excrete what we don’t need. Dr John Quinn, former GP, and founder and clinical director of Quinn Clinics, suggests the case is clear. “I strongly believe that we should be practising evidence-based medicine, and I’m not aware of any evidence that giving someone vitamins, unless they have a deficiency, has any benefit at all,” he says. The National Institute for Health and Care Excellence (NICE) recommends certain supplements for some groups who have or are at risk of deficiency,12 including:

Notwithstanding these risks, IVMT has an expanding fan base and there is a growing body of anecdotal evidence supporting its use. The suggestion of a placebo effect may not be without basis: it is said to be a factor in complementary and alternative medicines, where the time taken over consultation, the approach of the practitioner and the patient’s expectations all affect the impact of a treatment.16 Indeed, the very nature of how the treatment is delivered – the patient sitting or lying comfortably for 30 to 60 minutes in a relaxing environment – could itself contribute to the patient feeling refreshed and vitalised. For people who lead busy, stressful lives, the treatment provides a rare opportunity just to stop for an hour, without the usual distractions that prevent them from winding down. Many argue that if a treatment makes people feel better, through whatever means, then it can be considered worthwhile. As the popularity of IVMT continues to grow, it is unlikely this debate will subside any time soon. Whether you choose to adopt the treatment in your clinic or not, thorough research and safe practise are key components to successful treatment outcomes and patient satisfaction.

· · ·

Folic acid for pregnant women and those trying to conceive Vitamin D for children, the elderly, pregnant and breastfeeding women, and people who don’t get enough sun exposure Specific supplements for medical conditions, such as iron to treat iron-deficiency anaemia

It can be argued that many patients at clinics or spas offering IVMT do not represent these cohorts, and neither are they typically people with acute asthma or HIV, or any of the other conditions and illnesses in which IVMT has been anecdotally shown to provide beneficial effects. Certainly, nutrient deficiencies in the general population are not unheard of. “Some people don’t absorb vitamin B12; for example, people who don’t eat meat may need to have their levels checked,” explains Dr Quinn. “Vitamin D deficiency is also increasingly common and recognised, particularly among the immigrant population, so there are some situations where vitamin supplementation makes sense.” However, diagnosing a deficiency relies on blood testing,13,14 which, some argue, may not be routinely carried out as part of the consultation with patients seeking IVMT. In the absence of a proper diagnosis, the individual may be paying for supplementation they simply don’t need. A 2013 article in the Annals of Internal Medicine, an academic medical journal published by the American College of Physicians, concludes that “supplementing the diet of well-nourished adults with (most) mineral or vitamin supplements has no clear benefit and might even be harmful”.15 A further issue is the patient’s potential response to an infusion’s ingredients. Marie Duckett, a nurse and practitioner at London’s Fiona and Marie Aesthetics, says: “I would be concerned whether practitioners know if their patients are tolerant to everything that’s in it.” She also raises concerns of the industry offering a “quick fix”

REFERENCES 1. Alan Gaby, ‘Intravenous Nutrient Therapy: the ‘Myers’ Cocktail’’, Alternative Medicine Review, 7:5 (2002), 389-403 (p. 389) 2. Skobeloff EM, Spivey WH, McNamara RM, Greenspon L, ‘Intravenous magnesium sulfate for the treatment of acute asthma in the emergency department’, The Journal of the American Medical Association, 262:9 (1989), 1210-1213 3. Bloch H, Silverman R, Mancherje N, et al. ‘Intravenous magnesium sulfate as an adjunct in the treatment of acute asthma’. Chest, 107:6 (1995), 1576-1581 4. Rowe BH, Bretzlaff JA, Bourdon C, et al. ‘Intravenous magnesium sulfate treatment for acute asthma in the emergency department: a systematic review of the literature’. Annals of Emergency Medicine, 36 (2000), 181-190 5. Reed JC, ‘Magnesium therapy in musculoskeletal pain syndromes – retrospective review of clinical results’. Magnesium and Trace Elements, 9 (1990), 330 6. Moorkens G, Manuel y Keenoy B, Vertommen J, et al. ‘Magnesium deficit in a sample of the Belgian population presenting with chronic fatigue’. Magnesium Research, 10 (1997) 329-337 7. Ali A, Njike VY, Northrup V, et al. ‘Intravenous Micronutrient Therapy (Myers’ Cocktail) for Fibromyalgia: A Placebo-Controlled Pilot Study’. Journal of Alternative and Complementary Medicine, 15:3 (2009) 247-257. 8. Harakeh S, Jariwalla RJ, Pauling L, ‘Suppression of human immunodeficiency virus replication by ascorbate in chronically and acutely infected cells’. Proceedings of the National Academy of Sciences, 87 (1990) 7245-7249 9. Hemilä H, Chalker E, ‘Vitamin C for preventing and treating the common cold’. Cochrane Database of Systematic Reviews, 1 (2013) CD000980. doi: 10.1002/14651858.CD000980.pub4. 10. National Institutes of Health; Office of Dietary Supplements, Vitamin C factsheet for consumers (USA: NIH, 2011) <http://ods.od.nih.gov/factsheets/VitaminC-Consumer/> [accessed 31 January 2015] 11. NHS Choices, Vitamins and minerals – vitamin C (London: NHS, 2014) <http://www.nhs.uk/ Conditions/vitamins-minerals/Pages/Vitamin-C.aspx> [accessed 31 January 2015] 12. NHS Choices, Do I need vitamin supplements? (London: NHS, 2014) <http://www.nhs.uk/chq/ pages/1122.aspx?categoryid=51&subcategoryid=168> [accessed 31 January 2015] 13. NHS Choices, Vitamin B12 or folate deficiency anaemia – diagnosis (London: NHS, 2014) <http:// www.nhs.uk/Conditions/Anaemia-vitamin-B12-and-folate-deficiency/Pages/Diagnosis. aspx> [accessed 31 January 2014] 14. Vitamin D Council, Testing for vitamin D (California: Vitamin D Council) <http://www.vitamindcouncil. org/about-vitamin-d/testing-for-vitamin-d/> [accessed 31 January 2015] 15. Guallar E, Stranges S, Mulrow C, Appel LJ, Miller ER, ‘Enough is enough: stop wasting money on vitamin and mineral supplements’, Annals of Internal Medicine, 159:12 (2013) 850-851, doi:10.7326/0003-4819-159-12-201312170-00011 16. House of Lords Science and Technology Committee, Science and Technology Sixth Report – Complementary and Alternative Medicine, (London: UK Parliament) <http://www.parliament.the- stationery-office.co.uk/pa/ld199900/ldselect/ldsctech/123/12301.htm> [accessed on 1 February 2015]

Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015

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lateral orbital superficial fat compartments and the ROOF.9,10 The resultant brow ptosis occurs laterally more than medially, mainly due to the weight of unsupported tissue mass over the temporal fossa in association with lateral orbicularis oculi and corrugator muscle activity (brow depressors), lack of frontalis contraction in the lateral brow (brow elevator), and also from gravitational pull of the heavy cheek and lateral facial tissues. Lambros11 has shown the deflator effects of volume loss can cause an illusion of facial soft tissue descent, thus brow descent is often overestimated. Recent studies suggest that eyebrows can actually remain level or may even elevate with age.12

The Anatomy of the Eye London-based consultant oculoplastic surgeon Mrs Sabrina Shah-Desai discusses the importance of a thorough knowledge of the periorbital anatomy The periorbital area (Figure 1) is the aesthetic epicentre of the face; its delicate critical structures and intricate anatomic relations pose a unique challenge for even the most experienced aesthetic practitioner. The thin fragile eyelid skin and mobile orbicularis oculi lend themselves to the possibility of overfilling and Tyndall effect,1 whilst the complex vascularity can result in visible bruising and swelling,2 having a negative impact on the patient experience. Vascular compromise and visual loss2 are devastating complications that must be avoided at all costs. Mid-facial ageing is a combination of the ‘gravitational theory’ (vertical descent of soft tissues due to ligamentous attenuation)3 and the ‘volumetric theory’ (relative volume loss and gain of neighbouring fat compartments of the face).4 In 2007, Rohrich and Pessa published their seminal study on the facial fat compartments.5 This not only serves as a road map to understanding facial ageing, but has also revolutionised how we rejuvenate the ageing face. To successfully navigate the hollows and troughs of the periorbital zone, it is vital to understand how ageing in one sub-zone affects the other, rather than non-specific targeting of the tear trough or cheek. Using an anatomical guide to the deep and superficial facial fat compartments for volume restoration, in multiple key areas, results in a naturally harmonious rejuvenation to lift and fill the central face (eyelid, eyebrow, temple, cheek and mid-face).

The lid-brow junction Eyebrows form the lower boundary of the upper third of the face. They are often most aesthetically pleasing when they are positioned at the superior orbital rim, with a gentle arc which peaks at the middle and lateral third (this arch being flatter in men). The ideal ‘club-shaped’ female brow is positioned 3-5mm above, whilst the ‘T-shaped’ male brow should lie at the level of the supra orbital rim.6 The lid-brow junction is convex in youth, due to the retro orbicularis oculi fat pad (ROOF), the temporal fossa fat pad and superficial lateral orbital fat pad, which contributes to eyebrow and upper-lid volume.7 When people reach their mid 40’s, there is bony recession of the superior orbital rim8 and the upper lid orbital sulcus looses soft tissue volume. This is typically in the middle third and the entire brow extending onto the temple and the lateral orbital area, possibly due to deflation of the superior and Figure 1

Figure 3a

Aesthetics aestheticsjournal.com

Differentiating descent from deflation Volumetric deflation of the upper-lid and lidbrow junction causes a ‘flatness’ replacing the ‘convex’ fullness of this zone accompanied by an alteration in the drape of upper-lid skin. Landmarks for brow position are based upon underlying bony anatomy; the superior orbital rim is easily palpable and serves as a fixed landmark for the medial head of the brow. Deflation due to soft tissue volume loss can present as temple hollows, with skeletonisation of the lateral orbital rim and clipping of the eyebrow tail (Figures 2a pre- and 2b post-rejuvenation). Upper eyelid deflation can present as ‘medial A-shaped hollow’ or localised central and lateral hollowing of the upper lid sulcus, with the development of an extra fold of skin above the natural eyelid skin crease (Figures 3a and 3b). The lower lids and infraorbital junction As the infraorbital area is really a continuum of the mid face, treatment of this zone must include assessment and treatment of the related subzones in the mid-face. On the deep surface of the orbicularis muscle, at the superior border of the malar region, lays the medial compartment of sub orbicularis oculi fat (SOOF) and further

Figure 2a

Figure 2b

Figure 3b

Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015

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Treatment tips 1. Consider restoration of volume in the temple, brow and upper lid sulcus at three to four points, with the lateral canthal area as an optional extra (Figure 4). 2. Use a soft filler, which can be moulded. 3. The superior sulcus area needs very small aliquots injected supra periosteally along the supraorbital rim, above the orbital septum, staying lateral to the supraorbital notch. 4. The temple hollows need larger volumes, placed into the superficial fascia of each temple behind the frontozygomatic process, to soften the bony contour of the lateral orbital rim. laterally its lateral compartment. The deep medial cheek fat overlies the infraorbital foramen (Figure 5). At the medial infraorbital rim, the tear trough ligament (TTL), attaches to the skin, forming a gentle tear trough groove. Laterally this continues as the orbitomalar ligament (OML). Descent and atrophy of these bony attachments of the superficial musculo aponeurotic system (SMAS) and SOOF contribute to unmasking of the inferior orbital rim and the tear trough. Prolapse of the deep orbital fat, through a naturally weak area of the medial orbital septum, creates eye bags.13 Ageing changes can cause the inferolateral > inferomedial orbital rim to recede, and loss of the maxillary projection (bone) below the orbit14 is a major contributor to laxity and descent of the medial cheek soft tissue. Ageing of the mid-face is a mix of atrophy and descent of soft tissue, which is visible as a worsening tear trough deformity with a loss of the smooth blend between the SOOF and malar fat pad, leading to an abrupt transition between the lid-cheek junction, cheek flattening and mid-face ptosis. Superficial filler injections in the mid-face can weigh tissues down further, whilst deep injections with rigid fillers can “lift and fill” the midface, so it is important to target appropriate areas in the infraorbital and mid-face zones (Figure 5). Infraorbital zone: As the superficial inferior fat pad overlies the infraorbital rim and it tends to deflate early, it should be assessed and treated in three zones Zone 1: The tear trough extends inferolaterally Figure 4

Figure 5

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from the medial canthus to the medial corneal limbus. Zone 2: The middle infraorbital groove extends from the medial to lateral corneal limbus. Zone 3: The lateral infraorbital groove extends from the lateral corneal limbus to the lateral canthus. Mid-face sub zones: Zone 4: The infraorbital hollow lies directly under zone 2 and over the infraorbital foramen, which corresponds to the deep medial fat compartment. Zone 5: The infrazygomatic or sub malar hollow corresponds to the medial SOOF. Zone 6: The malar mound corresponds to the lateral SOOF. Lateral Canthal area: Where ROOF continues caudally as SOOF. Tear trough treatment tips: 1. Treat mid-face zones 4, 5 and 6 first, placing a rigid filler pre periosteal.1 This can decrease the need for treatment in the medial tear trough. 2. Use small aliquots of soft filler in zone 1, place filler pre periosteal but deep to the muscle. 3. Avoid over volumisation in zones 1 and 2 as this causes a sausagelike bulge in what is naturally a gentle depression. 4. Palpate the infraorbital bone and place filler below septum (not behind or above it), as this will only worsen any eye bag. Periorbital vascular anatomy Branches of the external carotid artery (ECA) provide the blood supply to the face with the exception of a mask-like area of the central forehead, upper eyelids and the upper part of nose, which are supplied though the internal carotid system (ICA) by the ophthalmic artery. Vascular anastomoses between ECA and ICA are danger zones for the aesthetic practitioner as inadvertent intravascular injection can lead to vascular compromise and permanent blindness.14 Figure 6

Vascular watershed areas (Figure 6) The infraorbital foramen: Infraorbital vessels arise from maxillary branch of external carotid which anastomose with branches of the ophthalmic artery. The supraorbital notch and glabella: Supraorbital and supratrochlear, infratrochlear and external nasal branches of ophthalmic artery anastomose with branches of the external carotid artery. The temple area: Superficial temporal artery crosses the zygomatic arch and 2cm above the arch divides into anterior and posterior branches. The anterior branch anastomoses with branches of the ophthalmic artery. Tips to avoid intravascular injection16,17 1. Mark the vascular watershed and inject ‘on the bone’ in that area. 2. Avoid fast anterograde injections and large volumes. 3. Always aspirate prior to injection. 4. Consider cannulas vs needles, unless using a smaller gauge needle. 5. Choose HA filler as hyaluronidase can be used to remove the product, if there is inadvertent intravascular injection. Conclusions A sound anatomic approach to surgery with thorough pre-operative planning remains the basis for achieving successful cosmetic and

Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015

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reconstructive outcomes. This should be no different for non-surgical rejuvenation of the eyelids and adjacent areas, where the injector is well trained with a firm understanding of the facial vascular anatomy, safe injection planes, varied injection techniques and types of filler for achieving pleasing aesthetic results in different anatomical areas. The hyper dynamic periorbital area should ideally be treated with low molecular weight, high viscosity materials which are easier to inject and mould. This area should be assessed with non-flash photography, whilst the patient is seated, to assist with patient education by identification of areas of deflation. Treating the patient whilst seated upright, after marking areas of deflation and key anatomic landmarks, allows for injection in the correct plane, using conservative volumes and avoiding adverse events due to incorrect placement and overcorrection. Using different injection techniques like retrograde linear threading for the cheek, lateral brow and lateral tear trough region (with a cannula or needle), serial puncture technique (with a needle) at targeted sites like the medial superior sulcus and fanning technique (with a cannula) for the lateral cheek and temple area, helps reduce adjacent tissue trauma and minimizes the risk of intravascular injection.1 The primary goal of ‘eye-zone’ rejuvenation is restoration of youthful 3-dimensional periorbital topography, so that the eyelids are not harshly demarcated from, but naturally blend into the brow and cheek.

Aesthetics Mrs Sabrina Shah-Desai is an expert oculoplastic surgeon well known for cosmetic eyelid lifts, scarless droopy eyelid correction (ptosis) and revision eyelid surgery. She is highly experienced in non-surgical aesthetic periorbital rejuvenation with botulinum toxin and dermal fillers.

REFERENCES 1. Jaishree Sharad. ‘Dermal Fillers for the Treatment of Tear Trough Deformity: A Review of Anatomy, Treatment Techniques, and their Outcomes’. J Cutan Aesthet Surg. 2012 Oct-Dec; 5(4): 229–238. 2. Lafaille P, Benedetto A. ‘Fillers: Contraindications, side effects and precautions’. J Cutan Aesthet Surg. 2010;3:16–9. 3. Wulc AE, Sharma P, Czyz CN. ‘The anatomic basis of midfacial aging’, Hartstein ME, Wulc AE, Holck DEE, eds. Midfacial Rejuvenation, (New York: Springer Science+Business Media, 2012) p.15-28. 4. Donofrio LM. ‘Fat distribution: a morphologic study of the aging face’, Dermatol Surg, 26 (2000), p.1107-1112. 5. Rohrich RJ, Pessa JE. ‘The fat compartments of the face: anatomy and clinical implications for cosmetic surgery’, Plast Reconstr Surg, 119(2007), p.2219-2231. 6. Freund RM, Nolan III WB. ‘Correlation between brow lift outcomes and aesthetic ideals for eyebrow height and shape in females’, Plast Reconstr Surg, 97 (1996) p.1343-8. 7. Rohrich R, Arbique GM, Wong C, Brown S, Pessa JE.‘The anatomy of suborbicularis fat: implications for periorbital rejuvenation’, Plast Reconstr Surg 124 (2009) p.946-951. 8. Kahn DM, Shaw RB Jr. ‘Aging of the bony orbit: a three-dimensional computed tomographic study’, Aesthet Surg J, 28 (2008) p.258-64. 9. Kikkawa DO, Lemke BN, et al. ‘Relations of the SMAS to the orbit characterization of the orbitomalar ligament’, Ophthal Plast Reconstr Surg, 12 (1996) p.77-8. 10. Lucarelli MJ, Khwarg SI, et al. ‘The anatomy of midfacial ptosis’, Ophthal Plast Reconstr Surg, 16 (2000) p.7-22. 11. Lambros V. ‘Observations on periorbital and midface aging’, Plast Reconstr Surg, 120 (2007) p.1367–1376, discussion 1377. 12. Matros E, Garcia JA, Yaremchuk MJ. ‘Changes in eyebrow position and shape with aging’, Plast Reconstr Surg, 124 (2009) p.1296-301. 13. Kakizaki H, Jinsong Z, et al. ‘Microscopic anatomy of the Asian lower eyelids’, Ophthal Plast Reconstr Surg, 22 (2006) p.430-3. 14. Mendelson & Wong. ‘Changes in the Facial Skeleton With Aging: Implications and Clinical Applications in Facial Rejuvenation’, Aesthetic Plast Surg, 36 (2012) p.753-760. 15. McCleve D, Goldstein JC. ‘Blindness secondary to injections in the nose, mouth, and face: cause and prevention’, Ear Nose Throat J, 74 (1995) p.182-188. 16. David Funt, Tatjana Pavicic. ‘Dermal fillers in aesthetics: an overview of adverse events and treatment a proaches’. Clin Cosmet Investig Dermatol. 2013; 6: 295–316. 17. Katie Beleznay, Shannon Humphrey, Jean D.A. Carruthers, Alastair Carruthers. ‘Vascular Compromise from Soft Tissue Augmentation Experience with 12 Cases and Recommendations for Optimal Outcomes’. J Clin Aesthet Dermatol, 2014 Sep; 7(9): 37–43.

V-SOFT LIFT is an innovative and less invasive alternative to traditional cosmetic surgery and dermal fillers. V-SOFT LIFT is performed using fine threads that “lift” your skin, increase elasticity and are completely absorbed. The threads are made of polydioxanone (PDO) which is known to be extremely compatible with the natural tissue in our dermis and has been used for over 30 years. An added benefit is that the material, PDO, stimulates the body’s natural production of collagen making your skin healthier and thicker.

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Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015

MAGROUP V-Soft Lift

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Aesthetic Journal November 2014 Issue

LOOK HOW YOU FEEL Azzalure Abbreviated Prescribing Information (UK & IRE)

Presentation: Botulinum toxin type A (Clostridium botulinum toxin A haemagglutinin complex) 10 Speywood units/0.05ml of reconstituted solution (powder for solution for injection). Indications: Temporary improvement in appearance of moderate to severe glabellar lines seen at frown, in adult patients under 65 years, when severity of these lines has an important psychological impact on the patient. Dosage & Administration: Botulinum toxin units are different depending on the medicinal products. Speywood units are specific to this preparation and are not interchangeable with other botulinum toxins. Reconstitute prior to injection. Intramuscular injections should be performed at right angles to the skin using a sterile 29-30 gauge needle. Recommended dose is 50 Speywood units (0.25 ml of reconstituted solution) divided equally into 5 injection sites,: 2 injections into each corrugator muscle and one into the procerus muscle near the nasofrontal angle. (See summary of product characteristics for full technique). Treatment interval should not be more frequent than every three months. Not recommended for use in individuals under 18 years of age. Contraindications: In individuals with hypersensitivity to botulinum toxin A or to any of the excipients. In the presence of infection at the proposed injection sites, myasthenia gravis, Eaton Lambert Syndrome or Amyotrophic lateral sclerosis. Special warnings and precautions for use: Use with caution in patients with a risk of, or clinical evidence of, marked defective neuro-muscular transmission, in the presence of inflammation at the proposed injection Date of preparation: March 2013

site(s) or when the targeted muscle shows excessive weakness or atrophy . Patients treated with therapeutic doses may experience exaggerated muscle weakness. Not recommended in patients with history of dysphagia, aspiration or with prolonged bleeding time. Seek immediate medical care if swallowing, speech or respiratory difficulties arise. Facial asymmetry, ptosis, excessive dermatochalasis, scarring and any alterations to facial anatomy, as a result of previous surgical interventions should be taken into consideration prior to injection. Injections at more frequent intervals/higher doses can increase the risk of antibody formation. Avoid administering different botulinum neurotoxins during the course of treatment with Azzalure. To be used for one single patient treatment only during a single session. Interactions: Concomitant treatment with aminoglycosides or other agents interfering with neuromuscular transmission (e.g. curare-like agents) may potentiate effect of botulinum toxin. Pregnancy & Lactation: Not to be used during pregnancy or lactation. Side Effects: Most frequently occurring related reactions are headache and injection site reactions. Generally treatment/injection technique related reactions occur within first week following injection and are transient and of mild to moderate severity and reversible. Very Common (≥ 1/10): Headache, Injection site reactions (e.g. erythema, oedema, irritation, rash, pruritus, paraesthesia, pain, discomfort, stinging and bruising). Common (≥ 1/100 to < 1/10): Facial paresis (predominantly describes brow paresis), Asthenopia, Ptosis, Eyelid oedema, Lacrimation increase, Dry eye, Muscle twitching

(twitching of muscles around the eyes). Uncommon (≥ 1/1,000 to <1/100): Dizziness, Visual disturbances, Vision blurred, Diplopia, Pruritus, Rash, Hypersensitivity. Rare (≥ 1/10,000 to < 1/1,000): Eye movement disorder, Urticaria. Adverse effects resulting from distribution of the effects of the toxin to sites remote from the site of injection have been very rarely reported with botulinum toxin (excessive muscle weakness, dysphagia, aspiration pneumonia with fatal outcome in some cases). Prescribers should consult the summary of product characteristics in relation to other side effects. Packaging Quantities & Cost: UK 1 Vial Pack (1 x 125u) £64.00 (RRP), 2 Vial Pack (2 x 125u) £128.00 (RRP), IRE 1 Vial Pack (1 x 125u) €93.50, 2 Vial Pack (2 x 125u) €187.05 (RRP). Marketing Authorisation Number: PL 06958/0031 (UK), PA 1609/001/001(IRE). Legal Category: POM. Full Prescribing Information is Available From: Galderma (UK) Limited, Meridien House, 69-71 Clarendon Road, Watford, Herts. WD17 1DS, UK. Tel: +44 (0) 1923 208950 Fax: +44 (0) 1923 208998. Date of Revision: March 2013

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

AZZ/020/0313

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Aesthetics Journal

Aesthetics

The Importance of Patient Satisfaction It’s every practitioner’s desired result, but how exactly is patient satisfaction measured? Dr Beatriz Molina discusses her role in recent groundbreaking research into the topic As aesthetic practitioners working in clinics and administering aesthetic treatments, we bear witness to patient reaction and feedback with each procedure performed. We witness patients’ delight following treatment with toxin, filler, radiofrequency or laser. Sometimes, if a complication has occurred, we witness patients’ frustration with a procedure. We talk about patient satisfaction and making a difference to patients’ lives at conferences and meetings across the globe. However, measuring this in quantifiable terms is difficult. How is it possible to measure what kind of difference you make to a patient’s life with the procedure you administer? The ANGEL study, a multi-centre, prospective, non-interventional observational study carried out in France, Germany, Spain and the United Kingdom aimed to do just that.1 This study, for which I was the lead investigator, looked at the relationship between treatment with botulinum toxin type A and patient satisfaction. The first study of its kind, it documented patient satisfaction following treatment of the glabellar lines with botulinum toxin type A (Speywood Unit). In this study, we recruited 559 patients, distributed amongst 66 clinics in four countries across Europe. Subjects were between 18 and 64 years old, with moderate or severe glabellar lines, and were eligible only if the investigator had already decided to prescribe BoNT-A (s.U), according to the labelling. This meant that no-one was paid to complete the study – patients would come in to our clinic for a consultation and the practitioner, myself in this scenario, would decide whether treatment with BoNT-A (s.U) was appropriate. Only then would the patient be offered the opportunity to fill out a questionnaire and be enrolled in the study. The study lasted for four months, and patients were required to complete two questionnaires. Subjects completed satisfaction questionnaires three weeks and four months following the first injection. 531 (95.0%) completed the questionnaire at week three and 485 (86.8%) completed the questionnaire at month four. The analysed population contained 533 patients who had completed at least one of the questionnaires. The main reason for treatment in terms of the patients’ motivations and desired results was a “personal wish (to enhance) appearance or attractiveness”, with 91.1% of patients choosing this as their main motivation. 93.4% and 88.7% of patients enrolled in the study considered that their results “surpassed” or “met” their expectations at week three and month four, respectively. Interestingly, satisfaction and reaction to the treatment did not revolve primarily around the patient’s perceived level of ‘beauty’ following the procedure. In fact, major reasons for satisfaction included a natural appearance, a rested look, and comfort of injection. More than 80% of patients felt they had a more rested appearance after three weeks; a concept that is pivotal to patients’ expectations and desired outcomes in aesthetics today. Levels of patient satisfaction are of course directly linked to patient loyalty – if a patient receives a positive experience and outcome at your clinic then they will more than likely return when considering a second treatment. The ANGEL study found that at month four, 93.4% of subjects would recommend the treatment to family and friends, and 93.2% would like to receive the treatment again. Of course, this outcome is related to the product used, the skill of the

practitioners and the patient’s reaction to the product. In terms of the link between patient satisfaction and patient loyalty, these high percentages speak volumes. In many scenarios, satisfaction and wellbeing are inextricably linked, as both rely on the idea of a ‘positive mood’. The idea that the use of botulinum toxin can enhance mood, and even in some cases aid depression, is one that has been explored recently by my colleague Dr Doris Hexsel in a study investigating the effect of treatment with onabotulinumtoxinA for glabellar lines on self esteem and depression. Utilising the Beck Depression Inventory (BDI) and Rosenberg Self-Esteem Scale (RSES) to assess depression symptoms and self-esteem, this study found that patients with depression had significant improvement in depression symptoms after injections with onabotulinumtoxinA.2 An additional study conducted by Dr Patrick Bowler and Dr Michael Lewis indicated that frowning can actually make a person unhappy, and therefore treatments that prevent frowning result in a happier mood, and thus a happier patient.3 Research into the topic of patient satisfaction naturally combines the two fields of clinical practice and psychology. To further aid our understanding of the subject it is crucial that more studies such as this one are carried out but in addition, it is important to highlight the significance of psychological training within the structure of aesthetics and core medical training. Exposing medical students to psychological practice and concepts is crucial to secure that only suitable patients who are sound of judgement receive aesthetic treatment. This goes a long way to lay the correct foundation for overall patient satisfaction. For the next step in our work to learn more about the link between aesthetic treatment and patient satisfaction, I would be keen to carry out research looking at treatment of the commissures of the mouth, in this case deploying the combined use of botulinum toxin and dermal filler. Many patients I treat day-to-day express a desire to appear on the outside how they feel on the inside – which is happy. Sometimes, as a consequence of the ageing process, which causes the commissures of the mouth to deflect downwards, an aged outward expression can give the impression of being unhappy or sad. A study treating this area could ask whether changing this expression with aesthetic treatment would have a significant impact on the patient’s satisfaction and overall wellbeing. To continue our research inspired by patient feedback is crucial to ensuring a forward-looking approach to aesthetic treatment that is holistic in nature, and puts the patient, and ultimately their satisfaction, first. Dr Beatriz Molina is a member of the British College of Aesthetic Medicine (BCAM) and founder of the Medikas Medispa Clinic. She also teaches techniques for botulinum toxin administration.

REFERENCES 1. B. Molina, Y. Grangier, B.Mole, N. Ribe, L. Martín Diaz, W. Prager, F. Paliargues, N. Kerrouche, ‘Patient Satisfaction after the treatment of glabellar lines with Botulinum toxin type A (Speywood Unit): a multi-centre European observational study’, Journal of the European Academy of Dermatology and Venereology, (2014). 2. Hexsel D, Brum C, Siega C, Schilling-Souza J, Dal’Forno T, Heckmann M, Rodrigues TC., ‘Evaluation of self-esteem and depression symptoms in depressed and nondepressed subjects treated with onabotulinumtoxinA for glabellar lines’, Dermatologic Surgery, 39 (7) (2013), pp. 1088-96. 3. Lewis, M, Bowler P, ‘Botulinum toxin cosmetic therapy correlates with a more positive mood’, Journal of Cosmetic Dermatology, 8 (2009), pp. 24-26.

Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015

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Hair Transplant Techniques: Restoration and Reconstruction Hair transplant surgeon Dr Greg Williams discusses current surgical treatments for Male Pattern Hair Loss and reconstructive approaches to correct previous procedures Introduction These days, modern hair transplants for Male Pattern Hair Loss (MPHL, also known as androgenetic alopecia) can produce extremely natural looking results. In the past, hair transplants were problematic, as those with MPHL would frequently continue to experience hair loss after hair plugs were inserted into the scalp, causing a patchy, ‘doll’s hair’ appearance and therefore requiring further surgery. Today, hair transplants appear far more natural, and allow for continued hair loss in a way not previously seen in the field. Furthermore, patients who had previously undergone hair transplant surgery can access newer techniques to correct their past procedures that may have caused aesthetic disfigurement. Technique A modern hair transplant technique should follow a specific aesthetic structure. The hairline should be irregularly aligned, with randomised single hairs in front of the main bulk of the hairline. The angle and direction of the transplanted hairs should mimic any residual natural hairs and, if an entirely new hairline is being recreated, then the transplanted hairs should be positioned in a forward direction. Even under close scrutiny, with the hair being combed aside, the untrained observer should not be able to differentiate transplanted hairs from naturally occurring ones. This is demonstrated in Figure 1, which shows the appearance of a hairline prior to a hair transplant; the natural growth direction of the hairs post-transplant; and a close-up view with the hairs combed back to demonstrate that, on close inspection of the roots of the hairs, there are no tell tale signs that these hairs have been transplanted. Currently, there are two main methods for performing hair transplant surgery. The first is known as Strip Follicular Unit Transplant (Strip FUT), in which the surgeon removes a strip of hair bearing skin from the back and sides of the head in the area referred to as the ‘donor site’. Under magnification, the strip is separated into the naturally occurring groupings of hairs known as ‘follicular units’. These consist of grafts that have between one and four hairs which are then re-implanted in the recipient area – either into pre-made incisions created with a variety of sharp instruments, or using implanters that create incisions at the same time as the hairs are implanted. The Strip FUT method has been continually refined over the years and, while it was prone to leaving poor quality, widened scars at the donor site when first developed, a good surgeon will now be able to perform the operation leaving a scar that averages just two-three millimetres in width. The main benefit of Strip FUT is that the hairs are taken from the most dense part of the scalp, where they are least likely to be affected by dihydrotestosterone (DHT) – the hormone responsible for male genetic balding. Therefore, not only can large numbers of good quality grafts be procured, but the risk of the transplanted hairs deteriorating with time is much smaller than if the other method1 – known as Follicular Unit Extraction (FUE) – is used, and hairs are harvested from outside this ‘safe’ donor

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zone. FUE involves the individual removal of follicular units from the occipital and parietal scalp, with each unit individually transplanted to the recipient area. The procedure was developed to avoid the linear scar that occurs with Strip FUT and has grown in popularity over the past decade. Global statistics from the International Society of Hair Restoration Surgery (ISHRS) suggest hair transplants performed using FUE accounted for 32.2% of all methods in 2013, compared with 10.8% in 2009.2 However, these figures vary widely between countries. One of the drawbacks with FUE is that the whole donor area needs to be shaved – something not all patients are keen on, as it makes it more obvious that surgery has been performed. Furthermore, the harvesting of hairs needs to be spread out over a much wider area than with Strip FUT, and donor areas that look like they have permanent hair in younger men can deteriorate with age. Hairs transplanted from areas outside of the ’safe’ donor zone may therefore not be permanent in their transplanted location. There are several methods of performing FUE – manual, mechanical and robotic. The first two use handheld devices, whereas the only robotic system currently available – known as the ARTAS3 – is automated (although it still needs a human doctor to set the parameters and to direct it). The ARTAS allows the surgeon to work with the utmost precision when harvesting donor hair follicles and new software technology allows the robotic system to automatically identify the size of follicular units and, therefore, harvest specific numbers of different sized grafts required for individual patients’ recipient sites. It also removes the element of fatigue and human error in the incision making. This is because a robot does the actual ‘punching’, or incision making, of the grafts, so the 1000th graft would be taken with exactly the same precision as the first. It is important to note that the terms ‘Strip FUT’ and ‘FUE’ only refer to the methods of harvesting follicular units and do not determine the final appearance of the hair transplant, as the design and incisions are made in the same way for both methods. There are pros and cons with both methods and the most appropriate type of surgery is entirely dependent Figure 1 upon the individual in question. Each procedure has its own risks and benefits but both should deliver natural-looking results which last a lifetime if performed by a skilled surgeon. However, this hasn’t always been the case. Historical techniques – such

Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015

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as flaps and plug grafts – may have provided short-term aesthetic improvements, but many have failed to stand the test of time. Where hair loss has progressed, these procedures have in some cases left patients aesthetically disfigured with an unnatural appearance to the hair, either in terms of looking ‘pluggy’ or having abnormal distribution or growth direction. Reconstructive surgery options are available, but they must be tailored to the individual’s needs, depending on what the unnatural appearance looks like and what it has been caused by.

Aesthetics Journal

Options include: • • • • •

follicular unit grafting to soften ‘pluggy’ grafts or harsh anterior flap margins total plug graft excision and hair redistribution partial plug graft excision and hair redistribution harsh anterior flap margin excision combinations of the above

CLINICAL CASE ONE

Before

After

This patient had a typical appearance of what occurs when plug grafts were used to increase density. He had a short to medium term improvement in appearance but, as his male pattern hair loss progressed, he eventually lost all of his natural hair in the area, with only the plug grafts remaining. The plug technique was one of the first methods of hair transplanting, but for those men who subsequently lost their native hair completely, it resulted in this ‘doll’s hair’ or ‘corn row’ effect. The patient opted to address this by having follicular unit grafts interspersed between the plug grafts to soften their appearance, giving a very natural look. Over three procedures spanning three years, he had a total of 5,278 follicular units (10,317 hairs) transplanted.

Before

CLINICAL CASE TWO

After

This patient had previously had plug grafts, but only to boost a receding hairline. As the hairline continued to recede and all the natural hairs were lost, the plug grafts remained isolated, limiting his hairstyle options to having a fringe brushed forward. This was treated by completely removing the plugs and using the hair within the excised plugs to create a rejuvenated and natural looking hairline by redistributing them and allowing him to brush his hair backwards or to the side.

Before

After

CLINICAL CASE THREE For ‘pluggy’ hairlines, where the coarse grafts are not completely isolated on the scalp or forehead, the plug grafts can be partially removed, leaving one or two hairs behind and then redistributing the rest of the excised hairs in front of and between the plugs to create a soft, natural looking new hairline.

Before

After

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CLINICAL CASE FOUR When flaps have been used in combination with plug grafts, an option is to excise a strip of hair bearing skin, along with any scarring, and redistribute the hairs yielded from this ‘strip’ as follicular unit grafts. In addition, the plug grafts can be either completely or partially excised (as in Clinical Cases 1 and 2) to soften the overall appearance and yield further follicular unit grafts. The procedure can be boosted with additional follicular unit grafts from a new strip follicular unit graft donor site in the occipital scalp region. This patient’s restorative procedure utilised a combination of methods to achieve a natural reconstruction.

Conclusion Many of these patients have experienced significant psychological distress as a result of their unnatural appearance and resort to wearing hats, wigs or toupés. In the most extreme cases, patients may avoid social situations completely. It is imperative that these patients should be made aware of the complete spectrum of reconstructive options available to them. Refined hair transplant surgical skills are required in order to carry out these restoration and reconstruction techniques, and unfortunately general practitioners seldom know where to refer individuals for this specialist care. As a result, patients continue to suffer, unaware of the modern options available to them; they may also be hesitant to trust a doctor to re-operate on them, given their poor experiences in the past. Along with raising awareness of the treatments available, we should encourage the opportunity in our practice for the patient to meet other patients who have undergone hair transplant reconstruction. In this manner we can work to build patients’ confidence and trust in these revolutionary and often life-altering procedures. Dr Greg Williams is a hair transplant surgeon and member of the British Association of Aesthetic Plastic Surgeons (BAAPS). With over 10 years of experience in hair restoration for burns and trauma, he also treats hereditary male/female pattern hair loss and other aetiologies. REFERENCES 1. Unger WP, ‘Delineating the ‘Safe’ Donor Area for Hair Transplanting’ The American Journal of Cosmetic Surgery 11 (1994), 239-243 2. International Society of Hair Restoration Surgery, ISHRS Statistics and Research (US: ISHRS.org, 2013) <http://www.ishrs.org/statistics-research. htm< [Accessed February 11] 3. Restoration Robotics Inc, Homepage (US: Restoration Robotics, 2015) <http://restorationrobotics.com/> [Accessed February 11]

Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015

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Vitamin C: SkinCeuticals Antioxidant Essentials ADVANCED SKINCARE BACKED BY SCIENCE Renowned for its ability to improve skin health and provide a beautifully radiant complexion, the SkinCeuticals range is built on the philosophy of skincare for life. Developed on an effective regime containing three fundamental elements, prevent, protect and correct their antioxidant collection is designed to optimize skin health all year-round. Research shows that ageing skin is the result of more than just years on the calendar. A comprehensive SkinCeuticals preventive programme not only addresses natural ageing issues, but further helps patients to protect their skin against environmental damage, as well as the onset of more serious skin conditions. With nearly three decades of research, SkinCeuticals has pioneered the industry in antioxidant technology, and their range of Vitamin C-based formulations have been scientifically proven to deliver superior results, helping to reinforce the skin’s natural protection against free radicals. Why Vitamin C? Though the skin naturally protects itself with antioxidants, as it is bombarded with environmental aggressors its natural supply is quickly depleted and requires supplemental protection. Vitamin C has been proven to successfully reinforce the skin’s natural protection against the free radicals generated when skin is exposed to environmental aggressors. SkinCeuticals’ award-winning antioxidant range, which consists of Phloretin CF, C E Ferulic, and AOX+ Eye Gel, is formulated in a way which combines, stabilises and delivers key antioxidants, including Vitamin C, into the skin. “Skin is naturally built for repair. When bombarded by environmental assaults, skin must focus on neutralizing oxidative damage, limiting its capacity for reparative functions. Daily use of pure antioxidants, when properly formulated to penetrate skin, protect against damage, enhancing self-repair to reduce signs of ageing,” says Dr Sheldon Pinnell, M.D, founder of SkinCeuticals. Only SkinCeuticals’ antioxidants have been proven to perform synergistically, providing superior results to single antioxidant formulations. Combine a SkinCeuticals antioxidants formulation with sunscreen to achieve a truly comprehensive protection against UVA, UVB, IRA and pollution allowing the skin to self repair and correct visible signs of ageing.

Phloretin CF Phloretin CF represents a new class of preventive and corrective topical antioxidant treatment. After 5 years of extensive research, SkinCeuticals have developed a patent-pending breakthrough technology combining the newlydiscovered, broad-range power of Phloretin with Vitamin C and Ferulic Acid in a bio-diverse formulation to divide and conquer sources of damage at every level of the skin. With a winning combination of 2% Phloretin, 10% L-Ascorbic Acid and 0.5% Ferulic Acid, it not only protects against free radicals but also defends against a vast range of other factors known to cause skin damage and DNA mutations. Simultaneously, Phloretin CF will work to correct existing damage by stimulating the synthesis of essential proteins and fibres and accelerating cell turnover. The result? A strengthened support structure on the inside and a more youthful, firm, radiant appearance on the outside. Recommended for oily, problematic and normal skin, Phloretin CF is the ideal solution for diminishing hyperpigmentation, improving skin laxity and accelerating cell renewal. C E Ferulic C E Ferulic is a revolutionary antioxidant combination that delivers advanced protection against photoageing - neutralising IRA, UV-induced and endogenously produced free radicals. More protection means more youthful looking skin and better defence against environmental ageing. Containing 15% pure L-Ascorbic Acid and 1% Alpha Tocopherol, the addition of Ferulic Acid doubles the already synergistic benefits of the original high-potency formula, Vitamin C+E, transforming C E Ferulic into a super-antioxidant combination. Suitable for dry and normal skin types, C E Ferulic has proven highly effective on fine lines, skin elasticity and wrinkles. AOX+ Eye Gel This breakthrough eye serum-in-a-gel helps to protect the delicate eye contour area from oxidative stress, while targeted actives revive under-eye skin and reduce the appearance of puffiness. A triple antioxidant treatment, which works to combat photoageing and signs of fatigue, preventing signs of accelerated ageing and correcting existing visible sun damage. With Phloretin, L-Ascorbic Acid and Ferulic Acid, the AOX formulation is a vital addition to help patients see improved drainage and congestion of fluids around the eye-area, using caffeine to effectively reduce the look of under-eye bags. A state-of-the-art gelifier suspends the ingredients in an acidic solution within an open matrix delivery system for controlled and precise delivery.

Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015

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A summary of the latest clinical studies Title: Nasal alar necrosis following hyaluronic acid injection into nasolabial folds: a case report Authors: A Manafi, B Barikbin, A Manafi, ZS Hamedi, S Ahmadi Moghadam Published: World Journal of Plastic Surgery, January 2015 Keywords: Alar necrosis, hyaluronic acid, injection, soft tissue Abstract: Injection of synthetic fillers for soft tissue augmentation is increasing over the last decade. One of the most common materials used is hyaluronic acid (HA) that is a safe and temporary filler for soft tissue augmentation. We present a case of 54-yearold female who experienced vascular occlusion and nasal alar necrosis following HA injection to the nasolabial folds. She suffered from pain, necrosis, infection, and alar loss that finally required a reconstructive surgery for cosmetic appearance of the nose. The case highlights the importance of proper injection technique by an anesthesiologist, as well as the need for immediate recognition and treatment of vascular occlusion. Title: Analysis of Incidence of Bulla Formation After Tattoo Treatment Using the Combination of the Picosecond Alexandrite Laser and Fractionated CO2 Ablation Authors: S Au, AM Liolios, MP Goldman Published: Dermatology Surgery, January 2015 Keywords: Tattoo treatment, Laser, Fractionated CO2 Ablation, Picosecond Abstract: The picosecond Alexandrite laser has shown increased efficacy in tattoo removal in comparison to Q-switched lasers. However, bulla formation is a well-known and expected side effect of this novel treatment and causes patient discomfort. The objective was to analyze the incidence of bulla formation after tattoo treatment using the combination of the picosecond Alexandrite laser and fractionated CO2 ablation. This is a retrospective chart review to determine the incidence of bulla formation after laser tattoo removal in 95 patients who were treated with either with the picosecond Alexandrite laser alone or in combination with fractional CO2 ablation. Twenty-six patients (32%) treated with the picosecond laser alone experienced blistering, whereas none of the patients treated with the combination of the picosecond laser and fractionated CO2 ablation experienced blistering. The difference in incidence of bulla formation between the 2 groups was found to be statistically significant (p < .05). This study shows a significant decrease in bulla formation associated with tattoo treatment when fractionated CO2 ablation is added to the picosecond Alexandrite laser, which is consistent with observations from a previous case series. This is important because decreasing extensive blistering likely results in increased patient satisfaction and willingness to return for future treatments. Title: Melasma treatment using an erbium:YAG laser: a clinical, immunohistochemical, and ultrastructural study Authors: E Attwa, M Khater, M Assaf, MA Haleem Published: International Journal of Dermatology, January 2015 Keywords: Melasma, laser, erbium:YAG laser, hyperpigmentation Abstract: Melasma is a common pigmentary disorder that

remains resistant to available therapies. The aim of the present study was to evaluate the efficacy of erbium:YAG lasers in the treatment of refractory melasma and investigate the histopathological and ultrastructural changes between melasma skin and adjacent control skin before and after surgery. Fifteen Egyptian female patients with melasma unresponsive to previous therapy of bleaching creams and chemical peels were included in this study. Full-face skin resurfacing using an erbium:YAG laser was performed. Clinical parameters included physician and patient assessment, and melasma area and severity index score were done. Adverse effects after laser resurfacing were recorded. Biopsies of lesions and adjacent healthy skin were stained using hematoxylin-eosin, immunohistochemically marked for Melan-A, and evaluated by electron microscopy. The amount of melanin, staining intensity, and number of epidermal melanocytes are increased in melasma lesions as compared to normal skin. Electron microscopic analysis revealed an increased number of mature melanosomes in keratinocytes and melanocytes, with more marked cytoplasmic organelles in melasma skin than in biopsy specimens from normal skin, suggesting increased cell activity. After surgery, the number of melanocytes and concentration of melanin decreased in melasma skin, and the mean melasma area and severity index score decreased dramatically. In conclusion, Erbium:YAG laser resurfacing effectively improves melasma; however, the almost universal appearance of transient postinflammatory hyperpigmentation necessitates prompt and persistent intervention. Title: Optimizing the use of topical brimonidine in rosacea management: panel recommendations Authors: EA Tanghetti, JM Jackson, KT Belasco, A Friedrichs, F Hougier, SM Johnson, FA Kerdel, D Palceski, HC Hong, A Hinek, MJ Cadena Published: Journal of Drugs in Dermatology January 2015 Keywords: Rosacea, brimonidine, treatment Abstract: Rosacea is a chronic inflammatory disease with a complex pathophysiology that manifests with central facial redness with or without papulopustular lesions. Often, patients with rosacea present with a constellation of signs and symptoms; for best results, the treatment plan should take into account all symptoms manifesting in the individual patient. The first available pharmacologic treatment to address the redness associated with rosacea is topical brimonidine. In the United States, brimonidine topical gel 0.33% is indicated for persistent facial erythema of rosacea; approval was based on clinically significant efficacy and good safety data from large-scale clinical trials. Use of brimonidine in routine clinical practice has yielded new insights that elaborate on the findings from clinical trials. For example, real-world use has shown that a percentage of patients (in our experience, approximately 10 to 20%) treated with brimonidine experience a worsening of erythema that has been called “rebound.” Our routine use of this agent for 1 year has yielded strategies to set patient expectations, optimize treatment initiation, and minimize potential problems; this article details those strategies. Because we believe that the term “rebound” has been used to describe several physiologically distinct events, we have also proposed more specific terminology for such events.

Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015

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Dr Hilary Allan looks at the factors that work together to ensure the perfect patient experience

Enhancing the Patient Journey My patients’ journeys have changed over the years as much as my journey as a medical practitioner has changed. Confidence and expertise gained through many patient interactions, treatments and masterclass training events have sharpened the sword of my skills and my ability to handle different personalities and, occasionally, difficult expectations. This training and experience has also worked to sharpen my view and understanding of the importance of the patient journey in aesthetics. These days, patients have – quite rightly – high expectations of the service on offer, and every single piece of that patient journey jigsaw must be in place to ensure the best outcome for that particular patient. Nowadays, most patient journeys usually start with some research on the internet. Making an impact with your online presence is key. In regards to your website, potential patients will quickly dismiss the unremarkable or worse, clunky and inefficient. It’s not difficult to see that time and money spent on optimising your online presence will be invaluable in guiding those enquirers securely in your direction. This is the first step. Making sure your website is classy, attractive, friendly, informative, easy to navigate and, most importantly, up to date and full of original material, is crucial in order for it to be effective. Never doubt how savvy patients are; they will have done their research and they will mostly have a good

idea of what they are looking for. In terms of providing online content (in the form of blogs and social media posts) they will spot work that has been cut and pasted a mile off – so don’t insult their intelligence and begin the journey on the wrong foot. Investing in a marketing strategy is one way to make sure the patient experience you offer is as comfortable and easy as possible for your patient. Our own clinic is fortunate enough to have a dedicated marketing team and a large part of their daily work is updating the website, posting on social media and writing relevant blogs relating to current trends, new treatments or simply everyday life at our clinic. They are also an integral part of designing and writing our own bespoke patient leaflets and creating a patient information pack full of relevant information and advice that can be sent to all enquirers, promising a comprehensive patient experience from the beginning. The size of your clinic may determine your marketing budget, but, for any practice, relevant information packs and keeping an updated website are the first steps to increasing patient retention rates. Further enquiries, either by email or by telephone, will hopefully follow this initial browsing. I would always advise that a clinic ensures all emails are answered immediately, or at least on the same day, and information packs sent where appropriate. Anything more complicated than a

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straightforward enquiry should be passed on to the doctors or therapists in order for them to provide more in-depth answers. This immediately gives the impression of a much more personal service; the one thing that most patients are looking for. Telephone calls are a priority in our clinic, with phone lines open from 9am to 7pm every weekday and 9am to 1pm on a Saturday. There is nothing more off-putting to a potential patient than an answerphone, so calls should be answered as efficiently as possible. Our present phone system gives five choices that are simple and clear, allowing important patient enquiries or potential bookings to be prioritised over marketing or sales calls. All new patient enquiries are handled by clinical treatment advisors. Their approach is friendly and cheerful yet highly informative, and, having impeccable telephone skills, they ensure a consistent 95% conversion rate of telephone enquiry to booking. On arrival at your clinic, patients should be greeted with a friendly face and made to feel as comfortable and as at ease as possible. Ways to optimise positive patient experience could include offering refreshments and seating them in a welcoming waiting room, which may be enhanced with a vase of flowers. Ensure there is information available on all the relevant and current offers at your clinic, and create tasteful displays of your chosen skincare range to stimulate their appetite for what is available. Contact forms should be completed at this time, asking for information about other treatments already undertaken, and their skin care regime, to ensure you are completely up to date with their aesthetic history. We introduced free consultations with either doctors or therapists a few years ago. Free consultations are extremely attractive to potential patients, and most patients like to see the practitioner who will actually perform the treatment, in order to attain their opinion on their perceived concern before proceeding with treatment. This reassures the patient and is a perfect time for the practitioner to fully assess the patient and discuss all aspects of their treatment, whilst formulating a treatment plan. Some patients will go ahead with a simpler procedure, such as a toxin treatment, straight away, whilst more complex treatments, such as volumising fillers, may need to be planned in advance and require a more thorough consultation. The use of clinical assistants is one way to enhance the patient journey and ultimately ensure patient satisfaction.

Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015

Patients should receive the appropriate empathy and support with suitable guidance on what could be the next step Working alongside the doctors and aesthetic therapists to look after the welfare of the patient at all times, with repeated visits these assistants build up a valuable rapport with the patient that is both welcoming and reassuring. This could be complemented by encouraging patients to contact the clinical assistant after the procedure with any concerns they may have. In return, patients should receive the appropriate empathy and support with suitable guidance on what could be the next step. Consultation is a crucial stage in the patient journey. I suggest encouraging your patients to vocalise their concerns and motivation for seeking treatment. This will aid in building a trusting relationship, and will also give you the essential opportunity to assess whether the patient is seeking treatment for the right reasons. Recent relationship breakdowns or serious illnesses commonly lead to the request for aesthetic work. Intricately linked to loss of self-esteem and low confidence, an improvement in appearance can provide an amazing development in wellbeing. My approach is cautious and supportive – I call it the ‘slow burn’. Before and after photos should be taken to allow for future evaluation of the patient’s progress, reinforcing the success of the treatments. This can be useful as many patients forget how they looked to begin with. When treatments are finally undertaken, any discomfort should be minimised by providing reassurance – and the occasional use of anaesthetic cream. Severe pain will be remembered and should not be repeated, so it’s helpful to always be aware of how your patient is feeling during the treatment session. Any obvious marks afterwards are also a source of discomfort and embarrassment and will put people off. Trying to minimise bruising in any feasible way is vital, as some patients will likely seek a different practitioner if they experience bruising as part of their treatment. If there are visible signs following treatment, offering mineral make-up, which can be applied by the clinical assistant, can help to conceal any blemishes. Follow-up appointments should always be booked to ensure that the end result is as it should be, and that the patient is happy with the result – this is, after all, only the start of a long relationship. Regular surveys canvassing feedback from patients can be utilised to check you are doing things right, or to highlight where needs improving, and these are essential for good practice. Creating a clear strategy, supported by an effective team at your clinic, is integral to the success of dealing with the concerns of every patient, whilst securing the format for an excellent patient journey that will guarantee future business and a loyal patient base. Dr Hilary Allan qualified as a medical doctor at St Bartholomew’s Hospital. Dr Allan practiced as a GP until 2000 when she decided to devote herself to the thriving aesthetic clinic, Woodford Medical. Dr Allan has been named in the top 10 cosmetic doctors in the UK by the Evening Standard and The Daily Telegraph.

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Whilst each practitioner will have a slightly different approach, the most important thing to consider when dealing with both kinds of communication is good structure and clear objectives. Although these occasions do arise, this article will focus on sharing knowledge and information specifically via presentation to an audience.

Preparation

The art of sharing knowledge Dr Kieren Bong uncovers the best methods of delivering and sharing information in aesthetics Each year, my diary contains a number of key engagements which see me swapping my Glasgow-based clinic treatment room with venues all over the world. In these venues – and these can range from university lecture theatres to exhibition halls and seminar rooms – I wear a different hat from my usual one of cosmetic doctor. I take on a new role as lecturer, trainer and key opinion leader, prepared to cover an extensive range of topics and techniques on advanced non-surgical facial aesthetics. The art of sharing accrued knowledge and expertise is one I’ve honed and fine-tuned over the last five years or so. This craft has taken me to international venues including those in Sweden, Kazakhstan, Monaco, Malta and Cyprus. More recently, I have been fortunate to take up a role with one of Norway’s most respected universities where I lecture on the topic of dermal fillers six times a year to students on the Masters degree equivalent of a postgraduate diploma in cosmetic dermatology. In this varied work, my audiences can change from a group of just 10 such students in a classroom-like setting, to almost 1,000 delegates at an international conference. For me, however, the requirements are near identical. As a result of my interest in developing how best to share the specifics of any presentation or training session, I aim to ensure that those on the receiving end of my information receive maximum benefit. In this article I would like to share some of the presentation skills that I have learnt over the years, outline some dos and don’ts, and highlight the pitfalls to avoid if you too embark on the wonderful journey of sharing your knowledge and expertise. In my opinion, there is a clear difference between training and presenting. It’s worth focusing on this difference and making it clear in your mind in order to correctly determine the content of what’s to be shared or communicated. Training: This is something that can occur in an every-day clinic setting, especially whenever a new team member joins. Training typically focuses on assisting a person or group to learn through activity, discussion and inclusion. Presenting: This is best described as the provision of information to an audience. Both sound straightforward enough, but the art of engaging with each focus group can present its own challenges. Of course, there are times when the types of sharing – presenting and training – can cross over and blend together. For instance, the advanced full-face contouring and volumising treatment requires complex mapping of the face prior to the actual procedure, and the drawing of landmarks and imaginary guide lines are both presented and demonstrated live, during the same session.

Without question, the most important step in the process of effectively sharing knowledge is planning. As the old adage states – ‘fail to plan and you’ll plan to fail’ It’s my ‘must-do’, no matter where I’m presenting or which audience is scheduled to listen. I really can’t underline enough the importance of good prep. As much as it’s about the attention to detail when looking after my patients in a clinical environment, detail is key when researching for a presentation. Knowing your audience is vital. Look at exactly who is attending. If the information is given, pore over who does what and where. Know how many candidates will be present, and look at their levels of experience and knowledge. As the first step when preparing for a new presentation, I will set out my objectives in list-form, and prepare an outline of a talk based on these aims. That initial draft may bear no resemblance to the end result – but it will provide me with a working document that keeps me focused on what I need to deliver. I call it my ‘work in progress’. When the occasion or setting calls for a PowerPoint presentation, I am a great believer in ‘less is more’ – formulate the content on each slide with just enough to deliver the audience the key information. Because you will be well-prepared and rehearsed, these will provide more than enough information as aides-memoires to keep you on the correct path and on-message. Before each presentation, I always take a close look at the actual venue and the facilities available. Thanks nowadays to search engines such as Google and the wonders of the web, it is often possible to have a 360 degree virtual tour of the venue. There is no point turning up with a presentation in a format that’s not compatible with the venue’s equipment. It can also be useful to find out the lighting options in a venue, as light can sometimes determine the style of presentation to adopt. Some event organisers provide additional external lights for the live demonstrations, especially when videographers are on-site to film the procedures for live broadcast throughout the venue. On the other hand, there have been occasions when I have had to make do with the existing lights in the auditorium. A trainer should always be prepared to adapt to the facility that has been provided.

Engaging with your audience In cases where my audience is located in an overseas venue, I carry out some local research and, where relevant, will work in some local references. These references will help you connect with your audience and will work to better spark

Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015

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their interest. It also clearly demonstrates to the audience your commitment to preparation and your respect for their time. If, for example, the presentation is going to involve a technique demonstration – perhaps a new advanced filler technique – then securing a model or several models is key to its success. To do this, work closely in advance with the event organiser and product distributor to ensure models are fully briefed on what will be involved, and to ensure that all consent protocols are satisfied. This will include both verbal and written consent. You will need your model to be as prepared and relaxed as you are when working under the spotlight. Recently at a one-day seminar and technique demonstration in London, the model I’d booked for the presentation fell sick so, at the last-minute, we were facing a crisis. No model meant I’d not be able to deliver a practical demonstration of the theory I was planning to present. Thankfully, the product distributor and I worked together and managed to secure a volunteer from one of the delegates who’d travelled from Belgium. After volunteering and signing the necessary consent forms, she gave me the green light to complete my presentation in the most effective way possible. In the event of working with a medical company, I find the preparation steps on many occasions to be simplified, as not only will the aims be made very clear at the outset, but in most cases the local product distributors will help to source the necessary model(s).

Participation No matter the type of presentation or training masterclass you are delivering, it is crucial to promote participation. This might be in the form of half-time practise sessions and/or workshops, or staging a questions/answers session. This kind of participation has a dualbenefit for you as a presenter and a trainer. Within minutes it’s possible to ascertain how successful your delivery has been, and just how switched on the audience has remained. If there’s a hint of any failing in one or the other aspect of your presentation, then conducting any kind of participation sessions gives you the chance to redress the balance and get your audience back on track and engaging with your content. Due to the aforementioned forward planning and research you should rarely find this to be the case, and your audience should be given multiple opportunities to engage via the mix of PowerPoint presentation slides or live demonstrations.

Potential pitfalls So what are the things to look out for when sharing knowledge in this way, be it training, presenting or running a workshop? First of all, you may well need to handle resistance from your audience. Don’t be over alarmed – it does happen. This will manifest either through immediate criticism of a point you’re making, insincere agreement, silence or inyour-face defiance! Don’t be swayed by any of the above. Be prepared. By being so, you’ll be able to tackle that resistance which may be caused by fear, misunderstanding, cynicism or a mixture of all three. The element of fear may stem from the audience’s concern they’ll be unable to develop the skills and competencies. Our job is to instil the necessary knowledge and boost their confidence in order to overcome such fear. In some cases – such as in a more intimate training environment – one-on-one contact may be a solution. Today, the sharing of presentations or training notes via technology is so simple and can, itself, allay fears. Cynicism may arise, as an audience can comprise different levels of experience, background and training. There may be questions arising about choice and availability of different brands or grades of products.

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My top 10 tips on presenting: •

Plan and prepare

•

Work out scope and format

•

Research your audience

•

Research your venue – especially for suitable equipment

•

Rehearse, rehearse and rehearse again

•

Ensure any live model is available and well briefed in advance

•

Be prepared for potential cynicism, fear or resistance

•

Use case studies or personal experience to boost audience engagement

•

Encourage participation

•

Be happy to answer questions

In my personal experience, although approaching my mid-30s, I have been told in the past that I appear younger, and so a cynic in the audience might question age and, therefore, gravitas and industry experience. It is my job at the outset to ensure that the audience not only understands my qualifications for speaking to them, but to build, point by point, a confidence in my skills and abilities so they appreciate my right to stand before them for that particular session. This is achieved through clear communication and thorough preparation.

A multimedia approach One very important point to be made is related to your content. I strive to personalise the topic at hand by example, whether by using personal experience or with case study illustration. Few of us in today’s aesthetics profession work exclusively among text books and the world of academia, so we will usually have a wealth of personal stories to share, or access to effective before and after images. Mixing the use of still photography with good video footage enriches any presentation. This multimedia approach helps to generate engaging content, and this kind of delivery improves the chances of the information and technique displays sticking in the audience’s memory. Lastly, aim to be as relaxed as possible before your appearance. Get a good night’s sleep. Have a reasonable meal ahead of the engagement. Nerves are normal, and some say these nerves help keep the mind focused. Even after years of experience and appearances before audiences small and large, I’ll still experience nervousness. In my experience, deep breathing helps to calm nerves, along with the knowledge that you have prepared 100% for the session. All in all, these factors should add up to a well-delivered presentation and an effective and fluid sharing of knowledge. Dr Kieren Bong is clinical director of Essence Medical Cosmetic Clinic in Glasgow, Scotland. He prides himself in his innovative approach to non-surgical facial treatments, and is well known for his unique methods of achieving beautiful yet natural results with minimal pain and downtime. Dr Bong is a sought after international trainer, speaker and key opinion leader, teaching other doctors and surgeons advanced facial aesthetic procedures.

Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015

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examine your budget to see what you can feasibly offer. Once you have noted all of these elements, you will have a far better idea of the person you need to recruit. If you still have doubts after this, then ask for help – fellow aesthetic professionals with past experience of hiring staff will be able to offer you valuable advice.

Update your adverts, interviews and employee packages

Hiring Staff Aesthetic recruitment brand manager Victoria Vilas shares her advice on choosing the right employees for your clinic The process of hiring new staff members for your practice has the potential to be time-consuming and costly. However, careful planning and research into industry recruitment trends can save you time and money, as well as providing potential employees with confidence in your knowledge and practice. Before you begin recruiting, make sure you’ve considered these key points, to ensure the process runs smoothly.

Start the recruitment process only when you know what you need As highlighted, the main hurdle of hiring new staff is that it can be time consuming. Planning your recruitment process is crucial to making this process more time-efficient. For example, if you’re unsure whether you want to hire an aesthetician or an aesthetic nurse to carry out particular treatments, then list the essential requirements of the role you have in mind. Consider all aspects of the role and match these up with the required experience or training. Your clinician may need to have training and practical experience in laser hair removal, but does that clinician also need to be a trained nurse and, if so, why? Perhaps your clinic’s USP is that treatments are only carried out by medical professionals who are qualified doctors or nurses. But, if not, then consider that a fully-qualified aesthetician, with the relevant skills and experience in performing the skin treatments you offer, could also be a fit for the role. Such factors should be noted, discussed and decided on before you advertise the role available, and certainly before you begin to interview, or you could waste days reading CVs and interviewing candidates who don’t meet your demands. If you think you know what you want, but are not entirely sure what you need, make a list dividing essential and desired skills and qualities. Look at the average salaries being offered for similar vacancies in your region, and

You may be well versed in the latest aesthetic trends, but does that include industry salaries?

When did you last revise your job specifications, your interview questions and your employee packages? If you haven’t reviewed any of these in the last few months, then you must make time to do so before you begin the hiring process again. You may be well versed in the latest aesthetic trends, but does that include industry salaries? It is not sufficient to simply offer the same remuneration year after year, as this may mean you are not keeping up with your direct competitors. Similarly, it could mean you are offering more than you need to, raising your costs unnecessarily. Before you advertise for a new employee, check what other clinics in your region are offering to ensure you are not losing key personnel to other clinics. You should also ensure that your job specification is in line with current requirements within the aesthetic and cosmetic surgery industry. As noted, before advertising you must know the minimum requirements for this role, both in terms of essential skills and also in terms of legalities. If you advertise for an aesthetic practitioner who is to perform laser treatments, but you do not state that they need to have completed their NVQ3 in Beauty Therapy and the Laser Core of Knowledge course, then you are likely to receive applications from underqualified practitioners who want to develop their skill set. Unless you are willing and able to offer, and sometimes fund, training for such applicants, then you will either waste time sifting through unsuitable applications, or hire someone who will not meet the minimum requirements for your clinic’s insurance. Speak to your insurer if you are in any doubt about the criteria for cover. If you are about to launch a start-up venture, contact a specialist insurer for the cosmetic industry, as they will be able to tell you which treatments you can and should be covered for, and the minimum requirements for practitioners.

Choose suitable recruitment methods When managing the recruitment process yourself, it is important to factor in costs for advertising fees for job boards, local press and other classifieds, as well as the time spent on preparing adverts, reading CVs, arranging interviews, and managing any contract negotiations. If you use a recruitment agency, you will usually pay one fee for these tasks. A recruitment agency will have access to a wide network of industry professionals, so they can proactively headhunt candidates when you have a

Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015

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specific person in mind for your vacancy. Though agency fees can seem expensive at first sight, if you add up the cost of your in-house recruitment process, you may find that agency fees are cheaper when all is taken into account. However, that isn’t to say that it is always advantageous to use an agency to recruit every new member of staff; this is very much dependant on the kind of candidate and the type of role you are looking to fill. Before making your decision on whether to recruit in-house or outsource, think about your vacancy. Is the role for someone with a very specific and uncommon skillset, or are the skills required easy to find in a wide range of applicants? If you are looking for a junior receptionist who does not need to have vast industry experience, for example, you may receive a high number of applications for that role and, out of those, you are likely to find some candidates worthy of an interview. If you are looking for a senior manager with a lot of industry experience and a detailed set of skills, you may end up spending a lot of time searching for your perfect employee, and possibly waiting longer than you desired to get that new staff member in place. While you may not need an agency to assist with junior roles within your company, it may be advantageous to use the help of a recruiter for roles that require specific skills and attributes.

Establish a comprehensive induction process Once you have gone through the recruitment process and successfully hired your ideal employee, you need to make sure they stay. Don’t take it for granted that your staff members will settle in and feel comfortable straight away; you need to ensure

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Give new staff members the time to learn your processes and protocols that you do everything you can to make new employees feel at ease, and have the confidence to do their job to the best of their abilities. Make sure you have an induction process that helps your new employees understand their role and responsibilities, as well as your company culture. Give new staff members the time to learn your processes and protocols before you leave them on their own, and be there to answer any key questions they may have. If you start off on the right foot, your new employee should get into their stride quickly and feel confident they have made the right decision in joining your clinic’s team. Taking a thorough approach to hiring new members of staff for your clinic will ensure efficacy in the long-term. Research and planning is key to finding the right candidate and ensuring a streamlined process for filling both current and future roles within your practice. Victoria Vilas is brand manager at ARC Aesthetic Professionals, a recruitment consultancy specialising in the aesthetic medicine and cosmetic surgery sector. Since 2008, managing director John Sellers and his team have helped numerous organisations within the industry grow their businesses by hiring the most talented aesthetic professionals in the UK.

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Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015

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Why Do You Need A Partnership Agreement? Solicitor Shuba Nath explains how investment in a partnership agreement can protect you and your business Partnership agreements are akin to marriages; when things are going well there are likely to be no complaints – however, when things do not live up to a partner’s expectations, business tensions arise which can result in an ugly and expensive divorce of the partnership. Time and money spent in having a carefully crafted and bespoke agreement, which takes account of the various needs of the partners and provides solutions to those often tricky questions or disputes can, on any analysis, only be viewed as an investment. If the parties involved choose not to put an agreement in place, the provisions of the Partnership Act 18901 will apply automatically. Unfortunately, these provisions may not always be suitable for the parties’ needs. The upfront costs involved in paying for a partnership agreement pale significantly when compared to the costs involved in managing a partnership dispute; the dispute may end up in litigation (a nonconfidential and public process) if no proper arbitration or mediation provisions (both confidential processes) are contained in the agreement. The old adage ‘prevention is better than cure’ applies equally to partnerships as to any other area of life. Some professions – in particular the GP sector – are very fortunate. The GPs have specific guidance provided to them in the form of the British Medical Association’s (BMA) Partnership Agreements 2014.2 Yet despite the availability of this resource, it is still surprising how many GPs either have no partnership agreement in place or if they do, it is likely to be outdated and not fit for the needs of the modern practice. However, GPs are not alone; there are many businesses, including private aesthetic clinics, where parties team up to work together, completely oblivious to the liability that they may attract through operating on a partnership basis. The Partnership Act 1890 is very clear that a partnership is formed when: “Partnership is the relation which subsists between persons carrying on a business in common with a view of profit.”3 Imagine you are a partner; you have been working in a practice or with your business partners for a considerable number of years. You have had some ups and downs over the years but you have generally gotten on well with your colleagues. One day, to your surprise, your colleagues tell you they do not think you are performing as well as you used to. This underperformance is the reason why your colleagues would like you to leave the partnership; they are keen to keep things amicable and will help you and support you but you have

to leave. You believe you are being asked to leave unfairly and, in any event, even if you were to leave you would want to secure your financial future to some extent; after all, surely you are due something back from the practice into which you have invested a large chunk of your life. Aren’t you? However, you have no partnership agreement in place. There is nothing which spells out what your share of the practice’s or the business’s profits are; there is nothing that spells out the circumstances in which the other partners can ask you to leave; you wonder if you could be protected in employment law; you seek advice; you realise that employment law does not always necessarily treat partners the same way as employees and this means you have no legal claim to compensation for dismissal.4 So much could have been avoided if only you had put an agreement in place. The consequence is you become embroiled in a lengthy and acrimonious dispute with your partners as to what you think you should be owed. The legal costs start to add up from this point onwards until a resolution is found. Apart from the financial impact there is also the psychological impact and stress that is imposed on all when a dispute arises; business owners are best left to running their businesses, not wasting valuable management practice time in trying to resolve disputes. Other key provisions under the partnership agreement will revolve around the decision making process, partnership premises, the partner’s shares of profits and liabilities, a valuation of the partnership if the others are to buy a partner out, partner targets, restrictive covenants to stop exiting partners setting in competition with an existing business within a defined geographical area and time frame; retirement, expulsion, holiday, absence leave and, finally, provisions for dealing with dispute resolution. Partnerships, like any other business, evolve. A partnership agreement is a valuable asset; it’s your responsibility to ensure that the agreement does not become a toxic asset. If you do have an existing partnership agreement in place you should get it reviewed regularly, perhaps every three to five years (depending on your business), to ensure that the agreement that was initially put in place still reflects the realities of your business and its needs. Shubha Nath is a solicitor and the managing director of Nath Solicitors Limited; she has spent more than 20 years practising partnership and company law and learning first-hand about partnership agreements and setting up and running of companies. REFERENCES 1. Legislation.gov.uk, Partnership Act 1980 (UK: legislation.gov.uk, 1890) <http://www.legislation.gov.uk/ukpga/Vict/53-54/39/contents> [accessed 4 February 2015]. 2. British Medical Association, Partnership Agreements (UK: British Medical Associations, 2014) <gppartnershipagreements2014.pdf> [accessed 4 February 2015]. 3. Legislation.gov.uk, Definition of partnership (UK: legislation.gov.uk, 1890) <http://www.legislation.gov.uk/ukpga/Vict/53-54/39/section/1> [accessed 4 February 2015]. 4. Tiffin v Lester Aldridge EWCA Civ 35 (2012), British and Irish Legal Information Institute, 2012

Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015

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Aesthetics

The Mobile Revolution Tracey Prior highlights why having a mobile-friendly website is crucial in 2015 In recent years, access to faster, cheaper mobile technology and more accessible data hotspots, WIFI and reliable 3G/4G connections has meant a surge in mobile usage across the world. Once businesses could simply provide an online portal for customers to find their address or contact details (and this on an unoptimised web page), but this is no longer viable. Forwardthinking companies now adopt the use of responsive web design (RWB), a design which adapts to whichever interface the user is deploying, ensuring that it is always formatted and functional to the size of that particular screen, be it a desktop, tablet or mobile. Others have a dedicated mobile website, with design and function built purposefully for mobile use, or craft apps that deliver content efficiently and directly. One sector that has witnessed a growth in mobile usage is the aesthetic sector. Patients used to purchasing food and other necessities online now expect a similar level of service in all areas of their life. Whether a consumer is using a tablet device in their

home or a mobile device on the move, an optimised web solution ensures you are on the right track to capture and capitalise on this growing tech-savvy clientelle. Statistics collected from a selection of our clients’ cosmetic aesthetic websites, as of December 2014, show that on average 50% of users are visiting websites via mobile, which equates to an increase of 10% from 2013. This increasing trend is further confirmed by OfCom official statistics.1 If, therefore, your website is not optimised for mobile use, it becomes difficult for approximately half of your patients to find what they require in a quick and accessible manner. As we know, the average attention span of consumers is waning, whilst the speed and accessibility of information is creating a mindset of, “Instant gratification and quick fixes”, according to Rob Weatherhead, head of digital operations at leading media agency MediaCom.2 In this digital revolution, an online presence is not enough. Your web and mobile presence has to secure the attention of a potential patient by providing key information in a fast,

Capitalising on the mobile boom When considering how to become mobile friendly, assess the content that you currently have on your website and imagine (or try out) how this displays on a mobile device – is there scrolling/panning to find information? Do images make up the bulk of the content and do they bury the informative text at the bottom of the page? Your aim is to de-clutter and simplify information displayed on the screen, ensuring there is a clear hierarchy to the information being presented, and that it is delivered in captivating yet bite-sized sections. There are many services out there that will allow you to begin your journey to becoming mobile ready. For example, you can utilise free website builders that supply responsive web templates. However, these may only get you so far. If you already have a functional web presence that just needs updating, or if you require an online overhaul, calling on the experience of a design/digital agency is key. Digital development is an evolving process and digital agencies are at the forefront of ensuring their clients see a return on their online presence.

accessible, understandable and engaging manner. If a user faces difficulty accessing information because your website is not optimised for mobile (for example, if they are having to pan around a mass of information and zoom in and out to read key parts) they will simply navigate away and find a better resource of information. It is not only important from an accessibility perspective to be mobile ready – new mobile and web technologies have made it easier to offer a wider range of services for patients. Online booking, appointment management, and access to specialists via ticketing and chat systems, all help patients make an informed decision on whether your service is right for them. Technological development has allowed for the increased use of new and often under-utilised techniques for capturing a potential audience. With the roll out of 4G it is becoming more viable to present video information to consumers; a great way to capture attention. Having a mobile solution for your web presence also improves the share-ability of information on social networks. 60% of social network access is via a mobile3 – and the majority of people have social network accounts directly linked to their mobile devices. This increases the chances that a consumer could share information that is useful to them (or potentially the people within their network) on social media, increasing your reach and promoting your clinic. There are many ways to tackle this evolving trend. It could be a responsive website, a dedicated mobile website or a mobile application. All methods focus on a similar and unified goal – to ensure the user is getting the best possible experience and level of service possible. Statistics show a definitive increase of companies deploying mobile solutions over recent years – with no impression of slowing down. Tracey Prior is the operations manager for Blow Media, a creative, design and digital agency which caters to the aesthetic industry. Having been a sales director for 12 years prior to joining Blow Media, Tracey Prior is very much commercially minded and knows the value creating a strong digital footprint can add to your clinic. REFERENCES 1. Ofcom, Facts and Figures (UK: ofcom.org.uk, 2014) <http:// media.ofcom.org.uk/facts/> [Accessed 4 February 2014] 2. Rob Weatherhead, Say it quick, say it well – the attention span of a modern internet consumer (UK: The Guardian, 2014)<http://www.theguardian.com/media-network/media-net work-blog/2012/mar/19/attention-span-internet-consumer> [Accessed 4 February 2014] 3. Emily Alder, Social Media Engagement: The Surprising Facts About How Much Time People Spend On The Major Social Networks (UK: Business Insider, 2014) <http:// www.businessinsider.com/social-media-engagement-statis tics-2013-12?IR=T>. [Accessed 4 February 2014]

Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015

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“Don’t let anyone tell you that you can’t do what you have your heart set on” Nurse Independent Prescriber Emma Davies talks to us about co-founding the BACN, and her unwavering passion for growth, learning and regulation Emma Davies has achieved many milestones in a career spanning 28 years. From co-founding the British Association of Aesthetic Nurses (BACN), to her current clinical director position at the newly-formed Save Face, her work has served as an important building block for a generation of practitioners campaigning for better regulation in aesthetic medicine. Qualifying as an NHS nurse in 1987, Davies recollects how she fell in love with the profession at a young age. “I had kidney disease when I was a child and spent a lot of time in hospital, so grew up wanting to be a nurse. Those nurses who looked after me inspired me,” she explains. Her interest in aesthetic work wasn’t sparked until 1998, when a colleague mentioned that a nurse who had treated her with collagen injections was looking to expand her practice – and was offering training in the field. The aforementioned nurse was AestheticSource director Lorna Bowes. “I was fortunate because she mentored me and helped me find my feet. I haven’t really stopped since,” says Davies. “The more I find there is to learn – which is what I love – the more I love my work.” In the beginning, Davies experienced a very gradual learning curve. “At the time there weren’t many reference points – if any,” she recalls. “It was a slow learning curve for me, it was such a foreign world.” However, she focused on building her skills by following her personal motto, ‘plough your own furrow’, which means don’t be distracted by what other people are doing – focus on doing what you do, and doing it well. Since 1998, Davies has worked in independent and national chains in London and the South West, before establishing her own clinic in Somerset and courses for vein-care training in 2003. She now also works alongside a plastic surgeon in Bristol. “I’ve never just focused on one thing, I’ve always had two or three different hats,” she says. Davies feels the BACN is her biggest achievement to date. Before its creation in 2010, turning to other professional bodies had left her disappointed. She felt their services were no longer adequate for the aesthetic nurse profession. “The BACN was really needed to take up the baton, celebrate our role, and bring aesthetic nurses together in a community. It was needed to develop our selves further,” she says, adding, “I was completely hooked on the journey.” Though it didn’t seem likely at the time, the BACN eventually grew to be much more than Davies and her fellow founding members had ever imagined. “I don’t think people fully appreciate how important it’s been, and how important it’s going to continue to be for those nurses that are passionate and committed to it,” she says. After retiring from her post as BACN Chair in 2014, though still actively involved in the association, she has since become the clinical director of voluntary accreditation register Save Face. “I was planning to have a quieter life, but this was far too exciting to say no to,” she says. Davies acknowledges the requirement,

as highlighted in the Keogh report, for an independent register of accredited professionals. “I think we’re all agreed that we will be in a better place when there are accredited standards and pathways to education, and when the consumer has a means to navigate to an independently verified, safe and accountable service provider.” For industry newcomers, she insists research is key. “Reading journals such as Aesthetics is hugely valuable, as is making time to get a feel for the field before jumping in,” she advises. Reflecting on her career and on how she has learnt from mistakes, she says candidly, “I would think the mistakes and the wrong turns, and there have been a few, have had so much more value than things that went right the first time, and I wouldn’t be where I am today if I hadn’t made and learnt from them. I wouldn’t change anything.”

What treatment do you enjoy giving the most? Dermal fillers. It’s a skill that allows you to be fairly artistic, and it provides that instant wow-factor for the patient.

What technological tool do you think best complements your work? The syringe or the needle. Having a good quality syringe – and the types do vary – and a very sharp needle, are the main things that complement my work.

What’s the best piece of career advice you think you’ve been given? “Don’t let anyone tell you that you can’t achieve something that you have your heart set on.” When I had big ideas, it would have been easy to ‘park’ them, the voice of doubt saying, “Well, if that’s such a good idea, why hasn’t it been done?” I might have played safe and simple, but I didn’t, and have thoroughly enjoyed and grown from all the challenges I’ve faced.

Do you have an industry ‘pet hate’? When role models brag about treating large numbers of patients every day, as though seeing a patient every 15 minutes is a measure of success. All I’m thinking is, what is that experience like for the patient? We have to remember there’s a person on that couch, and they’re paying a lot of money, so they shouldn’t be treated like something in a factory. Where is your job satisfaction when you’re working with that attitude?

What aspects of aesthetics do you enjoy the most? I love meeting with professionals who have a passion for the craft, care about their patients, and love what they do – and there are lots of them.

Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015

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The Last Word Dr Paul Charlson argues the value of dermatological training for aesthetic practitioners Aesthetic medicine and dermatology are interrelated specialties and, as such, it is harder to practise aesthetics effectively without a thorough understanding of the skin and how it functions. Conversely, having knowledge of aesthetics is complementary to modern dermatological practice. For this second point, it is important to note that the boundaries between what the state provides through a taxation-funded NHS and the private medical sector are becoming increasingly blurred – and this is particularly noticeable in dermatology. We no longer live in a society where people are content with the options that the NHS provides. From both my own experience, as well as that of colleagues, it has been noted that patients are increasingly consulting us on what aesthetic procedures are available, how they work and where they can go to receive treatment. However, NHS clinicians working in dermatology and primary care, who also work as aesthetic practitioners in the private sector, regularly encounter the difficulty of this multifaceted and interlinking interface. In order for our patients to make informed treatment choices, it is reasonable to advise them of all the options available. Whilst consulting within the NHS, good practice dictates that we should endeavor to answer patients’ direct questions about aesthetic treatments not available on the NHS reasonably and briefly. It is ethically prudent of NHS doctors and nurses to suggest patients do their own research, especially when they receive direct enquiries. This is frustrating as we are aware of the variability of quality within the aesthetic industry, and want to ensure our patients seek treatment from a practitioner who is clinically and ethically sound. Dermatology and aesthetic medicine are natural bedfellows. In my NHS practice as a GP and as a GPSI in dermatology, I am often confronted with conditions that can also be classed as aesthetic concerns. A typical example of this is melasma, which is often distressing for patients and cannot be comprehensively treated by an NHS prescription for Azeliac acid, a retinoid and sun block. Whilst being beneficial, these treatments only form part of a range of accessible options. There are excellent effective alternatives, which would be denied to a patient if the practitioner had no knowledge of their efficacy and indications. Furthermore, from the point of view of NHS clinicians, rosacea is another distressing condition, characterised by facial telangiectasia, which can be easily treated by vascular laser. It can be very helpful if practitioners are able to advise a patient of how lasers work and how they can aid the treatment of rosacea in a private aesthetic

Aesthetics Journal

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clinic. Acne scarring is another example of an aesthetic concern where there are little treatment options available within the NHS. Sound knowledge of other treatments can really help guide patients to make safe and effective choices. From an aesthetic practitioner’s perspective, skin lesion recognition is a valuable skill to bear. I advocate that all aesthetic practitioners should have basic training and understanding of how to recognise malignant or premalignant lesions. Many patients with aesthetic concerns have signs of ageing, most commonly from their 40s onwards, which is often associated with sun damage. As we know, solar-related skin lesions such as basal cell carcinomas, actinic keratosis, Bowen’s disease and melanoma are more common within this group. In my experience, many patients who seek aesthetic treatments are sun-bathers or use sun beds, which increases the risks of solar damage and raises the incidence of these lesions. Being able to use a dermatoscope, in particular to aid recognition of lesions, is very helpful in planning lesion management. This is often crucial if a surgical procedure is required and, with the correct diagnosis, can also ensure you avoid advising or performing unnecessary surgery. An understanding of dermatology can also help the practitioner choose suitable topical cosmeceutical agents for patients – further guaranteeing an effective treatment outcome. Similarly, when complications arise as a result of aesthetic treatments, it is really helpful for practitioners to understand how the skin might react and have the knowledge to correct the problem with confidence. Complications are inevitable, thus handling them correctly and having the understanding of how to treat them effectively can avoid potential medical litigation arising in the future. Traditionally, dermatology has not been a particularly welltaught subject at undergraduate level and, as a consequence, many doctors and nurses entering aesthetic practice will have significant gaps in their knowledge of skin function and care. Considering each of the points made in this article, I argue that anyone considering a career in aesthetics should also gain basic dermatological training at an early stage in his or her career. As dermatology is a visual subject, where pattern recognition is crucial, spending time in a dermatology clinic is very helpful. Most practitioners are happy to welcome colleagues into their clinics so I would certainly recommend contacting consultants in their local Trust or community clinics. Many dermatology courses are also available, and organisations such as the Primary Care Dermatology Society (PCDS) and the British Association of Dermatologists (BAD) run excellent short courses. I found the diploma in Practical Dermatology particularly beneficial to my understanding of skin function and care. Although these courses require a significant investment in time and money, they do provide an excellent dermatological grounding for aesthetic practitioners. In the future I believe a module on dermatology – specifically tailored to aesthetics – should form part of all diplomas in aesthetic medicine. The purpose of this piece is not to claim that dermatology training is absolutely essential to becoming an aesthetic practitioner, but to highlight that it is complementary to an aesthetic practice. The benefits to both the patient and to the practitioner are worth the effort from a clinical, as well as a commercial, point of view. Dr Paul Charlson is an NHS GP and GPSI in Dermatology. Joining aesthetic practice in 2002, he is now the president of the British College of Aesthetic Medicine and medical director of Skinqure Clinic. Previously Dr Charlson was a GP trainer and partner, with 20 years experience in a dispensing practice.

Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015

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