Aesthetics May 2016

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VOLUME 3/ISSUE 6 - MAY 2016

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Medium and Deep Chemical Peels CPD Dr Simon Ravichandran examines the properties of medium and deep chemical peels

Periorbital Rejuvenation

Treating Bingo Wings

Entering Awards

Practitioners discuss their methods for enhancing the eye area

Dr Martyn King shares advice on improving arm aesthetics

Amanda Elbourn details the value of entering industry awards

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Contents • May 2016 06 News

The latest product and industry news

12 AMWC 2016, Monaco

Aesthetics reports on the AMWC conference in Monaco

13 Advertorial: Allergan

Aesthetics reflects on the Allergan Medical Institute Meeting, London

14 News Special: ACE in Review

Aesthetics reports on the Aesthetics Conference and Exhibition 2016

CLINICAL PRACTICE 21 Special Feature: Periorbital Rejuvenation

Practitioners discuss their preferred methods for enhancing the eye area

27 CPD: Medium and Deep Chemical Peels

Dr Simon Ravichandran examines the properties and use of medium and deep chemical peels

33 Intravenous Nutritional Therapy

Dr Jacques Otto and Dr Samantha Gammell discuss the benefits of IVNT

39 Treating Bingo Wings

Dr Martyn King discusses the options available for improving the appearance of the arm

42 Nutraceuticals

Dr Martin Godfrey explains how effectively using nutraceuticals can improve aesthetic treatments

45 Combatting Stress on Skin

Dr Stephen McCulley details how stress affects the skin and advises how to recognise and treat symptoms

48 Mesotherapy for Cellulite Treatment

Dr Philippe Hamida-Pisal details the aetiology of cellulite and discusses treatments using mesotherapy

52 Advertorial: SkinCeuticals

The role of antioxidant skincare in post-procedural wound healing

53 Abstracts

A round-up and summary of useful clinical papers Details of the awards categories and entry process

IN PRACTICE 58 Entering Awards

Clinic operations director Amanda Elbourn explains the value of entering industry awards and shares her tips for creating a successful entry

60 Skin Imaging

Clinical Contributors Dr Simon Ravichandran is an ear, nose and throat surgeon, specialising in rhinology. He co-founded Cinetix Medispa in 2010, established the Scottish Advanced Aesthetic Training Programme and founded the Association of Scottish Aesthetic Practitioners.

Dr Jacques Otto has a Master’s in medical pharmacology, philosophy in medical law and family doctor practice degree. His main interests are researching new antiageing and cosmetic products and cosmetic non-invasive medical device development.

Dr Samantha Gammell is the founder and medical director of The Hadleigh Clinic and The Aesthetic MediSpa, and the former president of the BCAM. She trains with leading IVNT doctors in the US and provides IVNT to her patients.

Dr Martyn King is the director of Cosmedic Skin Clinic, medical director of Cosmedic Pharmacy, chair of the Aesthetic Complications Expert Group, member of the BCAM and board member for the British Association of Sclerotherapists.

Dr Martin Godfrey is head of research and development at MINERVA Research Labs Ltd. Dr Godfrey has expertise in health and nutritional product marketing and gains scientific verification for Minerva’s products through overseeing clinical trials.

54 Aesthetics Awards 2016

Special Feature Periorbital Rejuvenation Page 21

Dr Anita Sturnham discusses the benefits of incorporating surface imaging technology in a clinic

Mr Stephen McCulley is a consultant plastic, reconstructive and aesthetic surgeon. He is based at City Hospital in Nottingham and also runs a private practice that offers both surgical and non-surgical procedures.

Dr Philippe Hamida-Pisal is an aesthetic practitioner working in London and Paris. He is the president of the Society of Mesotherapy UK, the society partner of Euromedicom and IMCAS Paris and is a keynote speaker at major international events.

64 Personal Wellbeing Education

Independent nurse prescriber Jodie Grove discusses the positive gains of offering psychological referrals

67 In Profile: Mrs Sabrina Shah-Desai

Consultant ophthalmic plastic and reconstructive surgeon Mrs Sabrina Shah- Desai explains her love of treating the periorbital area and why teaching is a vital part of her career

69 The Last Word

PR consultant Tingy Simoes and Nikki Milovanovic argues why the industry needs to clamp down on cosmetic games aimed at children

NEXT MONTH • IN FOCUS: Skin Tightening • Treating Men with Botulinum Toxin

Entry is now open for the Aesthetics Awards 2016

www.aestheticsawards.com

• Case Study: Acne Scarring • Cyber Crime

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Editor’s letter The Aesthetics Conference and Exhibition 2016 (ACE) took place last month and what a brilliant two days it was! I must give my thanks to all of you who participated and attended – you made it our biggest and best conference Amanda Cameron to date. The free education in the form of the Editor Expert Clinics, Masterclasses and Business Track sessions proved to be extremely popular – it was fantastic to see them packed-out with delegates. The new Treatments on Trial agenda saw fascinating debate between the panel when comparing latest products and devices, and it was a pleasure to oversee the premium Conference sessions where delegates were provided with a superb educational agenda from expert speakers. Huge thanks must go to Mr Dalvi Humzah, the chair of the ACE Steering Committee.

He played a crucial role in the two-day programme, ensuring its smooth running and high-quality outcome. To read more about this year’s ACE highlights, turn to p.14. As I write this month’s letter, the new cosmetic surgery guidelines from the General Medical Council (GMC) have been issued. These guidelines are designed to apply to all doctors in the UK who carry out cosmetic procedures – surgical

and non-surgical – to make sure they provide the best possible patient care. This is good news and it’s gratifying to see that the Keogh report is having some impact on our industry. But while this is very welcome news, to me it still begs the question – what about the non-regulated groups? I am sure there will be much discussion to come. Now ACE is over it’s on to the Aesthetics Awards 2016, to recognise those who are performing to the best standards. We never stand still at Aesthetics and are always looking for ways to educate, inform and do our small bit for keeping standards high. Turn to p.54 to find out how you can enter. The wide range of topics covered this month demonstrates just what a huge specialty we work in.

ACE 2016 speaker Dr Simon Ravichandran has written May’s CPD on medium and deep chemical peels (p.27), Dr Martyn King details the various ‘bingo wings’ treatments available on p.39 and aesthetic nurse prescriber Jodie Grove talks about the benefits of incorporating personal wellbeing education into your clinic (p.64). Let us know what you enjoy reading by tweeting @aestheticsgroup or emailing editorial@aestheticsjournal.com. Don’t forget, we now have a brand new website (p.36), so visit www.aestheticsjournal.com to see the entire journal’s educational content and much more.

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

Dr Raj Acquilla is a cosmetic dermatologist with more than 12

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.

years experience in facial aesthetic medicine. In 2015 he won the Aesthetics Award for Aesthetic Medical Practitioner of the Year and in 2012 he was named Speaker of the Year. Dr Acquilla is a UK ambassador, global KOL and masterclass trainer in the cosmetic use of botulinum toxin and dermal fillers.

Sharon Bennett is chair of the British Association of

Dr Tapan Patel is the founder and medical director of VIVA

Cosmetic Nurses (BACN) and the UK lead on the BSI committee for aesthetic non-surgical medical standards. Bennett has been developing her practice in aesthetics for 25 years and won The Institute Hyalual Award for Aesthetic Nurse Practitioner of the Year in 2015.

and PHI Clinic. He has more than 14 years of clinical experience and has been performing aesthetic treatments for ten years.

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

Dr Christopher Rowland Payne is a consultant

Mr Adrian Richards is a plastic and cosmetic surgeon with

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.

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 Sarah Tonks is a cosmetic doctor, holding dual

Dr Maria Gonzalez has worked in the field of dermatology

qualifications in medicine and dentistry. Based in Knightsbridge, London she practices a variety of aesthetic treatments.

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

for the past 22 years, dividing her time between academic work at Cardiff University and clinical work at the University Hospital of Wales. Dr Gonzalez’s areas of special interest include acne, dermatologic and laser surgery, pigmentary disorders and the treatment of skin cancers.

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Regulation

Talk #Aesthetics Follow us on Twitter @aestheticsgroup #Education Simon Ravichandran @Ravichand1Simon A great day teaching applied aesthetic anatomy to Colombia’s top aesthetic surgeons and derms. #Regulation Nigel Mercer @NigelMercer #BAPRASvoice busy day talking to the BBC regions and 5live about new Cosmetic Surgery guidelines and now off to talk at the @RoySocMed #Launch Dr Nestor @DrNestorD Incredible first day of new clinic!

#Children BAAPS Press Office @BAAPSMedia Yes, it was an #AprilFools – this time. But #CosmeticSurgery games for kids are VERY real & no laughing matter.

GMC releases guidance for cosmetic doctors The General Medical Council (GMC) has released new guidance directed at doctors who perform cosmetic procedures in the UK. The new GMC guidance will come into effect on June 1 and says that doctors must advertise and market services responsibly, give patients time for reflection, seek a patient’s consent themselves, provide continuity of care and support patient safety.

The chair of the GMC, Professor Terence Stephenson, said, “Our new guidance is designed to help drive up standards in the cosmetic industry and make sure all patients, and especially those who are most vulnerable, are given the care, treatment and support they need.” The guidance follows the release of the Keogh Review by national medical director of the NHS, Professor Sir Bruce Keogh in 2013, which highlighted the risks associated with cosmetic interventions and the need for greater patient protection.

“The independent review I chaired, following the PIP breast implant scandal, highlighted major problems with unsafe practices in the cosmetic sector, including poor follow-up care and record keeping, and misleading and inappropriate advertising and marketing techniques,” Professor Keogh said, adding that the new guidance “addresses these issues and will drive safer care and better ethical practice.” To produce these guidelines, the GMC has worked closely with the Royal College of Surgeons (RCS), which also published its own set of standards for cosmetic surgery.

Vice president of the RCS, Mr Stephen Cannon, said, “The message to surgeons and doctors working in the cosmetic surgery industry is simple: if you are not working to the surgical standards we have set out today, you should not be treating patients at all.”

Antiageing

#Congress Dr David Jack @drdavidjack #AMWC #monaco 2016 with @thelovelyclinic Dr Sarah Tonks talking all things #aesthetic #cosmetic and #antiageing #skincare #fillers #juvederm #botox #montecarlo

Murad launches new range

#Responsibility Dr Anjali Mahto @DrAnjaliMahto #doctors have a moral responsibility to promote facts even if facts don’t sell magazines #integrity #dermatology #evidencebasedmedicine #Training Michael Lee, M.D @DrLeePlastic Teaching facial anatomy course with Steve Levine @DoctorJacob @DrJasonPlastics #ASAPS2016 #plasticsurgery

Skincare company Murad has introduced the White Brilliance range to its portfolio.

The range consists of four products, the Cleansing Cream, Luminous Essence, Porcelain Serum and the Luminous Shield SPF50, which are designed to give the skin a luminous, smooth and even appearance.

The key ingredients include porcelain flower extract and a native Asian flower that according to Murad, helps to illuminate and even skin tone, as well as moisturise, repair and purify the skin.

Reproduced from Aesthetics | Volume 3/Issue 6 - May 2016

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Industry

Pfizer and Allergan abandon $160 billion merger The Pfizer and Allergan deal has been terminated after new regulations issued by the US Treasury on April 5 were announced which crack-down on companies hoping to move abroad for more favorable tax rates. Allergan released a statement on April 6 confirming that the merger had been abandoned by mutual agreement and that Pfizer had agreed to pay Allergan $150 million for reimbursement of expenses associated with the transaction.

“While we are disappointed that the Pfizer transaction will no longer move forward, Allergan is poised to deliver strong, sustainable growth built on a set of powerful attributes,” said CEO and president of Allergan, Brent Saunders.

In November, US global biopharmaceutical company Pfizer made a deal to merge with Allergan, in a stock transaction valued at US $363.63 per Allergan share. Allergan’s residence in Dublin meant the merger would have provided Pfizer with a foreign address resulting in more than $2 billion in savings over the first three years.

Dermal fillers

Intraline releases dermal filler marketed to men Intraline Lifestyle Aesthetics has released a new hyaluronic acid (HA) dermal filler targeted towards men. Intraline for Men is said to use a ‘proprietary spherification technology’ which aims to smooth HA’s traditionally rhomboid molecular structure, providing the fillers with ‘some of the highest molecular density’ compared to other products.

CEO of Intraline Lifestyle Aesthetics, Reece Tomlinson, said, “We want to dissolve the stereotypes and continue to support the idea that aesthetic treatments are not just for women. We pride ourselves on bringing a fresh perspective and continual innovation to aesthetic treatments, through our commitment to provide safe and quality products with fantastic results.”

Acquisition

Energist Medical Group purchases Chromogenex Aesthetic manufacturer Energist Medical Group has bought the rights to laser manufacturing company, Chromogenex Technologies, outside of the US, in a bid to increase its aesthetic device portfolio.

The purchase of Chromogenex, which recently went into administration, will give Energist Medical Group access to products established by the company, including the i-Lipo brands.

Group CEO at Energist Medical Group, Max Humber said that by securing the R&D and IP rights to Chromogenex’s portfolio, the company will be able to keep up with the surge in demand for laser-based procedures.

“Strategically, this deal is perfect for Energist,” he said, adding, “The products we’ve acquired from the administrator are predominantly used for the non-invasive reduction of fat so they’re a perfect complement to our existing product portfolio.”

Aesthetics

Vital Statistics In a survey of patients treated by NHS or private doctors, almost a third of acne sufferers said they were not offered satisfactory treatment by a member of the medical profession (British Skin Foundation survey of 2,299, 2015)

Less than 15% of human faces are considered to be symmetrical (Facial Plastic Surgery, 2006)

Arm lifts in women have increased by more than 4,000% in the last 10 years (American Society of Plastic

4k%

Surgeons, 2013)

72% of internet users say they have looked online for health information within the past year (Pew Research Center’s Internet & American Life Project survey of 3,014 US adults, 2013)

Less than 1% of patients with

dermatologic conditions are screened for depression in the US (American Academy of Dermatology, 2016)

Women account for 91% of cosmetic surgical procedures in the UK (British Association of Aesthetic and Plastic Surgeons, 2015)

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

Reproduced from Aesthetics | Volume 3/Issue 6 - May 2016

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PDO threads

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Hair

Aesthetic clinics form PDO thread association Aesthetic practitioners have collaborated to form the Association of PDO Threads UK to ensure that the best possible practices are used when conducting procedures involving polydioxanone threads. The association will be chaired

by Professor Syed Haq and will offer help and guidelines for members, including discussions on the current threads available in the UK and their CE mark status.

Professor Haq said, “With PDO thread therapy experiencing a surge in popularity, never has it been so important to be part of a united medical community that offers education, advice and support.”

According to Dr Jacques Otto, who is a member of the board responsible for education and accreditation standards at the Association, the group will engage with regulatory bodies and several insurance companies to ensure practitioners are aware of the risks of buying from certain countries abroad.

“The aim of the Association of PDO Threads UK is to set and uphold minimum standards of excellence in polydioxanone threads education, training practitioners and CE Mark regulation, in collaboration with the Medicines and Healthcare products Regulatory Agency (MHRA),” said Dr Otto. “An important function of the Association is the provision of information to the public in terms of safety and the legal aspect of PDO threads and where to find accredited practitioners,” he added.

Vitiligo

Wellness Trading launches new vitiligo product in UK UK aesthetic distributor Wellness Trading has launched the Zanderm Vitiligo Concealer in the UK, which aims to provide long-lasting cosmetic coverage for vitiligo sufferers.

According to manufacturer Zanderm, the product is suitable for all skin types, is sweat and water-resistant, dries fast and is easy to use. The company also claims the product is hypoallergenic and has been formulated with natural ingredients.

The product comes with an applicator that assists with covering vitiligo spots and comes in 11 different shades.

Managing director of Wellness Trading Ltd, Adam Birtwistle, said, “The products from Zanderm fit perfectly into our Wellness product portfolio, vitiligo is very difficult to treat and a serious problem for many people, these products are not a cure but are boosting the confidence and improving the lives of sufferers around the world so we are absolutely thrilled to bring them to the UK.”

Farjo receives ‘excellence status’ for hair transplant procedure

The Farjo Hair Institute has been named as the first company in the UK to receive official certification from Restoration Robotics as a ‘centre of excellence’ for the provision of ARTAS treatments.

The ARTAS treatment, a robotic hair transplant system from the US, automatically finds the best donor hairs to harvest for transplantation and enables precision, speed and reproducibility during surgery. According to Farjo, the procedure is minimally invasive and tackles some of the issues associated with manual handheld methods and eliminates the risk of scarring because no stitches are required. Dr Bessam Farjo, founder of the Farjo Hair Institute, said, “Having used ARTAS for some time, it’s clear that it offers minimal pain and fantastic results for patients. We’re thrilled to have been recognised as a ‘centre of excellence’ for ARTAS and look forward to training many more physicians from across the world.” Brent Nixon, international vice president of Restoration Robotics Inc that manufactures ARTAS said, “Dr Farjo was one of the first hair transplant surgeons in Europe to purchase an ARTAS system.

Since then, he and his clinic have helped expose and train physicians from all over the world on the benefits and advancements of the ARTAS Robotic System.”

Laser

LUTRONIC launches new devices Laser and energy-based device company, Lutronic Corporation, has introduced the Pico+4 laser device and the enCurve radiofrequency system to its portfolio. The Pico+4 is a Nd:YAG laser device that offers both picosecond and nanosecond modes with four wavelengths, including 1064nm, 532nm, 595nm and 660nm. As well as the Pico+4, Lutronic also announced the release of enCurve, an apoptosis-inducing

radiofrequency system that targets adipocytes. The non-invasive device uses a frequency of 27.12MHz to heat adipocytes to cause denaturation of cells, leading to the death of the targeted adipocytes.

It employs features such as Personalised Impedance Synchronisation Application (PISA), which is a cool tech feature that aims to ensure that the maximum amount of energy is delivered consistently into the fat cells. Air Mode is also featured within the device, which aims to keep the skin perspiration free for added safety. According to the company, the devices will be available to practitioners in the UK when they have officially obtained their CE marks; the enCurve will be accredited this month and the Pico+4 later in the year.

Reproduced from Aesthetics | Volume 3/Issue 6 - May 2016

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Awards

Entry open for Aesthetics Awards Entry is now open for the UK’s most prestigious awards ceremony, the Aesthetics Awards 2016. The Aesthetics Awards brings together the best in the medical aesthetics industry and recognises and celebrates the special achievements made throughout the past year. With 23 possible categories to choose from, all aesthetic practitioners, clinics, distributors and manufacturers are invited to enter to be acknowledged for their hard work and high standards in clinical excellence, product innovation and practice achievement. Some of the most respected categories include the Best Clinic categories, Distributor of the Year, and Aesthetic Nurse Practitioner. New Awards sponsors have also been announced, including 3D Aesthetics, which is sponsoring the 3D-lipo Award for Best New Clinic UK and Ireland, Wigmore Medical is sponsoring the Best Clinic North England category, Med-fx is sponsoring Best Clinic London, and Lynton Lasers is sponsoring the Award for Best Clinic South England. To see a list of the full list of categories and sponsors, go to page 54 and read the Awards Special. Entries to the Aesthetics Awards close on June 30, with the Ceremony taking place on Saturday December 3. For more information and to enter the Awards, go to www.aestheticsawards.com Regulation

Clinic regulation comes into effect in Scotland All private healthcare clinics carrying out dental and non-surgical cosmetic interventions in Scotland will now be regulated by Healthcare Improvement Scotland (HIS). The Scottish healthcare improvement organisation is a part of NHS Scotland and will regulate services provided by doctors, dentists, nurses, midwives and dental care professionals working within the private sector. “This change is being implemented following a report by the Scottish Cosmetic Interventions Expert Group,” said Kevin Freeman-Ferguson, senior inspector at HIS, adding, “The focus of regulation is ensuring safe, effective and high-quality care for users of independent clinics across Scotland.”

The regulation means clinics must register with HIS for a fee of £1,990, undergo clinic inspections by the body and be subject to complaints from the public about bad services. The body can then take action against the clinic if they are found not to comply.

Dr Nestor Demosthenous, who owns an aesthetic clinic in Edinburgh and is on the board for HIS, said these regulations are a step in the right direction.

He explained, “What we are trying to do is improve public awareness that these are medical procedures and that they should be carried out in clinic. Therefore, if a premise isn’t regulated, it means that they haven’t gone through the necessary steps and their procedures aren’t fully qualified. If the public starts realising this, and realising that we should actually be going to clinics rather than X Y and Z, it will help to improve patient safety overall in Scotland.”

According to Dr Demosthenous, there has been some apprehension from Scottish practitioners as they feel that the regulation is not targeting the people who shouldn’t be offering certain procedures in the first place. He explained, however, that these regulations are only one stage of the final goal, with stage two hoping to address exactly who is giving the procedures, for example beauty therapists, who are not held accountable under the current regulations.

News in Brief 152 Harley Street adds UltraPulse CO2 to its product portfolio London aesthetic clinic 152 Harley Street has introduced the UltraPulse C02 Laser by Lumenis to its clinic. The UltraPulse C02 is a skin resurfacing laser that aims to treat a number of skin conditions including overall skin rejuvenation, improving fine lines and deep wrinkles, scarring and skin tone and texture. According to Lumenis, the device has good versatility and precision and comes with a cooling system for enhanced safety and comfort.

Dr Nestor Demosthenous opens new clinic Cosmetic doctor Dr Nestor Demosthenous has opened a new aesthetic clinic specialising in hair loss, facial ageing and other skin concerns in Edinburgh.

Dr Demosthenous said, “Hair restoration surgery has become far less of a taboo; popularised by footballers and appealing to men with thinning, receding hair. I feel these treatment options have been lacking in Edinburgh, and we are the first centre of its kind to offer this locally, by myself, a local dedicated doctor.”

Invasix announces new MD Medical device company Invasix has appointed Neil Wolfeden as its new managing director. According to Invasix, Wolfeden is highly experienced in the body-contouring and laser market with substantial leadership skills and knowledge. Wolfeden has 25 years worth of experience within the industry.

“Today, customers want the very best in clinical efficacy with minimum downtime. I look forward to working together with new and established customers to add and strengthen their treatment portfolios leading to greater customer satisfaction,” Wolfeden said.

Digital design company for clinics launches A new online creative agency that specalises in graphic and web design for clinics has launched. websites4clinics.com is a Dublin-based company that aims to create high-quality designs for print and web, advertising and displays for clinics. The interactive website aims to feature in-depth information about the services offered and incorporates a portfolio of work for potential clients to see.

Reproduced from Aesthetics | Volume 3/Issue 6 - May 2016

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Events diary 11th – 15th May 2016 Face Eyes Nose Conference, Coventry www.faceeyesnose.co.uk

29th June – 1th July 2016 British Association of Plastic, Reconstructive and Aesthetic Surgeons Summer Scientific Meeting 2016, Bristol www.bapras.org.uk

5th – 7th July 2016 British Association of Dermatologists Annual Meeting, Birmingham www.bad.org.uk

17th September 2016 British Association of Cosmetic Nurses Annual Conference and Exhibition, Birmingham www.bacn.org.uk

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

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

Skincare

SkinCeuticals introduces Mineral Matte UV Defense SPF 30 Cosmeceutical skincare company SkinCeuticals has launched a new high protection sunscreen. The product is said to have a matte-finish to smooth skin texture and prevent surface shine, with ‘100% weightless mineral filters’ for UVA and UVB oilabsorbing protection. SkinCeuticals claims to have developed a new technology, Aerated Silica, which aims to absorb fifteen times its own weight in oil, and, in turn, minimise the appearance of pores, helping to prime skin for makeup application.

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Rebrand

Galderma launches new branding for Restylane range Global dermatology company Galderma has launched its line of dermal fillers with new branding. The products, which have now integrated the Emervel range of hyaluronic acid fillers, have new brand names and packaging. The Restylane range now includes Restylane Fynesse, Restylane Refyne and Restylane Volyme; which aim to restore a healthy, youthful appearance by filling lines, wrinkles and adding volume, and Restylane Defyne and Restylane Kysse; which aim to enhance facial balance and harmony by providing shape and contour. Galderma hopes that the new branding will make it easier for practitioners to choose the right product to meet the specific needs of every patient under one brand name. “The expanded Restylane portfolio is now even more versatile,” said Anna Marsell, director of marketing, Galderma Aesthetic and Corrective, “With the new packaging and product names, we’ve made it even easier for practitioners to choose the right product. Healthcare practitioners who may have had limited experience with Restylane, can tailor every treatment to meet the individual needs of their patients, and have every reason to explore the brand further.”

Digital

Aesthetics launches new online platform Aesthetics has launched a new digital platform especially designed for industry professionals to use as a resource to access all things related to the aesthetics specialty. With enhanced usability and a fresh new design, the website will host everything from the latest in industry news, feature articles, CPD accredited education, job opportunities and training courses to a comprehensive supplier directory all in one hub. By simply joining as a member or logging-in to an existing Aesthetics account, users can create and update their own profile and join in engaging community discussions, watch interviews with renowned aesthetic practitioners and promote their products and services to other aesthetic professionals. The new Homepage comes with a prominent search bar, an interactive carousel with the latest industry news, conference and research and development reports, access to business and clinical articles as well as the monthly Special Feature, In Profile and Last Word features. The Aesthetics website also offers prime opportunities to increase brand awareness in the form of targeted banner advertising displayed alongside related content, providing members with information that is relevant to their interests.

To make the most of the new platform, go to www.aestheticsjournal.com Training

Experts to hold Face Eyes Nose Conference in Conventry Industry professionals will hold a five-day CPD accredited conference focused on facial aesthetic/oculoplastic surgery and rhinoplasty in Coventry on May 11-15.

The Face Eyes Nose conference will feature lectures, presentations and practical dissection workshops using cadavers from presenters including Mr Rana Das-Gupta, Mr Shahzada Khuram Ahmed and Mr Dalvi Humzah.

Conference organiser Anna Baker said, “This is a specialised and unique conference, with an esteemed international faculty of surgical and non-surgical aesthetic specialists presenting current treatments and concepts. The aesthetic non-surgical day is strongly educationally focused with leading experts.”

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Skincare

mesoestetic introduces stem Cell body serum Pharmaceutical manufacturer, mesoestetic Pharma Group, has introduced a cosmeceutical serum to its ‘stem Cell’ line of cosmeceuticals.

The stem Cell body serum features high concentrations of plant stem cells that have been specially formulated to attempt to reverse cell regeneration to improve the skin’s quality and texture.

The ingredients include plant-based stem cells and the chronosmart peptide from mesoestetic, a peptide that aims to detect and adapt to the skin’s needs by synchronising skin cell biorhythms and actions the needs within 24 hours. According to mesoestetic, during the day, stem Cell body serum protects cell structures and promotes younger, smoother skin. At night it aims to activate the genes responsible for skin renewal and intensively nourish the skin, thereby increasing its energy reserves. The new stem Cell body serum is an addition to mesoestetic’s stem Cell line, an antiageing line designed to protect existing skin cells by stimulating the skin’s natural self-repair process to increase cell regeneration, strengthen connective tissue structure and improve skin’s quality and texture. mesoestetic Pharma Group is a pharmaceutical laboratory that specialises in aesthetic medicine. Its products are distributed in the UK by Wellness Trading.

BACN

BACN completes 2016 revalidation roadshow The British Association of Cosmetic Nurses (BACN) has made it easier for aesthetic nurses to revalidate by holding a ‘Revalidation Roadshow’ for its members. The 2016 Revalidation Roadshow went to London, Cambridge, Milton Keynes, Birmingham, Manchester, Newcastle, Southampton, Bristol, Leeds, Glasgow and Belfast, and comprised presentations based on the guidelines from the Nursing and Midwifery Council and the extensive knowledge of the BACN members. Those who attended the presentations became ‘Registered BACN Confirmers’ to other members, enabling any BACN member to identify other aesthetic nurses in their area who can help them with revalidation.

BACN chief executive officer, Paul Burgess, visited the roadshow and said it was a great way for aesthetic nurses to help other nurses to make the revalidation process easier. “I never cease to be amazed at the fraternity that is the BACN,” he said. “The nurses turn up in numbers to every event and, in this case, have signed up to help each other with revalidation. As more and more of them go through the process it will become easier and, with our regional structures in place, they will be able to help each other even more.”

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60

60 Seconds with Toby Cooper, Head of Aesthetics & Corrective, Galderma UK & Ireland How do you differentiate your products in such a competitive market?

Galderma is committed to dermatology with an enviable product portfolio, and a long heritage and history in aesthetics. Restylane has been trusted by practitioners for more than 20 years, delivering an established safety profile and high levels of patient satisfaction with over 28 million patient treatments.

You’ve recently launched a portfolio-based approach, why?

Every patient is different and therefore requires an individualised approach. Galderma has a versatile portfolio of products with the broadest range of gel textures to support natural looking results, we have designed a patient-based needs approach, simplifying practitioner choice; Refresh, Restore and Enhance. A key initiative this year is to improve our communication with patients. We’re launching a direct to consumer (patient) communication strategy to assist our customers in communicating the benefits of our high-quality portfolio. Restylane is a well-recognised brand and by integrating the Emervel products under the Restylane name, we can improve consistency across the portfolio to facilitate HCP and patient dialogue. We will be launching a new digital media campaign this year, which begins shortly with the launch of a new Restylane website and myskinjounal app that will support the DTC. Going forward, what’s the primary focus for Galderma UK? We will continue to innovate and bring high quality products and services to the industry. We are working hard to ensure that our customer services and offerings are the envy of the industry and are concentrating on key areas: • Medical Education – The quality of the training will match the quality of our products.

We will roll out a programme of supportive and innovative training and our plans will continue to bring improvements and innovation.

• Customer Support – We have some exciting developments to launch that will enhance the experience of our customers and their patients, focussing on natural and safe results.

• Quality & Leadership – We’ll cement our position as market leaders by ensuring high quality products and customer support.

This column is written and supported by

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AMWC 2016, Monaco Aesthetics reports on this year’s AMWC conference in Monaco Monte Carlo played host to the 14th Aesthetic and Anti-Aging Medicine World Congress (AMWC) on March 31-April 2, 2016. Renowned for its beauty and luxury, Monaco was yet again an idyllic location for an aesthetic conference, and thousands of practitioners from around the world seized this opportunity to learn and educate in the very latest happenings in the aesthetic specialty. More than 10,000 aesthetic professional attended this year’s congress from 120 different countries.

They gathered at the Grimaldi Forum conference and exhibition centre where they enjoyed three days of connecting with industry leaders, partaking in stimulating sessions and discussions, and socialising and strengthening their aesthetic network.

Scientific directors of the congress, Dr Thierry Besins and Dr Claude Dalle informed delegates that the main theme for this year’s AMWC was the role and importance of prevention, “Prevention is an active process,” Dr Besins explained, “which makes the theme of the congress challenging and very relevant.” The theme was prominent throughout the three days with talks on: ‘Prevention and Practice of Glycation,’ ‘The Role of Inflammation in the Ageing Process’, and ‘Too Late for Prevention?’ Cosmetic and reconstructive surgeon Dr Bob Khanna spoke on the latter theme with his engaging talk: ‘Tomorrow is too late: The impact of healthy dentition on facial aging – when to start and what?’ which explored how the ageing peri-oral area affects facial aesthetics and the best ways to prevent ageing in this area. More than 300 companies showcased their latest products and treatments across the busy exhibition space, which was split over four floors. Some exhibitors launched new products; TSK Laboritory launched the iNViSiBLE NEEDLE, which they claim to be the thinnest needle currently available.

On the first day of the conference, global dermatology company Galderma held a four and a half hour symposium, which saw

the company launch its new rebranded product portfolio. The new branding of the products aims to make it less confusing for practitioners. The Galderma talk, led

by Dr Arthur Swift and Dr Steven Liew, included expert anatomy demonstrations, which were well received by the audience.

UK aesthetic practitioner Dr Kuldeep Minocha enjoyed the sharing of knowledge between the ‘world’s top aesthetic practitioners’, explaining, “The standard of lectures and use of audiovisual tools to heighten our experience as well as the live demonstrations has become a benchmark in our industry. We are presenting more and more evidence-based aesthetic practices, which is vital if we are to be taken seriously as a specialty in our own right.” Friday saw a day dedicated to the latest developments from pharmaceutical company Allergan in the symposium entitled, ‘International approaches to facial aesthetics’. Cosmetic surgeon and skin specialist Miss Jonquille Chantrey was first to take to the podium and spoke on consumer insights from countries around the world. Miss Chantrey aimed to communicate the cultural differences in how women feel about their appearance and their influences in seeking treatment. For instance, she said that in areas such as Korea, Japan and Taiwan, women want to transform how they look, in comparison to Australian and French women who would be more fearful to have such a transformation.

She encouraged practitioners to respect patients’ expectations and change their paradigm of thinking. Showcased at the Allergan session was the Earfold, a minimally invasive treatment for prominent ears. Plastic surgeon Mr Nilesh Sojitra, who trained under the Earfold product creator, explained the advantages of the treatment over traditional surgery and the advantage of being able to pre-determine the outcome and demonstrate this to patients by using the ‘preFold’ device. The preFold component can be placed on the ear to

demonstrate the effects of the treatment and allows the patient to dictate the result they want. The treatment appeared to be fast and simplistic and was indicated to be extremely effective with minimal side effects and risks. This year’s conference had many talking points and revealed numerous upcoming trends. Miss Chantrey said she was impressed by the diversity of models in the live injection sessions, “I moderated Dr Peter Peng from Taiwan as he treated a lady of half French, half Vietnamese descent. It was amazing as we debated how each injection point brought out the contrast in features of Caucasian versus Asian. It was a beautiful result respecting both elements.” Miss Chantrey also worked backstage with Dr Woffles Wu from Singapore during his live injections; he treated a young man of Italian and Filipino descent. “It was a true masterclass in how to take an attractive man and make him even more so by masculinising his features,” she said. According to practitioners, more and more men are presenting for treatment at aesthetic clinics and this was reflected at the conference as the topic was explored in much depth in different symposiums. Dr Anna Marie Chrysanthi-Olsen explained how to use focused ultrasound to treat the male breast and live demonstrations took place during the ‘Male Aesthetics’ session, which looked at understanding what men want, the male anatomy, and how to avoid feminising the male face during non-surgical treatment. Aesthetic practitioner Dr Beatriz Molina who attended AMWC from the UK reflected on the event, “I really enjoyed the social aspect and meeting friends from all around the world. It is always so great to see the different injection techniques and to be reminded to treat our patients holistically, and the importance of diet and skincare to complement aesthetic procedures.” She concluded, “This is a fast-moving industry, so it’s important to seize the opportunity to keep up-to-date and expand our knowledge.”

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Allergan Medical Institute Meeting, London

We look at the success of Allergan’s first international AMI meeting The first international meeting of the Allergan Medical Institute brought together more than 1000 delegates from 39 countries as far afield as Brazil, China and Australia, to hear 16 hours of educational content from world-leading surgeons, physicians and dermatologists, the crème de la crème of the international aesthetics industry. The objective of the meeting was to promote excellence in clinical practice, improve safety standards and achieve optimal patient outcomes. Over the two and a half days, it provided high-quality education through a diverse and sophisticated curriculum of practical, hands-on training and interactive learning opportunities, tailored to individual practitioner needs.

Day one delivered an international view of medical aesthetics and was introduced by Director of Medical Education at Allergan, Mark Chaplin, who spoke about cultural diversity and excellence in facial aesthetics. Paul Navarre, President of International Brands then explained Allergan’s vision to be the best aesthetic industry partner in three ways: to have the best products, to be the market driver and to provide the best education. Canadian plastic surgeon Dr Arthur Swift delivered an intriguing presentation on the pursuit of beauty, looking in-depth at facial proportions. He proclaimed ‘we are not ashamed of talking about beauty anymore’ and that every patient is ‘on a journey but they need the beauty GPS to get them there safely’. He spoke about the difference between what men and women want, suggesting women want beauty enhancement and men want

youthful looks. Plastic surgeon Mr Lakhdar Belhaouari discussed the differences between ethnicities, looking at the variations between Africans, Asians and Caucasians. Smaller live injection workshops took place in the afternoon allowing delegates to learn from market-leads on different multicultural approaches to beauty and treatment. Day two of the meeting focussed on international approaches to managing complexities in medical aesthetics. Renowned Brazilian plastic surgeon Dr Mauricio de Maio discussed the universal challenges in patient assessment. He engaged the audience and used case studies to demonstrate the differences between what patients ask for and what he believes they really should have, advising practitioners on how to handle patients with this mind-set.

A panel discussion followed, led by plastic surgeon Mr Massimo Signorini, who discussed international approaches to patient consultation. The audience then broke off into the workshop sessions, which focussed on international approaches to treating male patients, complex case studies and young patients with speakers including Woffles Wu, Greg Goodman and Kent Remmington. The meeting saw Allergan showcase some of the latest innovations in the pipeline. Inventor Dr Norbert Kang talked passionately about the development of his new minimally invasive treatment for prominent ears, Earfold™. He highlighted that the beauty of his invention is that the patient can dictate the results of the treatment via the preFold™ positioning tool. Norbert also explained the procedure in full and explained the advantages it holds over traditional surgical methods of prominent ear correction.

Paul Navarre closed the meeting explaining that it is Allergan’s duty as market leader in the sector to provide the best quality medical education to the physicians who are doing the work. “We take medical education very seriously,” he said.

Through the Allergan Medical Institute, Allergan aims to continue to pursue higher scientific and clinical standards in aesthetics and offer opportunities to help develop and advance medical aesthetics specialities to optimise patient outcomes. By launching the AMI internationally they are now in the postition to bring together the insights, advice and experience of experts practicing medical aesthetics in diverse regions across the globe.

UK/0273/2016 date of preparation April 2016

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ACE 2016 in Review

We look at the highlights from the Aesthetics Conference and Exhibition 2016 HEADLINE SPONSOR

Delegates, speakers and exhibitors who attended the Aesthetic Conference and Exhibition (ACE) 2016 have reported that the event was a huge success, following two busy days of learning and networking. On April 15 and 16 professionals throughout the aesthetics industry congregated at the Business Design Centre in Islington, London, to access outstanding clinical and business content and network with sponsors and exhibitors, as well as their fellow industry peers. 1938 delegates walked through the doors over the two days to enjoy presentations from 77 leading speakers who shared clinical and business guidance in 70 exceptional educational sessions. With the focuses ranging from peels and dermal filler injection techniques to body contouring and vaginal rejuvenation, ACE attracted delegates from a variety of different backgrounds including cosmetic doctors, surgeons, dermatologists, GPs, aesthetic nurses, dentists, aestheticians and clinic managers. The two days featured a wide range of content, including a comprehensive clinical Conference agenda, as well as free Expert Clinics, Masterclasses, Business Track workshops and, new for this year, the Treatments on Trial session. Each agenda included presentations from the industry’s most experienced and respected experts, with many featuring live demonstrations. The top-quality content provided delegates with invaluable advice and knowledge on the latest techniques, treatments and business insights, with more than 50 CPD points available over the whole event. Alongside these high-quality presentations, delegates enjoyed exploring the extensive Exhibition Floor, which hosted more than 80 exhibitors displaying the latest devices and treatments on offer.

AestheticSource was the headline sponsor for ACE 2016, and founder Lorna Bowes was thrilled with the outcome of this year’s event. She said, “It has been a really great experience, we have been busy all weekend with footfall the whole time and it’s been lovely to have our branding all over the place.” According to Amanda Cameron, Aesthetics journal editor and ACE 2016 programme organiser, delegates, speakers and distributors alike were impressed with the diverse programme and the positive atmosphere at the conference and exhibition. “People have approached us throughout the event saying what a great experience they have had,” she said. “Interest in the free agenda was overwhelming – the Expert Clinics in particular were overflowing with delegates who wanted to make the most of the

“It has been really fantastic, almost all areas of aesthetic medicine have been covered here” Dr Souphiyeh Samizadeh, speaker

live demonstrations. I was told the Exhibition felt more personal this year, and that the larger exhibitor size gave a great overall ambiance.

Those who purchased a Conference Pass said they loved the interactive agenda, which featured exclusive in-depth presentations from the likes of Mr Dalvi Humzah, Mr Adrian Richards, Sharon Bennett, Dr Tapan Patel and Dr Raj Acquilla.”

Conference The Conference agenda took place in the main auditorium and featured eight comprehensive sessions led by the UK’s leading aesthetic practitioners. The Conference sessions explored all aspects of aesthetics from treating the forehead, temple, brow, eye area and the mid-face, to the buttock, thigh and intimate area. The format of the sessions involved several specialised panellists discussing their knowledge and experiences in each topic and debating the best treatment options. Speakers made the most of the special interactive features of the Conference auditorium, including the individual voting keypads. Frances Turner Traill, who spoke on what to avoid when treating the mid-face, used this feature to ask the audience several questions to determine the group’s interests. In the same session, Dr Maria Gonzalez discussed treating pigmentation, concluding that, “You have to take your patients with melasma very seriously.”

Later in the Conference sessions, Dr Uliana Gout discussed medical skincare and chemical peels to rejuvenate the neck and décolletage and said that; “We need to combine treatments when we treat the neck and the chest, its not just about resurfacing the skin.” Plastic, reconstructive and aesthetic surgeon Mr Dalvi Humzah, who chaired several of the Conference sessions and was the chair of the ACE Steering Committee, stressed that in aesthetics, an understanding of the anatomy is extremely important. “I’m trying to bring anatomy into the injection field so that you can apply it and really take it forward,” he said, adding, “I think that anatomy is the foundation of treatment, so you really need to understand the anatomy and then change the anatomy to reach the optimum outcome.”

Dr Tapan Patel spoke and performed live demonstrations in two of the Conference sessions on the second day, focusing on facial contouring and the beautification of the lower face. After the day’s conclusion he said, “I think the real important point delegates take away from attending these sessions is that they are seeing a combination of the anatomy, the injection technique, the aesthetic reasons to inject, and also the treatments being performed, which is very hard to do when you are just working in your clinic on your own.” A popular session was the vaginal rejuvenation panel with Dr Sherif Wakil, Dr Shirin Lakhani and Dr Kannan Athreya, who described the vagina as the ‘new face’, in reference to the growth in popularity of treatment in this area.

Speaking after the session, Dr Wakil said, “I was very happy because a lot of people were interested and engaged in the presentation and this is what we want to do, we want to open the door so that more

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doctors can offer this treatment.”

Cosmetic dermatologist Dr Raj Acquilla spoke after his session on the forehead, eyebrow and temple, and said these Conference sessions are integral in maintaining practitioners’ learning. “The most important thing is education, we know that good medical education is at the heart of excellent clinical practice. This industry is moving so fast; we’ve got technologic advancements, we’ve got on-going improvements in knowledge and details so you’ve got to keep up with the pace to make sure you’re delivering the best results to patients,” he said. The feedback from delegates attending the Conference was tremendously positive, with one delegate commenting on the helpfulness of the live demonstrations and the opportunity to learn from more experienced professionals. Dr Roopa Jaiswal, a GP from East London, commented on how it is good to hear that, “other people started in a similar way to me and have had, or still have, the same sort of insecurities and worries that I have – ACE is a great platform, it’s just invaluable.”

Expert Clinics The extensive education continued in the two Expert Clinic workshops on the Exhibition floor, where practitioners could witness top specialists perform live demonstrations and provide technique tips.

The diversity of sessions ranged from surgical versus non-surgical options for the face from Mr Adrian Richards and Mel Recchia, to lasers in aesthetic dermatology by Dr Daron Seukeran. Among the sessions were fascinating discussions by Dr Souphiyeh Samizadeh, who presented a session on harmonising the face. She said after her talk, “I hope that delegates understand the importance of the skeletal foundation of the face better and how it affects the soft tissues.” The Expert Clinic agenda also included sponsored sessions provided by Rosmetics, Naturastudios, AestheticSource, AesthetiCare, 3D-lipo Ltd, Fusion GT, BTL Aesthetics, Healthxchange, Syneron Candela, Medico Beauty, SkinCeuticals, and Lynton Lasers, which were all very popular with delegates.

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Masterclasses Delegates at ACE took the opportunity to further their knowledge on different products from key opinion leaders representing top manufacturers. The sponsored Masterclass sessions were hosted by some of the leading medical aesthetic companies and gave delegates information on possible patient outcomes and Interested in learning more?

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advised them on the best techniques for using their products. The companies that held Masterclasses were Medical Aesthetic Group, Filorga, Intraline, Galderma, HA-DERMA, Vida Aesthetics Ltd, Zeltiq and Neauvia. ACE delegate Dr Liesel Holler said the Masterclasses were the highlight for her, “I’ve been here participating in the Masterclasses; you always need to update yourself, see what’s out there, new things, new techniques and I have really enjoyed it,” she said. Among the many topics discussed was a presentation on how to deliver successful results safely by overcoming dermal filler challenges by Professor Daniel Cassuto, Dr Irfan Mian and Professor Hema Sundaram. While performing his live demonstration Professor Cassuto compared injecting to choosing breast implants, “One of the main criteria is soft tissue coverage – how much fat, muscle, gland and skin we have in order to conceal the implant and hide it – I just think the same way here and it works.” Delegates were also captivated by a presentation from Dr Vincent Wong speaking on behalf of Intraline, who performed a live demonstration and discussed male facial rejuvenation. Dr Philippe Petit and Dr Phillippe Hamida-Pisal discussed the Filgora range in their Masterclass and how it can be used to support a hostilic approach to full rejuvenation. Dr Nicola Zerbinati, Dr David Jack, Jodie Grove and Dr Miguel Montero spoke at the Neauvia Masterclass about the new organic hyaluronic acid filler. After the talk independent nurse prescriber Jodie Grove said, “Our Masterclass featuring Neauvia was an opportunity to showcase the range to delegates and show how unique and flexible the product is and its ability to get great results from a safe, organic filler.”

Medical Aesthetic Group’s Masterclass by Dr Sabine Zenker was of great interest to delegates who were eager to learn more about how modern nutraceuticals can benefit the skin and discussed the science behind the food supplement Estechoc. The Vida Aesthetics Ltd Masterclass featured Dr Irfan Mian, who explained and performed his pioneering MASH technique for a non-surgical face lift to a packed auditorium. The Masterclasses also included a session by Dr Sach Mohan discussing the ZELTIQ coolsculpting technology; explaining how the device works to naturally eliminate fat cells without harming surrounding tissue. The Galderma Masterclass focused on perorbital rejuvenation and was presented

by Mrs Sabrina Shah-Desai. Dylan Griffiths, product manager at Galderma said, “I think ACE is one of the most important events of the year for us in the aesthetic calendar with its medical education agenda, and also the delegates that come, we know its going to be a well appreciated and well valued event for our customers.”

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Business Track For delegates wanting to enhance their practices from a non-clinical perspective, the ACE Business Track, sponsored by Church Pharmacy, provided exceptional tips and advice on how to achieve the ultimate patient experience. Session topics included presentations from Zain Bhojani, co-director of Church Pharmacy, on the benefits of the company’s free online prescription system.

Dr Chris Blatchley explained how to grow your patient database by treating migraines with botulinum toxin, while Professor Andy Pickett examined the types of counterfeit products practitioners and distributors need to be wary of in the aesthetic industry, and medical aesthetic and consumer health PR Julia Kendrick focused on techniques for business growth and profile building for increased revenue. In her session, Kendrick emphasised the need to keep messages to the press short and sharp with clear communication and opinions that shouldn’t ‘sit on the fence’. US author and international business consultant Wendy Lewis presented two sessions, discussing the best practices for marketing an aesthetic clinic online and how to take a business Facebook page to the next level. Her session on digital marketing was particularly popular, and attracted a packed audience. After her sessions she said, “Education is really important in our industry and the more conferences like this you are able to attend, even one little pearl that you pick up from an aesthetic nurse or a doctor or a plastic surgeon that you can bring to your practice, it’s really going to make a difference in excelling your clinic to the next level.” Speaking about the Business Track agenda as a whole, Bhojani said, “We found it was very useful for the delegates, and being a family business ourselves we know how difficult it can be for practitioners, so we are very happy to be able to provide some good education for them.”

Treatments on Trial Company representatives presented their latest technologies before a lively panel discussion, with delegates able to watch and take part in the engaging debates of which products would suit particular clinics. Treatments on Trial was a new agenda for ACE 2016 and was supported by BTL Aesthetics, Lumenis, Aqualyx and Syneron Candela, who each supplied a company representative to discuss and compare their latest devices for body contouring and weight loss. Speaking in the sessions was BTL consultant Lee Brine, director of body contouring at Lumenis, Yoram Eshel, Syneron Candela representative, Dr Sabika Karim and Aqualyx representative Dr Vincent Wong. Dr Karim noted at the end of her presentation that even though all of the devices discussed had lots of evidence behind them, sometimes good equipment can be used in the wrong hands and the industry needs to do more to stop this happening. Consultant plastic surgeon Mr Taimur Shoaib, who chaired the session, said, “The Treatments on Trial session allowed participants to speak directly to four leading industry treatment representatives, so that we could compare their effectiveness, their costs, the science behind the mechanism of action and the way the treatments are delivered. Without this education how can any practitioner make a sensible decision about what treatments they are going to offer their patients?”

Aesthetics Journal

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Networking Event At the end of an eventful first day, delegates were able to wind down with a glass of prosecco at the Networking Event. Supported by medical aesthetic manufacturer and distributor 3D-lipo Ltd, the event was the perfect opportunity for delegates to liaise with colleagues and business partners and discuss the latest developments within the aesthetic industry. Roy Cowley, founder and managing director of 3D-lipo, said, “We chose to sponsor the Networking Event because it gives a great platform for everybody to meet and one thing I like about this show is that people are networking continually, talking about their favourite devices, talking about the latest technologies and why they should be buying from you.” Amanda Cameron added, “The networking event was a lovely way to end the day, everybody could get together, relax, exchange ideas, and talk about their views of ACE so far. I think that more importantly, everybody got a chance to see their customers on an informal basis, and as we know a lot of the best business gets done informally at these meetings.”

Exhibition Floor The Exhibition Floor was filled with more than 80 diverse stands featuring live demonstrations of different products and devices. From lasers to cosmeceuticals and training courses to insurance, delegates were not lost for choice in the 2500m2 hall. Exhibitors noted that the knowledge of the visitors was extremely high. “One of the things that has powerfully impressed me is the quality of the people who attended the stand,” said Steven Warren, Bioptron consultant, adding, “There was an understanding; the questions that they asked, they were open to assimilating the information we were talking about.”

Delegates also enjoyed the variety of interactions offered at different stands on the Exhibition Floor, including special offers on dermal fillers, machines and courses, as well as competitions from Viviscal Professional and 5 Squirrels. Delegates were also particularly engaged with the colour coding guidelines quiz held by the ACE waste management sponsor, Initial, and the popular bike-juicing machine on the Med-fx stand. Dyan Williams, national sales manager at Med-fx, which was also the registration and consumables partner of ACE 2016, said, “We feel really engaged with the event, there’s lots of positivity in the room, lots of experience, its been lots and lots of

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“I’m really looking forward to next year and I’m sure it will be bigger and better”

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#ACE2016 Dr Raj Acquilla @RajAcquilla Fabulous weekend #ACE2016 @aestheticsgroup #London with friends and colleagues in the #UK

Wendy Lewis, speaker fun. The reason Med-fx decided to sponsor ACE this year is because it is one of the leading events in the aesthetics calendar and we wanted to support it.” The Merz Aesthetics stand was a particular highlight of the Exhibition and featured a Live Demo Zone, which was popular for many delegates throughout the two days. Speakers at the Demo Zone included Dr Kate Goldie, who among other topics, provided demonstrations on the tear trough technique as well as the anatomy and treatment strategies of the forehead and temple in accompaniment with Mr Dalvi Humzah.

Another popular session was a contouring workshop on the male face led by Dr Tahera Bhojani-Lynch and Dr Emma Ravichandran. A delegate who attended ACE said that she particularly likes these types of sessions and said, “I love the workshops, I always learn something new. I really want to learn about men’s faces because I have some clients now that are men and I want to learn about the techniques and the proper products to use for the male face.”

ACE Steering Committee ACE 2016 was organised and successfully run by the 2016 steering committee, which comprised the UK’s most experienced industry leaders.

The team included committee chair Mr Dalvi Humzah, programme organiser, Amanda Cameron, as well as Dr Raj Acquilla, Dr Tapan Patel and Sharon Bennett. “It’s been a real honour and a great pleasure to work with the likes of Tapan Patel, Dalvi Humzah, Sharon Bennett and Mandy Cameron,” said Dr Raj Acquilla, adding, “taking those experts from each individual’s sub section of this industry allows us to take that information, pool it together and give the delegates what they really want.”

Chair Mr Dalvi Humzah said he was thrilled that ACE 2016 was a success and was happy delegates appreciated the hard work that went into organising the event and speakers. “Getting it together has been great! I think the committee and the Aesthetics team in particular have been really supportive,” he said, adding, “As a committee we chose some great speakers who are leaders in their field, and also people who gel together and I think that really came out in all the sessions that we did, we all played along together, we communicated and I think the audience really enjoyed that and they saw some great experts in action.”

The success of this year’s ACE has confirmed its place as the leading medical aesthetics conference and exhibition in the UK, with no other conference offering an agenda as in-depth and extensive as that seen at the Business Design Centre in 2016. Preparations have already begun for next year’s event, which is sure to be a success in maintaining and continuing the valuable education that is so important in this ever-developing industry.

Stay up to date with the latest news and developments for ACE 2017, taking place on 31 March and 1 April 2017, by joining the Aesthetics website www.aestheticsjournal.com

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Reproduced from Aesthetics | Volume 3/Issue 6 - May 2016

See us at

Stand No 19

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

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

Azzalure Abbreviated Prescribing Information (UK & IRE) Presentation: Botulinum toxin type A (Clostridium botulinum toxin A haemagglutinin complex) 10 Speywood units/0.05ml of reconstituted solution (powder for solution for injection) Indications: Temporary improvement in appearance of moderate to severe glabellar lines seen at frown, in adult patients under 65 years, when severity of these lines has an important psychological impact on the patient. Dosage & Administration: Botulinum toxin units are different depending on the medicinal products. Speywood units are specific to this preparation and are not interchangeable with other botulinum toxins. Reconstitute prior to injection. Intramuscular injections should be performed at right angles to the skin using a sterile 29-30 gauge needle. Recommended dose is 50 Speywood units (0.25 ml of reconstituted solution) divided equally into 5 injection sites,: 2 injections into each corrugator muscle and one into the procerus muscle near the nasofrontal angle. (See summary of product characteristics for full technique). Treatment interval should not be more frequent than every three months. Not recommended for use in individuals under 18 years of age. Contraindications: In individuals with hypersensitivity to botulinum toxin A or to any of the excipients. In the presence of infection at the proposed injection sites, myasthenia gravis, Eaton Lambert Syndrome or Amyotrophic lateral sclerosis. Special warnings and precautions for use: Use with caution in patients with a risk of, or clinical evidence of, marked defective neuro-muscular transmission, in the presence of inflammation at the proposed injection site(s) or when the targeted muscle shows excessive weakness or atrophy . Patients treated with therapeutic doses may experience exaggerated muscle weakness. Not recommended in patients with history of dysphagia, aspiration or with prolonged bleeding time. Seek immediate medical care if swallowing, speech or respiratory difficulties arise. Facial asymmetry, ptosis, excessive dermatochalasis, scarring and any alterations to facial anatomy, as a result of previous surgical interventions should be taken into consideration prior to injection. Injections at more frequent 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. Azzalure and Galderma are trademarks owned by Galderma S.A Date of preparation: February 2016 AZZ/003/0216

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

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Periorbital Rejuvenation Practitioners discuss their preferred methods for enhancing the eye area using injectable treatments “I want to look less tired” is a phrase that aesthetic practitioners are likely to hear on a daily basis. Increased skin laxity, volume depletion and the development of fine lines and wrinkles all contribute to the ageing face. When these factors affect the periorbital region, they often have a significant impact on a person’s aesthetic appearance. As well as making a person look older, research has suggested that variations in eyebrow shape, eyelid position and wrinkles greatly influence how others perceive your facial expressions, as well as your subsequent mood.1 And while there are numerous reliable periorbital treatment options on the market, the popularity and success rate of injectable treatments in particular continues to grow.

According to the American Society for Aesthetic Plastic Surgery, there was a 21% increase in injectable treatments performed in 2015, and botulinum toxin and hyaluronic acid (HA) dermal filler treatments topped the list of the most performed non-surgical procedures in the same year.2 Patient concerns and causes According to the practitioners interviewed for this article, there’s little surprise that the demand for non-surgical injectable treatments is so popular compared to traditional blepharoplasty surgery. “We find now that a large percentage of patients do not want to undergo surgery,” explains Dr Beatriz Molina, founder and medical director of the Medikas clinics in Bristol and Somerset. As a result, she explains, practitioners are developing their skills to offer bespoke treatments that offer safe results with minimal downtime.

The interviewees also agree that the most common periorbital concerns are loose skin, eye bags, hollowness and dark circles. Other concerns include excess eyelid skin, saggy eyebrows, crepey skin, fine lines and wrinkles.

Laser technician and aesthetic practitioner Shadi Danin notes that it is important that

practitioners identify the cause of the concern before offering treatment. She says, “Dark circles under the eyes can be an inherited trait, caused by fatigue, or a lack of sleep.3 With age, the skin loses collagen, becomes thinner and more translucent, which allows the darker blood vessels to be seen. Other causes include anaemia, diet and a lack of oxygen in the blood.”3 Danin continues, “Eye bags can be caused by sleep deprivation, diet, alcohol and tobacco use, allergies, local water retention caused by the salt in tears, hyperthyroidism and periorbital cellulitis.”3 Choosing treatment Creating a suitable treatment plan and advising patients on the expected results is the next step practitioners need to take on the periorbital rejuvenation journey. “Patients don’t always know what they need, but they know what they want,” explains Dr Gertrude Huss, founder and medical director of Hill Clinic in Jersey. As such, she recommends practitioners offer a thorough examination and discussion about the risks and benefits of a treatment to establish realistic expectations of likely results.

With such variable concerns, and a wide range of causes, consultant ophthalmologist and oculoplastic surgeon Mrs Sabrina ShahDesai recommends a personal approach to treatment. She says, “The consultation is essential, treatment is bespoke and highly individualised, based on each person’s unique anatomy, taking into consideration skin, soft tissue and bony changes, budget and psychological assessment.”

Dr Molina also notes that the choice of treatment is often dependent on the age of the patient. “We have to distinguish between the younger patient and the older patient, even though they often complain of the same things when they present to us,” she explains. According to Dr Molina, the majority of younger patients will be suitable

for dermal filler treatment as the reason they have periorbital concerns may be due to a deficiency in natural hyaluronic acid. She explains, “You can just plump them a little bit and the results will be very natural and subtle.” Older patients, however, may require more invasive treatment. “Sometimes, we have to advise patients that their concerns are more of a ‘surgical case’, however some still like us to try to make them look a little more refreshed using non-surgical treatments.” Dr Molina notes that while nonsurgical treatments can produce excellent results, practitioners need to develop their experience in treating the region in order to ensure they offer the most appropriate and effective treatment.

Treatment options For many practitioners, HA dermal fillers are their preferred choice of treatment. Dr Kieren Bong, founder and medical director of Essence Medical in Glasgow, said, “When it comes to the infra-orbital hollowness, one of the most effective and safe treatment modalities is with hyaluronic acid dermal filler.” Mrs Shah-Desai adds, “Dermal fillers act as ‘injectable spacers’ that improve bony projection, augment soft tissue volume and improve the hydration and structure of the skin. Evidence has shown that these products can improve collagen and elastin, and alter the SMAS.”4 For Dr Bong, Teosyal’s Redensity II is his filler of choice. “This is a product that has been specifically formulated for the under eye hollows,” he says, explaining that Redensity II’s balance of cross-linked and non-crosslinked HA means that it’s viscous enough to provide lifting capability without causing lumpiness. He adds, “It also has the right balance of bio-chemical specification that coats the under eye area smoothly without the risk of migration.” On the other hand, Dr Huss uses the Belotero range of HA fillers

Reproduced from Aesthetics | Volume 3/Issue 6 - May 2016

LIFT, CONTOUR & REJUVENATE 1,2

with sustained collagen stimulation2

RAD/7/SEP/2015/DS Date of preparation: September 2015

Adverse incidents should be reported. Reporting forms & information can be found at www.mhra.gov.uk/yellowcard. Adverse incidents should also be reported to Merz Pharma UK Ltd by email to ukdrugsafety@merz.com or on +44 (0) 333 200 4143.

The Lifting Filler

1. Sundaram H. J Drugs Dermatol. 2012 Mar; 11(3): S44-S47 2. Yutskovskaya Y, et al. J Drugs Dermatol. 2014; 13(9): 1047-1052

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The Lifting Filler

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Before

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After

Figure 1: Before and after deep fill treatment using Restylane and Restylane Vital Light. Images courtesy of Mrs Sabrina Shah-Desai.

from Merz Aesthetics. She explains, “Belotero has a unique cohesive polydensified matrix technology that allows optimal dermal integration.” Similarly to Dr Bong, Dr Huss has chosen this range to lower the risk of product migration. She says, “My product of choice for the periorbital area is Belotero Balance, because of its dynamic cross-linking, allowing homogenous tissue integration and its high cohesivity, which reduces the risk of the product migrating or becoming displaced.”

According to Dr Huss, its low viscosity makes it easy to inject and its high elasticity provides good support.

For Dr Molina, Galderma’s Restylane is her preferred HA range, again because it is not as hydrophilic as other products on the market. The selection of products, which last month integrated the Emervel range and launched new branding and packaging, incorporates nine different textures that aim to enable the practitioner to choose the most appropriate product for the patient’s individual concerns.

Dr Molina explains, “Depending on the quality of skin, the age and sex of the patient, I will choose the most suitable product within the range. For example, if I have a male patient with good quality skin in his mid 40s, who obviously has thicker skin because he is male, then I will probably use Restylane Lyft.” According to Galderma, Restylane Lyft aims to enhance facial balance and harmony by providing shape and contour. For a younger female patient, Dr Molina says she could choose Restylane Refyne, which aims to restore a healthy, youthful appearance.

Before

As well as offering dermal filler treatments for periorbital rejuvenation, Dr Huss also offers her patients botulinum toxin to soften the dynamic lines in the area. She says, “You can’t just separate the eyes – you’ve got to look at the areas around them and frown lines fall into that area because they impact on other muscles. As such, there is definitely a dynamic component for which the treatment is botulinum toxin.”

Alternatively, Danin offers her patients mesotherapy and carboxytherapy treatments.

She explains that the Toskani ECPR (Eye Complex Poli Revitalising) mesotherapy formulation from Vida Aesthetics, designed specifically for the periorbital region, aims to increase hydration, regenerate collagen and elastin fibres, stimulate collagen synthesis in fibroblasts, inhibit the formation of free radicals and prevent melanin production.

“Mesotherapy helps damaged cells repair themselves, decelerates the degradation of the skin matrix and stimulates replenishment, inhibits glycation in the skin around the eyes and decreases the amount of fluid that accumulates in eye bags,”5 she says.

Danin also offers her patients carboxytherapy treatment, which aims to reduce the appearance of dark circles. She explains, “Carbon dioxide is injected in very small amounts at very low pressure. It forces the capillaries to open allowing more oxygen to the area and assist the toxins to drain away.”6 As CO2 is naturally occurring in the body, there are no contraindications according to Danin. She notes, “Side effects might be a small bruise or some local swelling that subsides with a few hours.”

After

Figure 2: Before and after treatment to the tear trough using Belotero Balance. Images courtesy of Dr Gertrude Huss.

Technique A number of practitioners have created their own techniques to offer optimal periorbital rejuvenation results to patients. Four years ago Dr Bong trademarked the

Two-Point Eyelift, which utilises only two injection points to aim to reduce the risk of complications occurring from incorrect injection placement and technique. “It is a structured technique, which allows the practitioner to establish the depth of injection correctly and confidently,” he explains. According to Dr Bong, complications can arise if the filler has been placed too superficially, rather than under the orbicularis oculi muscle in the deep fat compartment where it is designed to be injected. Dr Molina adds that practitioners need to have a thorough understanding of the periorbital anatomy before offering these treatments. Mrs Shah-Desai also uses toxin for smile and frown lines, as well as for brow lifts. To treat dark circles, however, her preferred method involves the use of skin boosters. She has pioneered her own technique called the Eye-Boost, which aims to rejuvenate the tear trough. She explains that she will inject a skin-boosting filler in the under-eye skin and/or place a hydrating filler deep in the inner tear trough hollow. “I use a softer product for the inner tear trough and a firmer product for the lateral trough, but the ultimate decision is based on individual soft tissue and bony changes,” she explains.

Dr Huss notes that it is important to make patients aware that the lid-cheek junction is part of the normal anatomy and that the aim is not to eliminate it. When using HA dermal fillers, she explains that she always aims to under correct the tear trough to avoid over volumisation as the area settles over time. Dr Molina adopts a similar approach, commenting that she has had many unhappy patients come to her for correction after different practitioners have used too much filler. Dr Huss explains that her technique is to inject the filler very slowly, using a 25G needle for entry point and a 25G cannula for injections. She injects in slow boluses, combined with a threading and retrograde technique for the medial and middle part of the tear trough. For orbital rim correction, she then administers supraperiosteal injections with a 30G needle laterally.

Mrs Shah-Desai agrees with Dr Huss that a combination of needle and cannula can produce optimum results, explaining that she believes needles give her the precision required to achieve successful results. Dr Bong, however, prefers to use a cannula exclusively. He says, “Bruising is usually a result of sharp hypo-derma needles, so we use a blunt-tip cannula, especially if it’s a bigger gauge such as 25G, so we can drastically reduce the risk of bruising our

Reproduced from Aesthetics | Volume 3/Issue 6 - May 2016

L E T YOU R ART S PE AK Thanks to its ergonomic, light-weight design and homogenous delivery, TEOSYAL速 PEN offers you a greater ease of injection in difficult or sensitive areas, for products requiring high pressure and a smooth experience for your patient.

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Before

After

Figure 3: Before and after treatment using the TwoPoint Eyelift. Images courtesy of Dr Kieren Bong.

patients.” According to Dr Huss it is important to consider the face as a whole, and not just focus on the periorbital area. She explains, “Facial rejuvenation requires a global approach. Although the periorbital area is a facial unit, it cannot be addressed in isolation and neither can other facial areas be treated without considering the eyes.” Dr Huss explains that she sometimes finds volume loss in the periorbital area is highlighted when the mid-face of a patient has been repeatedly treated, emphasising, “You can’t just treat the eyes without the cheeks.” Dr Huss also notes that the periorbital area can sometimes be enhanced indirectly by treating the mid-face.

“This is especially the case in patients with a central cheek deformity,” she says, explaining, “this is when they may have lost a bit of volume in the cheek and that emphasises the tear trough. To restore that sometimes restores the whole area. This is obviously case dependent.”

Side effects and complications Bruising, swelling and lumpiness are all common side effects of undergoing periorbital treatment with injectables.

According to Dr Bong, however, these can be avoided with the correct injection technique and correct product selection. “To make a procedure safe and successful, one would have to fulfil two variables – product and skill,” he explains, adding, “One would have to choose the product carefully and have the skills and technique to perform the procedure successfully.” Mrs Shah-Desai emphasises that practitioners can also reduce the risk of side effects and complications by providing valuable pre- and post-procedure care. She advises that practitioners should tell their patients to not drink alcohol for 48 hours

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Aesthetics

before and after treatment, avoid aspirin7 or herbal supplements8 that can increase the risk of bruising, not undergo exercise for 24 hours and avoid facial massage for one week after treatment. She adds, “There is a negligible risk of infection as I perform these treatments as sterile procedures, however the patient can help by ensuring they do not apply makeup on the day and for a few hours after to reduce the risk of infection.”

Dr Huss recommends practitioners apply firm pressure and ice packs before and after the treatment session to further reduce the risk of bruising and swelling. “They should also use a cannula where indicated, inject slowly with minimal pressure and minute quantities, and adopt an aseptic technique to reduce the risk of infection,” she advises. For Danin offering mesotherapy and carboxytherapy treatments, she advocates that practitioners do not overtreat the area and follow protocol precisely. “If the protocol is followed, there should be no complications,” she says.

Other potential issues include oedema, Tyndall effect, asymmetry, post-inflammatory hyperpigmentation, migraines and nodules.

If complications do occur, hyaluronidase is the most common treatment used to dissolve the HA filler. Dr Molina explains that the substance, which usually comes in a powder form, is diluted when a patient presents with a complication and should be injected very superficially. “It works very quickly; you can see it working in front of your eyes and it continues working for 24 hours,”9 she says, adding, “You have to understand how to deal with hyaluronidase because if you inject too much it could get rid of the whole filler, which may be unnecessary.”

The majority of practitioners will be aware that the most serious risk of using dermal fillers is blindness. Dr Bong explains that, although rare, a patient could lose their sight if a practitioner injects dermal filler into the blood vessel. “This can result in two possible outcomes,” he says, explaining, “Firstly, if the obstruction is localised, it may result in localised necrosis. If the accidental injection results in the formation of an embolism then there may be a risk of it travelling to the back of the eye and obstructing one of the blood vessels that supply oxygen and blood to the eye, potentially causing blindness.”10 In the event of this happening, Dr Bong advises practitioners employ measures that promote vasodilation such as introducing localised heat, use of an anticoagulant or the application of localised glyceryl trinitrate. He says that they should also seek emergency help from an ophthalmologist.

Considerations For practitioners hoping to add periorbital rejuvenation to their repertoire, Dr Bong advises that they should be patient with their training; ensuring they are competent and understand the different clinical characteristics of HA dermal fillers on the market before offering treatment. He also emphasises that practitioners should take note that the tissues and anatomical structures in the periorbital area are not the same as other parts of the face, so treating around the eye should not be trivialised. Dr Molina adds, “Periorbital rejuvenation can offer amazing results but it is a very advanced technique.” Dr Huss suggests, “I think, when you look at the tear trough, it’s not just a technique where you put a needle in and inject a filler – it’s really the whole history, the assessment, the procedure, the expectation.

Every little bit adds to a good treatment, because if your assessment is not right, you’re not going to get a good treatment.”

It is apparent that being a confident injector, having a thorough understanding of the anatomy of the area and knowing how to handle complications is essential if you are to begin offering these eye-enhancing treatments. Dr Bong concludes by emphasising, “Periorbital rejuvenation should be considered as an advanced procedure and therefore only practitioners who have had considerable experience should offer treatments in this area.”

REFERENCES 1. Looking tired or angry may have more to do with facial aesthetic than how you feel (US: ScienceDaily, 2008) <https:// www.sciencedaily.com/releases/2008/05/080528102900.htm> 2. Cosmetic Surgery National Data Bank Statistics (US: The American Society for Aesthetic Plastic Surgery, 2015) <http:// www.surgery.org/sites/default/files/Stats2015.pdf> 3. Dr Mounir Bashour, Dr Stephen Thompson, Dark Circles Under Eyes – What You Can Do (US: EyeHealthWeb, 2016) <http:// www.eyehealthweb.com/dark-circles-under-eyes/> 4. Fredric S Brandt, Alex Cazzaniga, ‘Hyaluronic acid gel fillers in the management of facial ageing’, Clin Interv Aging, 3 (2008), pp.153-159. <http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC2544360/> 5. G Sivagnanam, ‘Mesotherapy – The French connection’ J Pharmacol Pharmacother’, 1 (2010), pp.4-8. <http://www.ncbi.nlm. nih.gov/pmc/articles/PMC3142757/> 6. Carboxytherapy for Dark Undereye Circles (US: Carboxytherapy, 2016) <http://www.carboxytherapy.com/ carboxytherapy_for_dark_undereye_circles.html> 7. Steven Novella, Aspirin Risks and Benefits (US: Science-based Medicine, 2012) <https://www.sciencebasedmedicine.org/ aspirin-risks-and-benefits/> 8. Debbie Hillman, Vitamins or Supplements That May Cause Bruising of the Skin (US: Livestrong, 2015) <http://www.livestrong. com/article/440488-vitamins-or-supplements-that-may-causebruising-of-the-skin/> 9. Cavallini M, Gazzola R, Metalla M, Vaienti L, ‘The role of hyaluronidase in the treatment of complications from hyaluronic acid dermal fillers’, Aesthet Surg J, 33 (2013), pp.1167-74 <http:// www.ncbi.nlm.nih.gov/pubmed/24197934> 10. Carruther JD, Fagien S, Rohrich RJ, Weinkle S, Carruthers A, ‘Blindness caused by cosmetic filler injection: a review of cause and therapy’, Plastic Reconstr Surg, 135 (6) (2014), pp.1197-201 <http://www.ncbi.nlm.nih.gov/pubmed/25415089>

Reproduced from Aesthetics | Volume 3/Issue 6 - May 2016

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Medium and Deep Chemical Peels Dr Simon Ravichandran discusses the properties and use of medium and deep chemical peels

Introduction Chemical peels are treatments that aim to improve the skin of the face or body by using a chemical solution, resulting in controlled destruction at a specific level of the skin. The result is usually a sloughing off of dead skin with regeneration of newer healthier tissue. The regenerated skin is typically smoother, less wrinkled and has less pigmentation and blemishes than the old skin. Chemical peeling in dermatology has been practised from the early 1950s with the use of phenol in the treatment of acne scars. The techniques have evolved over time with the development of other peeling solutions such as trichloroacetic acid (TCA) and alpha-hydroxy acids (AHAs), which penetrate to different depths and elicit different results with an improved side effect profile and shorter recovery periods.1 In the field of aesthetic dermatology, the chemical peel is a common procedure due to its efficacy in reversing the cutaneous stigmata of ageing such as wrinkling, sallow complexion, pigmentation and cutaneous laxity.1 The aesthetic practitioner requires a detailed understanding of the different types of chemical peel, the mechanisms of action, expected results and potential undesired outcomes, as well as cautions and contraindications in order to select the appropriate treatment for the appropriate patient. For the non-dermatologist aesthetic practitioner, the choice of peels from a wide number of companies is often confusing and training is typically focused on specific products, rather than general concepts. This again reinforces the necessity for further research and learning on the properties and use of chemical peels.

are used sequentially for a synergistic effect and lower side effect profile. Examples include the Jessner’s TCA peel and the 70% glycolic acid peel, prior to 35% TCA.

Preparation for chemical peeling It is considered essential nowadays for patients to have a regime of skin preparation prior to undergoing any chemical peel. The purpose of this is to reduce the likelihood of undesired sequelae such as postinflammatory hyper-pigmentation (PIH), to allow for a more effective rejuvenation and to identify any potential issues with products that may be used either during or after the peel. Typical regimes will include a low concentration alpha hydroxy acid cleanser or moisturiser, retinol/ isotretinoin and/or a skin-lightening agent such as hydroquinone, kojic acid or similar. The use of a sunscreen is also included to aid the reduction of melanocyte excitability. Preparation of the skin is generally advised for a minimum of two weeks prior to peeling.

Medium peels

Classification of chemical peels

Medium depth chemical peels are indicated in the management of fine lines and wrinkles associated with photoageing, as well as pigmentary disorders and superficial atrophic scars. The traditional medium-peeling agent was TCA in concentrations of 40% to 60%.

This was effective, however it did have a higher risk of complications such as scarring and pigmentation.4 Nowadays, similar results are achieved using 35% TCA solutions in combination protocols, typically with Jessner’s, 70% glycolic acid or solid carbon dioxide. These combination treatments have been found to produce the same results as 50% TCA but with fewer risks.4

Chemical peels are currently classified according to the depth of penetration and injury caused. Superficial peels penetrate to any depth within the epidermis, down to the stratum basale, mediumdepth peels penetrate through to the papillary dermis, while deep peels penetrate down to the level of the reticular dermis.2 Superficial chemical peels may be further subdivided into very superficial and superficial, with very superficial peels only affecting the stratum corneum.2 The peeling solution used does not necessarily determine the depth of peel. Depth can be determined by a number of factors including the concentration of the solution, the pH, the availability of free acid, the length of time applied to the skin, the condition of the skin, and the method of application.3 For example, a glycolic acid 70% solution may act as a superficial peel when applied for five minutes, however it can cause a medium peel effect if left for 15 minutes. TCA in various concentrations can be used as a superficial, medium or deep peel.

A more recent development in the evolution of chemical peeling has been the combined peel approach, where different agents

Jessner’s solution and 35% TCA Jessner’s solution consists of 14g salicylic acid, 14g lactic acid and 14g resorcinol; made up to 100ml with ethanol.5 Prior to application the skin is cleansed and thoroughly scrubbed with acetone in order to remove sweat and sebum. Curettage may also be performed to hypertrophic actinic keratoses at this stage. The peel is applied to cleansed and degreased skin using a cotton applicator to achieve an endpoint of a speckled white frost and uniform erythema. After application, and once the endpoint has been reached, cool water compresses may be applied to help soothe the burning discomfort that occurs with Jessner’s peel. This application serves as a keratinolytic, altering the permeability of the epidermal barrier to permit a more even and rapid penetration of the TCA solution.6 After the Jessner’s solution has been washed off, a topical anaesthetic such as EMLA or LMX may be applied to improve the patient’s comfort during the TCA peeling process.

After the skin has been cleansed of any topical anaesthetic and dried, 35% TCA is painted onto the skin uniformly using cotton

Reproduced from Aesthetics | Volume 3/Issue 6 - May 2016

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a reduction in recovery times with less incidence of prolonged erythema following medium depth peels.

The epidermis above the level of chemical injury will separate from the underlying skin from approximately the third day, and there will be some associated serous exudate and crusting. The skin tends to start to peel from the perioral area and radiate out to the whole face, with the forehead peeling last. Patients are advised not to pick at the exfoliating epidermis as this may cause scarring, however they can trim off the dead skin with sharp scissors. A moisturiser may be applied after five days and the peeling process may continue for ten days.

After the epidermal peel layer has cleared, patients usually notice the new skin is brighter and more even.

Pigmentation and blemishes should have reduced and fine lines and wrinkles should have effaced. There is an ongoing process of dermal remodelling that results in neocollagenesis after about six weeks, providing an ongoing improvement in skin quality.10 Depending on the degree of photodamage and ageing, further peels may be recommended to continue the rejuvenation.

The patientâ&#x20AC;&#x2122;s pre-treatment skincare regime can be reinstated after three weeks.

There is an ongoing process of dermal remodelling that results in neocollagenesis after about six weeks, providing an ongoing improvement in skin quality tipped applicators or small gauze swabs. The end point is identified as a uniform white frosting with a background erythema. Cool compresses are then applied to help soothe the burning sensation that subsides over the next 10 minutes. When the discomfort has resolved completely an occlusive ointment such as Vaseline or Aquaphor is typically applied. These simple ointments serve to reduce some of the dryness of the skin post treatment.

Glycolic acid 70% and 35% TCA This approach has the same benefit as the Jessnerâ&#x20AC;&#x2122;s technique but uses glycolic acid as an alternative initial superficial peel. The glycolic acid is keratinolytic and allows for greater penetration of 35% TCA.7 Typically, it is applied for two minutes prior to neutralising with bicarbonate solution or cool water. 70% glycolic acid is not suitable for inflamed or dry areas of skin, as the penetration is increased in these areas and may give rise to an inadvertent medium depth peel.8 Solid carbon dioxide and 35% TCA This technique involves using a solid block of CO2 coated with acetone and applied to the skin to create an epidermal injury. The depth of epidermal injury created is related to the time the CO2 is applied, as well as the depth of penetration and peel that will occur with the subsequently applied TCA solution. Thus, areas that require deeper peeling, for example, deeper wrinkles, scarring and thick actinic keratosis, may be pretreated with a prolonged application for a better peeling outcome. The advantage of this technique is a greater aesthetic improvement, however, it is important to note that the results are operator and technique dependent.

Mechanism of action The main medium depth peeling agent, TCA, acts as a protein denaturant. TCA is a water soluble agent that does not penetrate easily in the lipid rich sebaceous skin, thus the role of skin preconditioning and superficial peeling, prior to application of the TCA, is to thin and increase the permeability of the stratum corneum and remove oils from the surface of the skin. This allows for a deeper and more even penetration, as well as a more even and consistent depth of protein denaturation.9 Outcomes Immediately after a medium depth chemical peel, the patientâ&#x20AC;&#x2122;s skin can be swollen and can feel tight. Continuous application of occlusive ointments several times a day is recommended by some practitioners. We adhere to this principle in our clinics; finding

Deep peels When deep peeling is discussed in the literature, it generally concerns the use of phenol. TCA at concentrations of greater than 50% have been employed, however the incidence of complications with such a high concentration can make phenol a more attractive alternative.11 Mechanism of action Like TCA, phenol works by penetrating through the skin and causing denaturation and coagulation of proteins at a specific depth in the dermis. Unlike TCA, phenol penetrates the skin quickly through the skin to the reticular dermis. Phenol peels are therefore described as a quick peel, which allows Before for less adjustment over the depth than can be achieved with TCA.12 Phenol has been used as a peeling agent for several decades and a number of formulations have been used. Originally, undiluted 88% phenol was used as a medium depth agent, however the BakerAfter Gordon formula described in 1961, which combines phenol with water, septisol soap and croton oil allows a deeper penetration than pure phenol alone.

Further modifications of the formula were described by Stone and Venner-Kellson, whereby the concentrations of the Figure 1: Before and after 10 months of treatment for acne using CosMedix Purity croton oil were modified Peel x5, Blueberry Jessner x2, Timeless Peel and additional agents x2 and Deep Sea Peel x1. Images courtesy of Medico Beauty. such as olive oil and

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glycerin were added.13 Whichever phenol preparation is used, if the result is a reticular dermis protein coagulation, the end result will be the same.14 The indications for deep peeling are therefore moderate to severe wrinkles, dyschromias and acne scars. As the epidermolysis with a deep peel is complete and also involves the papillary dermis, it will achieve a far better improvement in rhytids and pigmentation than a medium depth peel, which only penetrates to the papillary dermis.

Before

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Figure 2: Before and after treatment using Easy Phytic and Purifying Cream. Images courtesy of SkinTech and AestheticSource.

Before

After

Phenol deep peeling A deep phenol peel carries more risk than medium depth peels as, not only does the increased depth of dermal injury associate with a higher incidence of scarring, delayed healing, PIH, and hypo-pigmentation, the phenol itself is systemically absorbed and is cardiotoxic, thus carrying a risk of heart failure.15 The risk is related to the volume of phenol used and, thus, when a full facial treatment is performed it is undertaken in sections, with one area being completed before moving onto the next. For full facial treatment with phenol, cardiac monitoring in an appropriate clinical environment is Figure 3: Before and after treatment using Easy TCA, Blending Bleaching Cream and DHEA highly recommended. Antiviral and antibiotic cover is Phyto. Images courtesy of SkinTech and AestheticSource. required during the procedure, and oral steroids are Before After also often administered.

Phenol peels induce an intense discomfort and are sometimes performed under general anaesthetic for this reason. At the very least, either oral or intravenous sedation is used pre-, intra- and post-operatively. For the procedure, the skin is cleansed and degreased in the same fashion as for a medium peel. The phenol solution is applied to the skin using rolled and rung gauzes to an area. When one area has been treated the solution is washed off and the next area is treated.

Figure 4: Before and after treatment using Easy Phytic, DHEA-Phyto and Re-Nutriv ACE The end point for a deep peel is identified as a frost of Lipoic Complex. Images courtesy of SkinTech and AestheticSource. coagulated protein that is a grey-white colour, the loss of erythema within the frosting indicates the peel has progressed selection, appropriate choice of peel, pre-treatment and close beyond the vascular loops of the papillary dermis.6 observation of endpoints should all reduce the rates of occurrence of complications.

Outcomes Erythema following medium depth chemical peeling is common and The recovery period from a deep phenol peel is longer and more should fade within three to four weeks. Sometimes the erythema involved. An occlusive dressing such as a waterproof tape mask will be prolonged and may be an indicator of contact sensitisation, is employed for the first 48 hours. The skin at this point is wet prior skin disease (rosacea/eczema) or an inadvertent deeper depth and exudative and requires careful wound care, with applications of peel. Scarring is uncommon following medium depth peels but of thymol iodide several times daily for a further week. During may occur several months after the peel. It may be spotted early the first week, movements of the perioral area can crack the by the identification of areas of intense and prolonged erythema developing wound so patients may be advised to limit mouth and induration. Early and prompt treatment with topical steroids movements by ingesting a blended diet through a straw. Epidermal may be of value.17 Development of herpetic lesions is common re-epithelialisation should occur by approximately day nine, and and more common in patients with a history of herpetic lesions.17 the dead peel mask can be gently debrided with regular warm This should be specifically enquired for in the patient history and compresses and emollient applications. The new skin will be antiviral prophylaxis should be prescribed to patients who are at erythematous and swollen and, for very deep peels, can persist for risk. Some practitioners routinely prescribe antiviral medication up to four weeks. Phenol peels result in a dramatic and long lasting as a matter of course to all patients undergoing chemical peels. improvement in facial rhytids, texture and pigmentation.16 Infections following medium depth chemical peels are uncommon and should be identified early in the recovery phase due to a greater Complications from chemical peels than expected erythema, pustules, excessive crusting and pain.

Whilst medium chemical peels usually produce excellent results, Swabs for bacteriology, mycology and virology should be taken and there are a number of complications that can occur. Careful patient empirical treatment commenced pending lab results. Permanent

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Figure 5: Before and after eight months of treatment for melasma using CosMedix Benefit Peel x3, Timeless Rx Peel x1 and Deep Sea Peel x1. Images courtesy of Medico Beauty.

hypo-pigmentation is a complication of peeling and more likely to develop in darker skinned individuals after deeper peels. This may be related to other complications such as infection in the recovery period. PIH is also a risk and, as with hypo-pigmentation, is more likely to occur with deeper peels and patients with pre-existing pigmentation problems. The risk can be reduced by appropriate pre-treatment preparation and, if it occurs, can be managed with the topical application of 4% hydroquinone.18 Risk factors for complications should be identified in the pretreatment stage and high-risk patients should be dissuaded from treatment. Risk factors include cigarette smoking, poorly controlled diabetes, immunocompromised status, recent facelift or laser resurfacing, a history of recent or current herpes simplex infections and a history of hypertrophic and/or keloid scarring. A history of isotretinoin use should also be enquired for, as use within the preceding six to twelve months is associated with an increased likelihood of scarring.18

Summary The patient requesting rejuvenation procedures for the reversal of skin ageing has a number of options. The first step in the consultation is to address the degree of photoageing and the desired outcome. The two assessment scales of importance are the Glogau scale of photoageing19 and the Fitzpatrick classification20 of skin type. The Glogau scale is an indicator of the degree of damage and will point towards the correct peel type; for example, type II and III would benefit from medium peeling and types III and V would benefit from deep peeling. There would be little advantage in offering a deep peel to a Glogau scale II patient and not much improvement would be seen with a medium peel in a type IV patient. The Fitzpatrick classifies skin types into their colour and their reaction to sun exposure. It is a good indicator of the behaviour of melanocytes and a predictor of the chances of PIH, hypopigmentation and scarring. Darker skin types are more prone to these complications and peeling needs to be undertaken with caution and respect.

A patient history will also help direct the treatment as there are a number of contraindications that would preclude a deeper peel, for example hepatic and renal impairment, history of scarring, previous surgery or radiation treatment. Due to the cardiac toxicity associated with phenol peels a detailed cardiac history should also be obtained.

The patient undergoing a peel needs to understand and be involved in his or her own care as there is a degree of pre-treatment and posttreatment wound care that is essential to the outcome. For patients less motivated, or for patients less willing to undergo a prolonged recovery period, a medium depth peel repeated every six months to a year would be a more sensible option than a single deep peel. The risk benefit profile also needs to be considered by the patient, as they need to be able to justify the higher risk of the phenol peel with the

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potential greater outcome, and vice versa for the medium depth peel.

The final consideration when choosing a treatment is the experience of the practitioner performing the procedure. The procedures are practitioner dependent, as an experienced practitioner who has performed hundreds of deep peels is likely to get a better result, with a lower risk profile, than a novice. The medium peeler with considerable experience will also be able to achieve better results than a novice medium peeler, as they will be more familiar with a number of skin types and be able to match the end point to the desired outcome more easily. The practitioner beginning their journey in chemical peels should therefore make every effort to direct their learning and training towards gaining a thorough understanding of skin physiology and anatomy, modes of action of chemical peels and perform as many chemical peels, under the supervision of an experienced peeler, as possible.

Dr Simon Ravichandran is an ear, nose and throat surgeon, specialising in rhinology. He trained in aesthetic medicine in 2007 and co-founded Cinetix Medispa in 2010. Dr Ravichandran has established the Scottish Advanced Aesthetic Training Programme with Glasgow University, and is the founder and chairman of the Association of Scottish Aesthetic Practitioners.

REFERENCES 1. E. Clark, L. Scerri, ‘Superficial and medium-depth chemical peels’, Clinics in Dermatology, 26 (2008), pp.209-218.

2. Marta I. Rendon, Diane D Berson et al., ‘Evidence and Considerations in the Application of Chemical Peels in Skin Disorders and Aesthetic Resurfacing’, Journal of Clinical and Aesthetic Dermatology, (2010), pp.32-43.

3. Maina Landau MD, ‘Chemical Peels’, Clinics in Dermatology, 26 (2008), pp.200-208.

4. Gary D. Monheit, ‘Combinations of Therapy: Chemical Peels’, Procedures in Cosmetic Dermatology, 2nd edition, pp.133-150.

5. Pearl E. Grimes., (2006). Jessner’s Solution. In: Tosti, A. Grimes, P. Padova, M Colour Atlas of Chemical Peels. Berlin: Springer-Verlag. p.23-29.Barry I. Resnik., ‘The Role of Priming the Skin for Peels: Chemical Peels’, Procedures in Cosmetic Dermatology, 2nd edition, pp.23-24.

6. Suzan Obagi, Shauna Kranendonk, ‘Proprietary Peels: Chemical Peels’, Procedures in Cosmetic Dermatology, 2nd edition, pp.109-116. Janie M. Leonhardt, Kathleeen M. Rossy, Naomi Lawrence., ‘Thricholoacetic Acid (TCA) Peels: Chemical Peels’, Procedures in Cosmetic Dermatology, 2nd edition, pp. 61-70.

7. Kakita LS, Petratos MA., ‘The use of glycolic acid in Asian and darker skin types’, Journal of Geriatric Dermatology, 4 (1996), pp.8-11.

8. Rubin MG., ‘Manual of Chemical Peels’, Philadelphia: JB Lipincot, (1992), pp.89-102.

9. Monheit, ‘The Jessner’s-trichloroacetic acid peel: An enhanced medium-depth chemical peel’, Dermatologic clinics, 13 (1995), pp.277-283.

10. Nelson BR, Fader DJ, Gillard M, et al., ‘Pilot histologic and ultrastructural study of the effects of medium-depth chemical facial peels on dermal collagen in patients with actinically damaged skin’, J Am Acad Dermatol, 32 (1995), pp.472-8.

11. Leonhardt, JM. Rossy, KM. Lawrence N., ‘Trichloroacetic Acid (TCA) Peels. In: Tung, R. and Rubin M. Chemical Peels. London: Elsevier. (2011), pp.61-70.

12. Benjamin A Bassichis, ‘Superficial and medium-depth chemical peels’, In: Shiffman, M. Mirrafati, S.Lam, S. Cueteuax, C Simplified Facial Rejuvenation. Berlin: Springer-Verlag, (2008), pp.99-109 13. ASKEN, S., ‘Unoccluded Baker-Gordon Phenol Peels—Review and Update’, The Journal of Dermatologic Surgery and Oncology, 15 (1989), pp.998–1008.

14. Deprez P., ‘Textbook of Chemical Peels. Superficial, Medium and Deep Peels in Cosmetic Practice’, Informa UK, (2007).

15. S Friedman, J Lippitz., ‘Chemical Peels, Dermabrasion and Laser Therapy’, Dis Mon, 55 (2009), pp.223-235.

16. Langsdon PR, Milbrun M, Yarber R ‘Comparison of the laser and phenol chemical peel in facial skin resurfacing’, Arch Otolaryngol Head Neck Surg, 126(10), (2000), pp.1195-9.

17. Duffy DM, ‘Avoiding Complications’, In: Tung, R. and Rubin M. Chemical Peels. London: Elsevier, (2011), pp.151-171.

18. Coleman KM, ColemanIII WP., ‘Complications’, In: Tung, R. and Rubin M. Chemical Peels. London: Elsevier, pp.173-181.

19. Dr Heather Brannon, What is the Glogau Classifaction of Photoageing? (US: abouthealth, 2016) http://dermatology.about.com/od/wrinkles/a/glogau.htm 20. Where does your skin fit in? (US, Skin Cancer Foundation, 2013) < http://www.skincancer.org/ prevention/are-you-at-risk/fitzpatrick-skin-quiz> FURTHER READING • Phillip A. Stone., ‘Phenol Peeling: Chemical Peels’, Procedures in Cosmetic Dermatology, 2nd edition, pp.71-87.

• David M Duffy, ‘Avoiding Complications: Chemical Peels, Procedures in Cosmetic Dermatology’, 2nd edition, pp.151- 171.

• Kyle M. Coleman, William P. Coleman III, ‘Complications: Chemical Peels’, Procedures in Cosmetic Dermatology, 2nd edition, pp.173-180.

• TC Fischer, E. Perosino et.al., ‘Chemical peels in aesthetic dermatology: an update’, 2009 JEADV, 24 (2010), pp.281-292.

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Intravenous Nutritional Therapy Following last month’s Introducing IVNT article, Dr Jacques Otto and Dr Samantha Gammell discuss the benefits of IVNT ingredients and factors to be aware of when treating patients Demand for intravenous nutritional therapy (IVNT) has increased in the UK since it became popular in 2014.1 However, despite this growing trend, IVNT is still considered by some as a controversial topic, perhaps because, often in medical school, there is little or no time spent learning about vitamins and nutrients in detail.

As a result, many medical professionals remain uninformed about the benefits of IV nutrition. This article will outline the importance of understanding the theoretical basis for IVNT, what IVNT ‘cocktails’ are composed of, how these differ, and the possible side effects to be aware of.

Theoretical basis for IVNT Every day, our body produces skin, muscle and bone. It churns out rich red blood that carries nutrients and oxygen to remote outposts, and sends nerve signals skipping along thousands of miles of brain and body pathways. It also formulates chemical messengers that shuttle from one organ to another, issuing the instructions that help sustain your life. To do all this, our body requires raw materials.

These include at least 30 vitamins, minerals, and amino acids that your body needs, but cannot manufacture on its own in sufficient amounts. Many believe that we should be able to get all nutrients we need through our diet, however, with increasingly busy lifestyles, the decreasing trend of cooking from scratch with fresh organic produce and the overwhelming increase in convenience food, fast food and takeaways, this is often not the case. Even for those who are conscious about what they eat, the nutrients in our food are simply not the same as they were in previous generations, and the main culprit of this disturbing nutritional trend is soil depletion.

Studies published in the Journal of the American College of Nutrition (Dec 2004) and the British Food Journal show that today, modern intensive agricultural methods have stripped increasing amounts of nutrients from the soil and, in our attempts to grow climate adaptable, pest resistant crops which are bigger and grow more rapidly, nutrient uptake simply cannot keep pace. In addition, there are also numerous conditions and circumstances in which additional nutrients are required above and beyond the ‘recommended daily allowance’ such as poor digestion, food sensitivities, chronic inflammation, stress, exercise, alcohol or simply just the ageing process.

A vicious cycle then ensues. When cells are not healthy or not

functioning to their maximum capacity they are not as effective in transporting vitamins and minerals to where they are needed. This is because many cells require energy (obtained from these same nutrients) in order to transport nutrients. Unlike oral supplementation, IV administration of nutrients can bypass gastrointestinal absorption saturation and increased renal clearance, resulting in high serum concentrations not obtainable with oral or even intramuscular administration.2 This is important not only to allow cells to rapidly repair, regain strength and function normally again, but also because various nutrients only exert their pharmacological effects depending on the concentration of the nutrient.

For example, an antiviral effect of vitamin C has been demonstrated at a concentration of 10-15 mg/dL,3 a level achievable with IV but not oral therapy. Similarly, oral magnesium supplementation results in little or no change in serum magnesium concentrations, whereas IV administration can double or triple the serum levels.4,5 Types of products Just like all areas of medicine and aesthetics, the results, benefits and risks of any procedure depend largely on the quality of the products, the type and combination of products used and the knowledge and skill of the administering physician.

Whilst adverse events are extremely rare, with IVNT it is of vital importance to understand what is in the ‘cocktail’ you are administering, what the osmolarity is of that cocktail and how fast the IV infusion should run. A short overview of the most widely used IVNT products are given below.

Minerals 1. Magnesium Research has indicated that the mineral content of magnesium in food sources has decreased.6 As well as this, studies in the US have also indicated that an estimated 75% of people do not meet the recommended daily allowance of magnesium, which has raised concern about the health effects of magnesium deficiency.6 Magnesium is a cofactor for more than 300 metabolic reactions in the body7,8 and is essential for healthy bones, teeth, heart and brain tissue. It is also critical for energy production, relaxes muscle, lessens headaches, reduces stress and promotes restful sleep.9-12

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2. Calcium Calcium is required for healthy teeth and bones. It also helps trigger the clotting process by activating fibrin and together with magnesium, calcium helps in the regulation of heartbeat, muscle contraction, muscle tone and nerve conduction.13,14 Magnesium and calcium need to be in balance with each other to fully experience good health. Because vitamin C is a mild calcium chelator, IV calcium replacement is also used in our protocols for IVNT. 3. Zinc Conservative estimates suggest that 25% of the worldâ&#x20AC;&#x2122;s population is at risk of zinc deficiency15 and the World Health Organisation put the prevalence of zinc deficiency at 31%.16 Zinc plays an essential role in numerous biochemical pathways. Zinc is vital for the immune system; for good skin, hair and nails, it acts as a mood stabiliser, is vital for taste, smell and appetite; fertility and vision.17,18 4. Selenium A decline in blood selenium levels in the UK and other European countries has raised concern about possible public health implications, particularly in relation to cancer and cardiovascular disease.19,20 Incorporated into protein to make selenoproteins, selenium has a huge range of health benefits, it is antiageing, boosts immunity, improves brain function, antiviral, improves fertility and regulates the thyroid.21

Vitamins 1. Vitamins B5, B6, B12 and vitamin B complex Whilst many B vitamins work in tandem, each B vitamin is chemically distinct and has its own specific benefits from converting food into energy, cell metabolism, promoting cell growth and division, forming red blood cells, enhancing the immune system, maintaining healthy skin and muscle tone and easing stress and improving mood.22 2. Vitamin C (ascorbic acid) Although humans cannot synthesise vitamin C, every tissue and cell in the body needs it for healthy growth and repair. Vitamin C is beneficial for the skin, enhances wound healing, helps lower cholesterol, improves blood flow, regulates sugar levels in diabetics, improves asthma symptoms and reduces risk of cataracts.23

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2. Carnitine Hugely popular with athletes, carnitine enhances fat burning, supports the immune system, reduces stress, increases vitality, protects against degenerative neurological disease and boosts male fertility.30-33 3. Cysteine Known as the antiageing amino acid, cysteine has many qualities that prevent or help reverse the ageing process. In fact it has been suggested that ageing may actually be a deficiency in cysteine.34-35 4. Glutamine Glutamine is integral to a whole host of systems in the body. It helps build and maintain muscle mass, helps against stress, anxiety and depression, improves cerebral performance and counteracts fat storage.36-38 5. Taurine Made popular by the energy drink Red Bull, taurine reduces anxiety and stress, burns fat, improves insulin sensitivity, acts as an antioxidant, improves training performance and reduces recovery time, reduces fatigue and improves brain function.39-42 6. Methionine Helps to process and eliminate fat, boosts athletic performance, essential for healthy collagen formation, helps the body eliminate toxins.43-44 7. Ornithine Promotes release of growth hormone that promotes the metabolism of excess fat necessary for immune system and liver function, reduces stress and improves sleep.45 8. Phenylalanine Phenylalanine is used to produce tyrosine, a precursor of dopamine, adrenaline and noradrenaline, which are important for maintaining a sense of wellbeing and energy. Phenylalanine also directly affects mood, helps with fatigue, depression, food cravings and chronic pain.46

Approximately 24 known amino acids are needed by the body to form more than 50,000 unique proteins it requires. Listed below are a few of the main amino acids, however other amino acids such as choline and lysine are also commercially available for IVNT.

Administering IVNT â&#x20AC;&#x2DC;cocktailsâ&#x20AC;&#x2122; As briefly outlined above, vitamins, minerals and amino acids are active products and even though they are considered as basic nutrients, they still require in-depth training in order to be administered in a safe and effective manner. It is important that the practitioner knows the mechanism of action of each nutrient and which products together are complementary and which are antagonistic. Companies that train, manufacture and supply IV products also provide physicians with IV protocols that they can start using in their clinics immediately. The benefits of using such protocols is that the osmolarity of each protocol/cocktail will have been calculated for you and this in turn will determine how quickly the cocktail can be administered. Whenever any IV is given, it is imperative that the osmolarity of the final solution is known to avoid any unwanted side effects and complications.

1. Arginine Arginine performs many vital functions within the body, largely due to its formation of nitric oxide. Arginine improves cardiovascular health, strengthens the immune system, improves insulin resistance; supports production of collagen; improves burning of excess fat and minimises stress.25-29

Reactions and side effects As with any treatment, safety comes from understanding and thus avoiding any risks and potential side effects. Allergic reactions from IVNT are now extremely rare if preservative-free products are used.

However, knowledge of minor details such as calcium gluconate being derived from shellfish is imperative if one is to avoid

Glutathione In our opinion, glutathione (GSH) is the superhero of all antioxidants. If you are sick or elderly or are just not in peak shape, you are likely to have glutathione deficiency. In fact, a leading British medical journal, The Lancet, found the highest glutathione levels in healthy young people, lower levels in healthy elderly, lower still in sick elderly and the lowest of all in the hospitalised elderly.24

Amino acids

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complications in patients with a shellfish allergy. Other precautions such as pre-treatment blood pressure checks should also be done to avoid any transient hypotension in susceptible patients when administering IV magnesium. The most common issues we see in our practice is nausea if the infusions are given too quickly or a patient hasn’t eaten for several hours, or possibly a vasovagal incidence, which is typically due to poor cannulation technique in needle-phobic patients.

Conclusion It is quoted that nutrient deficiencies are common in the US population, with research from the 2010 Dietary Guidelines Advisory Committee’s report citing 90% of Americans are nutrient deficient due to poor diet.47 With the UK following similar trends and lifestyles to those in the US it is not surprising that IVNT in the UK is growing at an exponential rate. IVNT is a very safe and beneficial treatment to the large majority of patients. However it is imperative that practitioners are adequately trained and that proper high quality nutrients are used in the IV cocktails. It is unfortunate that already we have seen clinics offering bags of saline mixed with anti-emetics and anti-inflammatories, and still labelling this as ‘nutrition therapy’. Anti-emetics and anti-inflammatories are not by definition ‘nutrients’ (a substance that provides nourishment essential for the maintenance of life and for growth), they have nothing to do with nutrients and have been used purely to treat hangovers. Hopefully, with correct training and the medical REFERENCES 1. Data on file with IntraVita Ltd 2. Frustaci A, Caldarulo M, Schiavoni G, et al. ‘Myocardial magnesium content, histology, and antiarrhythmic response to magnesium infusion,’ Lancet 2(1987).

3. Harakeh S, Jariwalla RJ, Pauling L, ‘Suppression of human immunodeficiency virus replication by ascorbate in chronically and acutely infected cells,’ Proc Natl Acad Sci, USA 87(1990) pp.7245-7249.

4. Okayama H, Aikawa T, Okayama M, et al. ‘Bronchodilating effect of intravenous magnesium sulfate in bronchial asthma,’ JAMA. 257(1987), pp.1076-1078.

5. Sydow M, Crozier TA, Zielmann S, et al. ‘High-dose intravenous magnesium sulfate in the management of life-threatening status asthmaticus,’ Intensive Care Med, 19(993), pp.467-471.

6. Alaimo K, McDowell MA, Briefel RR, et al. ‘Dietary intake of vitamins, minerals, and fiber of person ages 2 months and over in the United States,’ Third National Health and Nutrition Examination Survey, Phase 1, 1988–91 Adv Data, 258(1994), pp.1–28.

7. Elin RJ. ‘Magnesium: the fifth but forgotten electrolyte,’ Am J Clin Pathol, 102(1994) pp. 616–622.

8. Takaya J, Higashino H, Kobayashi Y, ‘Intracellular magnesium and insulin resistance,’ Magnes Res, 17(2004), pp. 126–136.

9. Newhouse IJ, Finstad EW, ‘The effects of magnesium supplementation on exercise performance, Clin J Sport Med, 10(2000)195–200.

10. Bohl CH, Volpe SL, ‘Magnesium and exercise,’ Crit Rev Food Sci Nutr, 42(2002) pp.533–563.

11. Shike M, Ross AC, Caballero B, Cousins RJ. , ‘Modern Nutrition in Health and Disease (Modern Nutrition in Health & Disease (Shils)),’ Philadelphia, 10(2005) pp.223–248.

12. Chubanov V, Gudermann T, Schlingmann KP, ‘Essential role for TRPM6 in epithelial magnesium transport and body magnesium homeostasis,’ Pflugers Arch, 451(2005), pp.228–234.

13. Drinkwater BL, Bruemmer B, Chestnut III CH, Menstrual history as a determinant of current bone density in young athletes, JAMA, 263(1990) pp.545–8.

14. Nattiv A, Agostini R, Drinkwater B, Yeager KK, ‘The female athlete triad: the inter-relatedness of disordered eating, amenorrhea and osteoporosis,’ Clin Sports Med, (1994) 15. Wessells KR, Brown KH, ‘Estimating the Global Prevalence of Zinc Deficiency: Results Based on Zinc Availability in National Food Supplies and the Prevalence of Stunting,’ PLoS ONE 7(2012).

16. Caulfield LE & Black RE, Zinc deficiency, Comparative Quantification of Health Risks, <http://www.who. int/publications/cra/chapters/volume1/0257-0280.pdf> 17. Mason JB, ‘Vitamins, trace minerals, and other micronutrients,’ Goldman’s Cecil Medicine, 24(2011).

18. Salwen MJ, ‘Vitamins and trace elements,’ Henry’s Clinical Diagnosis and Management by Laboratory Methods, 22(2011).

19. Rayman MP, ‘The importance of selenium to human health,’ Lancet. 15(2000), pp.233-41.

20. Willett WC, Stampfer MJ, ‘Selenium and cancer,’ BMJ, 297(1988) pp.573-4.

21. Rayman MP, The importance of selenium to human health’ Lancet, 15(2000), <http://www.ncbi.nlm.nih. gov/pubmed/10963212?dopt=Abstract> 22. NHS Choices, Vitamins and minerals - B vitamins and folic acid (2015) <http://www.nhs.uk/Conditions/ vitamins-minerals/Pages/Vitamin-B.aspx> 23. Smith, L, ‘Clinical guide to the use of vitamin C: The clinical experiences of Frederick R. Klenner, M.D’.

Life Sciences Press, (1988).

24. SL Nuttall, U Martin, AJ Sinclair, MJ Kendall, Glutathione: in sickness and in health, 351(1998) <www. thelancet.com/journals/lancet/article/PIIS0140-6736(05)78428-2> 25. Chen, J., Wollman, Y., Chernichovsky, T. et al, ‘Effect of administration of high-dose nitric oxide donor Arginine in men with organic erectile dysfunction: results of a double-blind, randomized, placebocontrolled study,’ BJU International 83(1999) pp.269-273.

26. Zorgniotti, A.W., Lizza, E.F, Effect of large doses of the nitric oxide precursor Arginine on erectile dysfunction. Int J Impotence Res 6(1994) pp.33-36.

Aesthetics

technicalities required to administer IVNT we can prevent IVNT falling into rogue, untrained hands, as occurs too often with many aesthetic treatments.

In 2014, Dr Samantha Gammell and Dr Jacques Otto, together with aesthetic distributor Mr Vernon Otto, founded IntraVita Ltd. They now manufacture and supply IV products and teach and train other medical practitioners in the use of IVNT. Dr Samantha Gammell is the founder and medical director of The Hadleigh Clinic and The Aesthetic MediSpa, and the former president of the British College of Aesthetic Medicine. She has a medical degree and a first class honours degree in molecular medicine. Dr Gammell trains with the leading IVNT doctors in the US and provides IVNT to her own patients.

Dr Jacques Otto is a cosmetic doctor with a master’s in medical pharmacology, philosophy in medical law and family doctor practice degree. His main interests are researching new antiageing products, cosmetic products, and cosmetic non-invasive medical device development.

He is also a polydioxanone (PDO) thread trainer and is the co-founder of IntraVita Ltd.

27. Krause M et al, ‘Arginine is essential for pancreatic beta-cell functional integrity, metabolism and defence from inflammatory challenge,’ J Endocrinol, (2011).

28. Ammann, P., Laib, A., Bonjour, J.-P., Meyer, J. M., Rüegsegger, P. & Rizzoli, R. ‘Dietary essential aminoacid supplements increase the bone strength by influencing bone mass & bone microarchitecture in an isocaloric low-protein diet,’ Journal of Bone and Mineral Research, 17(2002) pp.1264-1272.

29. Shaheen E Lakhan, Karen F Vieira et al. ‘Nutritional and herbal supplements for anxiety and anxietyrelated disorders: systematic review,’ Lakhan and Vieira Nutrition Journal 9(2010).

30. Müller, D.M., Seim, H., Kiess, W., Löster, H. & Richter, T. ‘Effects of Oral l-Carnitine Supplementation on In Vivo Long-Chain Fatty Acid Oxidation in Healthy Adults Metabolism,’ 51(2002), pp.1389-1391.

31. M. Malagurnera et al. L-carnitine treatment reduces severity of physical and mental fatigue and increases cognitive functions: a randomized an controlled clinical trial, American Journal of Clinical Nutrition; Vol. 86(2007) pp.1738-1744.

32. Serati AR, Motamedi MR, Emami S, Varedi P, Movahed MR. ‘L-carnitine treatment in patients with mild diastolic heart failure is associated with improvement in diastolic function and symptomsm,’ Cardiology. 116(2010); pp.178-82.

33. Mataliotakis, I. et.al, ‘L-Carnitine levels in the seminal plasma of fertile and infertile men: correlation with sperm quality,’ International Journal Fertility and Women’s Medicine, 45(2000), pp.236-240.

34. Wulf Droge, ‘Oxidative stress and ageing: is ageing a cysteine deficiency syndrome?’ Phil Trans Roy Soc Lond B Biol Sci 360(2005), pp.2355-72.

35. Katayama and Mine, ‘Antioxidative activity of amino acids on tissue oxidative stress in human intestinal epithelial cell model,’ J Agric Food Chem, 55(2007), pp.8458-64.

36. Bowtell, J.L., Gelly, K., Jackman, M.L., Patel, A., Simeoni, M., Rennie, M.J. ‘Effect of glutamine on whole body carbohydrate storage during recovery from exhaustive exercise,’ Journal Of Applied Physiology (1999), pp.1770-1777.

37. Hertz, L., Kvamme, E., McGeer, E.G. & Schousboe, A. ‘Glutamine, Glutamate, and Gaba in the Central Nervous System,’ Alan R Liss Inc., (1983).

38. Hasler, G., Van der Veen, J.W., Tumonis, T., Meyers, N., Shen, J. & Drevets, W.C. ‘Reduced Prefrontal Glutamate/Glutamine and -Aminobutyric Acid Levels in Major Depression Determined Using Proton Magnetic Resonance Spectroscopy,’ Archives of General Psychiatry, 64(2007), pp.193-200.

39. Kong, W., Chen, S., et al. ‘Effects of Taurine on Behaviors in Three Anxiety Models,’ Pharmacology, Biochemistry, and Behavior, 83(2006), pp.271-276.

40. Yatabe, Y., Miyakawa, S., et al. ‘Effects of Taurine Administration on Exercise,’ Advances in Experimental Medicines and Biology, 643(2009), pp.245-255.

41. Rutherford, J., Spriet, L., et al. ‘The Effect of Acute Taurine Ingestion on Endurance Performance and Metabolism in Well-Trained Cyclists,’ International Journal of Sport Nutrition and Exercise Metabolism, 20(2010), pp.322-329.

42. Seidl, R., Peyrl, A., et al. ‘A Taurine and Caffeine-containing Drink Stimulates Cognitive Performance and Well-Being,’ Amino Acids, pp.635-642.

43. Haneke, E. & Baran, R. ‘Micronutrients for Hair and Nails,’ Nutrition for healthy skin, (2010) pp.149-163 44. Alonso, L. & Fuchs, E, ‘The hair cycle,’ Journal of Cell Science, 119. (2006), pp.391-393.

45. Lavie, L., Hafetz, A., Luboshitzky, R. & Lavie, P. ‘Plasma levels of nitric oxide and L-arginine in sleep apnea patients,’ Journal of Molecular Neuroscience, 21(2003), pp.57-63.

46. University of Maryland Medical Center, Phenylalanine, <http://umm.edu/health/medical/altmed/ supplement/phenylalanine> 47. Dietary Guidelines Advisory Committee, Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for Americans, (2010) <http://www.nutriwatch.org/05Guidelines/dga_ advisory_2010.pdf>

Reproduced from Aesthetics | Volume 3/Issue 6 - May 2016

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Treatment of bingo wings Exercise There is no doubt that exercise is one of the simplest and most successful methods of toning the muscles of the upper arm and does not require any specialist equipment, meaning it can be done at home.

There are many exercises recommended for treating bingo wings, including press-ups, wall push-ups, bench dips and triceps kickbacks.4 Exercise should be combined with diet so further fat loss is achieved along with some skin tightening and improved skin tone. Losing weight alone may further exacerbate the problem as it may lead to worsened skin laxity when fat is lost.

Treating Bingo Wings Dr Martyn King details the various options available for improving the appearance of arms Introduction ‘Bingo wings’ is the rather unaffectionate term used to describe the loose skin and fatty tissue that hangs beneath the arms in many women and some men. It is particularly noticeable when the arms are raised and then shaken such as when calling out in bingo, hence the terminology. One website reported that three in four British women stated they are more unhappy with their upper arms than any other part of their body – some to the point where they refuse to wave in public.1 The term ‘bingo wings’ covers a spectrum of concerns related to the upper arms that have been classified into separate entities by personal trainer Rich Jones.2 The classic bingo wing is caused by a lack of muscle tone in the upper arm, often in slimmer women. ‘Arm charms’ describes an extension of this, often when there has been significant weight loss and there is considerable redundant skin hanging from the upper arm. When there is a little extra fatty tissue at the upper arm and into the pectoral region, a bulging appearance is seen at the axillary fold. Finally, where there is excessive fat in the whole arm, this can create bulges and rolls under the arm leading to an unsightly appearance. Whatever the type, bingo wings cause concern and poor self-esteem for a large number of people and may even dictate what clothes a person will wear.

Endermologie A popular, non-invasive and quick treatment for bingo wings is lipomassage. This involves mechanical rolling of the skin using suction and independent rollers whilst wearing a garment. The process folds and unfolds the skin and subcutaneous fat, triggering a biological response leading to improved blood flow, the elimination of resistant fat and the stimulation of fibroblasts.5 Although there are no specific clinical studies relating to the treatment of bingo wings, one study has suggested this technique increases lipolytic responsiveness of femoral adipose tissue in women with cellulite, having undergone 12 sessions of mechanical massage.6 Often, a course of 12 treatments twice a week is recommended. It is a very safe procedure with no downtime, although the results may be quite minimal.

Radiofrequency Radiofrequency (RF) may be used where the main concern is mild to moderate skin laxity. There are many devices available and they may be unipolar, bipolar or even tripolar, depending on the number of electrodes used to deliver the energy to the body. The position and depth of RF energy is controlled and will travel through the skin and subcutaneous tissues, creating heat at areas of increased resistance, such as in adipose tissue. This has the effect of causing lipolysis. The frequency of RF can also stimulate fibroblasts and lead to contraction of collagen fibrils resulting in skin tightening.7 A recent study indicated a mean reduction of almost 2cm in circumference of the upper arm when treating the bingo wings using tripolar radiofrequency, without pain or complications and with good patient satisfaction scores.8 The procedure is considered safe with no downtime, although repeated treatments are likely to be needed.

Before and after five radiofrequency (4 pixel) treatments using 3D-lipomed. Images courtesy of Suzette Varga.

Before

After

Anatomy The upper arm contains a deep and superficial fat layer. The deep layer is thin and found in the posterior and deltoid region of the arm. The superficial fat layer is circumferential and tends to increase in size with age, particularly in the posterior onethird of the arm, resulting in a fatty appearance of the upper arm. The type of fat also has a further detrimental effect, being less thick and non-fibrous. The overlying skin of the medial aspect of the arm is thin, mobile and prone to sagging.3

Deoxycholate A more recent treatment that is available for treating bingo wings is an injectable deoxycholate solution branded as Aqualyx. It is CE approved as a medical device and indicated for the reduction of localised areas of stubborn fat.9 Results may be apparent after a single treatment, although a course of injections is likely to produce better results. Aqualyx aims to work by liquefying the fat cells, leading to permanent destruction of the adipocyte, before the fatty contents

Reproduced from Aesthetics | Volume 3/Issue 6 - May 2016

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are then removed via the lymphatic system. Sometimes it is used in combination with ultrasound to improve the dissipation of the product. There can be some discomfort following the procedure along with some swelling, redness and irritation.10 Although this treatment may be suitable for some cases of bingo wings, it does not deal with skin laxity and so may need to be combined with other modalities.

Cryolipolysis Cryolipolysis is one of the latest and most impressive technologies for non-surgical fat reduction and is suitable for treatment of excessive fat in the upper arms. It is based on the principle that low temperatures destroy fat cells in the body, whereas the skin is more resilient. There are several devices on the market which all work on the same principle of applying a suction cup to the body area, aspirating the fatty tissue and then freezing the tissue to about -5 degrees and holding at that temperature for about 45 minutes.

This causes apoptosis of adipocytes, which are then removed by the body in the following weeks. The treatment has no downtime, is relatively pain free and produces a low risk of complications.11 There is also evidence that suggests cryolipolysis will lead to some secondary skin tightening. A clinical study published in 2016 demonstrated a 15.3% decrease in the fat layer thickness, as measured by ultrasound, after a single cryolipolysis treatment to the upper arms after eight weeks.12

Patient before treatment on left arm and after cryolipolysis on right arm using 3D-lipo+

Laser-assisted lipolysis Laser-assisted lipolysis appears to be an effective treatment for bingo wings and can not only lead to fat loss and reduction in circumference, but can also lead to a skin tightening effect. A 2015 study involving 45 patients reported a reduction in circumference of just under 5cm, as well as a reduction in skin calliper measurements.13 The pain associated with laser-assisted lipolysis is minimal during the procedure by the administration of a tumescent anaesthetic solution and as laser-assisted lipolysis is less traumatic than conventional liposuction, the pain afterwards tends to be minimal. Prolonged oedema can be a complication in up to 25% of patients.13 The results for laser-assisted lipolysis can be better than the previous methods described but the price for the procedure tends to be higher.

Ultrasound-assisted lipolysis VASER lipolysis is a minimally invasive procedure that uses pulsed ultrasound energy to emulsify fat with minimal damage to surrounding structures and vessels. It offers similar results to laser-assisted lipolysis although there is a lack of clinical evidence demonstrating its benefit for bingo wings. Complications can include tenderness, bruising and swelling. Compression is normally required after a procedure and additional massage may sometimes be required. In my experience, most patients will see some improvements in skin laxity following treatment.

Aesthetics Journal

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Brachioplasty Arm lift surgery or brachioplasty is a surgical procedure that reduces the circumference of the upper arms and removes excessive skin.

It can be combined with liposuction to give better results. In the US, 15,457 brachioplasty surgeries were performed during 2012, a significant increase compared with the 338 surgeries in 2000,14 demonstrating the rapid increase in demand. There are many types of surgical procedures performed including minimal incision, traditional and extended brachioplasties, although all of them involve considerable operating time and costs often in excess of £5,000.

There are also significant risks with surgery including bruising, asymmetry, nerve damage, prolonged swelling, blood clots and necrosis. Following brachioplasty, there can often be a large unsightly scar, which, anecdotally, may cause almost as much distress as the problem being treated.

Summary Although bingo wings appear to be a significant aesthetic concern, particularly for women, there are no miracle cures available either surgically or non-surgically. As practitioners, we need to be mindful that bingo wings cover a spectrum of upper arm problems and when deciding on treatment, we need to focus on whether fat or skin laxity is the predominant concern, ensuring we are realistic in what we can achieve with the most appropriate treatment. Personally, I use a layered, multi-platform treatment, such as the 3D-lipomed device that I use in my clinic, as I find it is most beneficial in order to target all aesthetic concerns relating to the upper arms. We also need more clinical trials that detail the evidence for individual treatments and outcomes, as we cannot simply rely on claims from manufacturers.

Dr Martyn King is the director of Cosmedic Skin Clinic, medical director of Cosmedic Pharmacy, chair of the Aesthetic Complications Expert Group, member of the British College of Aesthetic Medicine and board member for the British Association of Sclerotherapists. He is a national and international accredited trainer and speaker and has written articles for leading journals.

REFERENCES 1. Beat those bingo wings – for good! (GoodtoKnow, 2015) <http://www.goodtoknow.co.uk/wellbeing/ galleries/28042/10-ways-to-beat-bingo-wings> 2. Hannah Roberts, The six types of bingo wings…and how to banish them for summer (MailOnline: Femail, 2012) <http://www.dailymail.co.uk/femail/article-2158271/The-types-bingo-wing--banishsummer.html#ixzz423PCjtwA> 3. Illouz Y-G, DeVillers Y., ‘Body Sculpturing by Lipoplasty’, Churchill Livingstone, (1989).

4. 10-minute bingo wings blaster (NHS Choices, 2015) <http://www.nhs.uk/Livewell/fitness/Pages/Bingowings-blaster.aspx> 5. Moseley AL1, Esplin M, Piller NB, Douglass J., ‘Endermologie (with and without compression bandaging)--a new treatment option for secondary arm lymphedema’, Lymphology, 40 (3) (2007), pp.129-37.

6. Lafontan M., ‘Evaluation of the effects of LPG Technique on lipolysis and gene expression using respectively microdialysis and DNA microarray technologies’, Clinical Investigation Center, Research Report (2009).

7. Radiofrequency For Cellulite & Fat Information (UK: Consulting Room, 2016) <http://www. consultingroom.com/Treatment/Radiofrequency-Cellulite-Fat> 8. McKnight B, Tobin R, Kabir Y, Moy R., ‘Improving Upper Arm Skin Laxity Using a Tripollar Radiofrequency Device’, J Drugs Dermatol., 14(12) (2015), pp.463-6.

9. Clinical Evidence (UK: Aqualyx, 2014) <http://www.aqualyx.co.uk/studies> 10. Salti G, Motolese P., ‘Cavitational adipocytolysis with a new micro-gelatinous injectable for subcutaneous adipose tissue volume reduction: ex-vivo histological findings’, Eur J Aesth Med Dermatol 2 (2012), pp.94-97.

11. Avram MM, Harry RS., ‘Cryolipolysis for subcutaneous fat layer reduction.’, Lasers Surg Med, 41 (2009), pp.703-8. Review. Erratum in: Lasers Surg Med (2012) 44(5) p.436.

12. Lee SJ, Jang HW, Kim H, Suh DH, Ryu HJ., ‘Non-invasive cryolipolysis to reduce subcutaneous fat in the arms’, 8 (2016), pp.1-4.

13. Leclère FM, Alcolea JM, Vogt P, Moreno-Moraga J, Mordon S, Casoli V, Trelles MA., ‘Laserassisted lipolysis for arm contouring in Teimourian grades I and II: a prospective study of 45 patients’, Lasers Med Sci., 30 (3) (2015), pp.1053-9.

14. American Society of Plastic Surgeons, 2012 Cosmetic plastic surgery statistics (Arlington Heights, IL: American Society of Plastic Surgeons; 2012). <http://www.plasticsurgery.org/Documents/newsresources/statistics/2012-Plastic-Surgery-Statistics/Cosmetic-Procedure-Trends-2012.pdf.>

Reproduced from Aesthetics | Volume 3/Issue 6 - May 2016

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The Role of Nutraceuticals Dr Martin Godfrey explains how effectively using nutraceuticals can improve aesthetic treatments and wound healing Medical practitioners of all specialties have long understood the importance of good nutrition in determining optimal treatment outcomes. Ensuring patients receive a healthy balance of protein and carbohydrates in particular, together with boosting levels of vitamins and minerals if needed, has been widely suggested to be almost as important as the treatments themselves. This is particularly the case for skin health and wound healing1 – two central issues in the practice of aesthetics.

Now, many practitioners are looking closely at going one step further: boosting and focusing the positive effects of good nutrition with the use of nutraceuticals (often referred to as ‘nutricosmeceutials’ in the aesthetic world). These terms are used to describe any product derived from food sources with extra health benefits in addition to the basic nutritional value found in foods.13

Both these types of ageing can be exacerbated by unbalanced diets, for example, containing too much sugar, and/ or poor diets, which lack essential nutrients such as essential fatty acids.4 High sugar levels lead to the development of Advanced Glycation End products (AGEs), due to a chemical reaction between glucose and the free amino groups in proteins. AGEs remain in the skin and other tissues because they cannot be degraded normally by enzymes. These affect the fibroblasts in the dermis, causing a reduction in the amount and quality of elastin and type I collagen fibre production.2

Skin health Collagen levels and the presence of free radicals in the skin are critical factors in determining skin health. For the skin to function normally and appear young the structure of the dermal layer must be maintained, as the dermis, which provides structural support to the epidermis, carries the blood vessels and supplies the skin with important nutrients for its functioning.2

Moreover, aged fibroblasts synthesise lower levels of collagen, both in vitro and in vivo, compared to young adult fibroblasts.5 This results in visible signs of ageing (development of fine lines and wrinkles, sagging and loss of tone), which are usually most prominent on the face, and also have a negative effect on wound healing – although this latter effect remains to be conclusively clinically proven.

The dermis is home to fibroblasts, which generate the collagen as well as elastin and hyaluronic acid. Natural ageing, usually accelerated by the presence of free radicals, will affect this structural integrity, plus sun-

Treating patients with oral supplements One approach to supporting the skin as it undergoes the necessary trauma of aesthetic procedures is to boost the

exposed areas of the body will develop signs of photoageing – the result of the breakdown of collagen fibres.2 It is estimated that we lose about 1.5% of our collagen from our skin every year as we age.3

Aesthetics aestheticsjournal.com

collagen production within the dermis. Since collagen cannot penetrate the tight junctions of the epidermis, doctors are increasingly looking at oral collagen supplements to support collagen synthesis from within, rather than using only topical treatments externally. The addition of oral antioxidants may also reduce the harmful effects of free radicals, allowing collagen to remain in the skin for longer.6 It is worth noting that the amount of transport across the intestinal barrier is a rate-limiting step that will affect the efficacy of these compounds in the skin. In order to be active in the deeper layer of the skin, native collagen has to be hydrolysed to cross the intestinal barrier and reach the blood stream. Second, given that the dermal tissue contains fibroblasts, the bioactive collagen peptides that arrive in the blood stream must bind to fibroblast membrane receptors and stimulate these cells to produce new collagen, elastin and hyaluronic acid.2 Few studies have been carried out to confirm the effects of supplemental oral collagen peptides in conjunction with aesthetic procedures, but initial published results are promising. One such study published last year in Clinical Interventions in Ageing,7 indicates an improvement in the depth of nasolabial folds in patients undergoing an aesthetic procedure, with and without a nutricosmeceutical.

Interestingly, the results were similar in both the patients that had filler injections and a collagen supplement, and those that received the collagen supplement alone – suggesting the nutricosemeceutical had a true effect of its own. On the strength of both this clinical and observational/anecdotal evidence, aesthetic practitioners, particularly in the UK, Italy and the US, are increasingly turning to nutricosmeceuticals to support improved outcomes and longer lasting effects for their procedures.8 The use of oral retinoids Various other oral (and topical) treatments for wrinkled and photoaged skin are sometimes used to augment aesthetic procedures, with products containing retinoids recognised as a benchmark.

Retinoids are a family of compounds made up of various mixtures of vitamin A and its derivatives, and follow the vitamin A pathway when ingested or applied.

Retinoid treatments gained popularity in the 1980s partly because of the work of Kligman et al.9 Studies have indicated that the end process may be similar and

Reproduced from Aesthetics | Volume 3/Issue 6 - May 2016

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that collagen content can be increased in the upper papillary dermis by retinoids. This process is carried out by inhibiting collagen degradation, thereby leading to an increase in collagen synthesis.10 The use of retinoid creams in aesthetic procedures is becoming more common today since the benefits have been indicated to be positive, for example in patients where these products were used before they were subjected to chemical peels and dermabrasion.11 However, adverse effects such as skin irritation, dryness, burning, and erythema are common and well documented.12 Conclusion Larger studies of nutricosmeceuticals containing both collagen peptides and antioxidants are underway both in pre-treatment and during aesthetic procedures, but until results are published, hard proof of their efficacy is frustratingly still a year or so away.

Ultimately, the decision to recommend nutricosmeceuticals to patients belongs to the aesthetic practitioner. Intuitively it would seem sensible to recommend that patients eat healthily both before and after their procedures, including a high intake of fruit and vegetables (particularly those high in antioxidants). Reducing intake of foods with high sugar content may also be sensible.

Tantalisingly, the scientific jury is still out on nutricosmeceutical use. I believe, however, the prospects look very promising.

Aesthetics Dr Martin Godfrey is head of research and development at MINERVA Research Labs Ltd. A trained medical practitioner, Dr Godfrey has a wealth of expertise in health and nutritional product marketing. His main responsibilities are gaining scientific verification for Minerva’s products through overseeing clinical trials and obtaining the support of medical professionals.

REFERENCES 1. Barbul, Adrian, Nutrition and Wound Healing. Arnold, Meghan M.D, Plastic and Reconstructive Surgery: June (2006) - Volume 117 - Issue 7S – pp.42S-58S. 2. Licia Genovese, Sara Sibilla, Innovative Nutraceutical Approaches to Counteract the Signs of Aging. Textbook of Aging Skin, Nov (2015) 3. Lavker RM, Zheng PS, Dong G, Morphology of aged skin. Dermatol Clin. (1986) Jul;4(3):379-89.

4. Freinkel RK, Woodley DT, The biology of the skin. Pantheon (2001) 5. Brun C, Jean-Louis F, Oddos T, Bagot M, Bensussan A, Michel L. Phenotypic and functional changes in dermal primaryfibroblasts isolated from intrinsically aged human skin. Exp Dermatol.

2016 Feb; 25(2):113-9. Epub 2016 Jan 11.

6. Fernández-García E. Skin protection against UV light by dietary antioxidants, Food Funct, 2014 Sep; 5(9):1994-2003.

7. Borumand M, Sibilla S, Daily consumption of the collagen supplement Pure Gold Collagen reduces visible signs of aging. Clin Interv Aging. (2014) Oct 13;9:1747-58 8. Skin Care Starts with a Sip – Fact or Fiction? Hydrolyzed Collagen Helps Counteract the Signs of Aging. Dr Martin Godfrey MD. American Academy of Aesthetic Medicine’s 20th World Conference of Aesthetic Medicine 9. Kligman AM, Grove GL, Hirose R, Leyden JJ, Topical tretinoin for photoaged skin, Journal of the American Academy of Dermatology. Oct (1986)15(4 Pt 2):836-859.

10. de Campos Peseto D, Carmona EV, da Silva KC, Guedes FR, Filho FH, Martinez NP, Pereira JA, Rocha T, Priolli DG, Effects of tretinoin on wound healing in aged skin, Wound Repair Regen (2016) 11. Mandy SH, Tretinoin in the preoperative and postoperative management of dermabrasion, Journal of the American Academy of Dermatology. Oct (1986)15(4 Pt 2):878-879, 888-879.

12. Saurat JH, Side effects of systemic retinoids and their clinical management, J Am Acad Dermatol.

1992 Dec; 27(6 Pt 2):S23-8.

13. Tomislav Mestovic, What are Nutrceuticals, News Medical, (2016) <http://www.news-medical.net/ health/What-are-Nutraceuticals.aspx>

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Reproduced from Aesthetics | Volume 3/Issue 6 - May 2016

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Combatting Stress on Skin Mr Stephen McCulley details how stress can affect the skin and provides advice on how to recognise the symptoms in patients to manage it effectively Activation of stress Stress can have a damaging influence on the skin, from contributing to premature ageing to aggravating symptoms of chronic skin conditions such as eczema and psoriasis.1 When we experience stress our bodies respond with a chemical reaction. When we feel threatened, a signal is sent to an area of the brain called the amygdala, which is responsible for regulating our emotions.2 Once a threat is recognised here, the amygdala triggers a response in the hypothalamus, which is responsible for the production of hormones in the body. Simultaneously, the peptide hormone corticotrophinreleasing factor (CRF) is activated and is responsible for triggering a response in the stress hormone system (also known as the hypothalamic-pituitary-adrenal axis).2 The CRF activates the release of adrenocorticotropic hormone from the pituitary gland, which moves through the bloodstream to the adrenal glands, causing the stress hormone cortisol to be released into the bloodstream.3 When cortisol has been triggered, a person will experience a ‘flight or fight’ response to the stress and a number of changes in the body occur, including appetite suppression, increased blood pressure and increased anxiety.4,5 Influence of cortisol Chronic stress can be the result of a person having too much CRF in their body and therefore high levels of cortisol, which can have a negative impact on the skin and general wellbeing.6 A recent study on the effect of stress on the skin of mice claimed that mice subjected to chronic psychological stress experienced oxidative damage to proteins (protein carbonylation) and lipids (lipid peroxidation) in the skin.7 Mice were exposed to rotational stress for 28 days and the skin was then analysed. The study indicated that chronic stress induces wrinkle formation in mice skin and causes the dermis to thin.2 It’s clear there is a direct link between stress and skin deterioration in normal skin, but it’s also important to note that psychological stress may intensify skin disorders by impairing the recovery of the skin barrier function, for example, through patients picking, scratching or rubbing the skin. I will now detail some of the issues high levels of cortisol can have on the body and how this affects the skin.

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Increase in blood sugar levels Cortisol causes blood sugar levels to increase in order to give the body enough energy to perform a ‘fight or flight’ response in a stressful situation.2 As well as making a person more vulnerable to health conditions such as diabetes, a long-term increase in blood sugar levels can have a negative impact on the skin. A high level of sugar in the blood encourages the glycation process. Glycation happens when excess sugar molecules in the body crosslink with protein and fat molecules to form advanced glycation end products (AGEs).8 AGEs are not recognised as normal proteins by the body so the immune system responds by producing antibodies, which can cause the skin to become inflamed. A further negative effect of AGEs is that the proteins collagen and elastin, which are responsible for keeping the skin looking youthful, are most at risk from glycation.9 Glycation hardens and discolours collagen and elastin, which makes wrinkles more prominent and causes skin to lose its natural glow.10 A vicious cycle can occur when a person under stress seeks to handle this stress by comfort eating foods that will increase sugar levels further, such as sweets and fast food, therefore increasing the level of sugar in the blood.

Decrease in hyaluronic acid High cortisol levels can also cause the skin to dry out by decreasing the production of hyaluronic acid, which is a natural moisturiser.

Hyaluronic acid plumps the skin by absorbing water so when levels are reduced, the skin can become dry and damaged, intensifying the ageing process.11 Weakened digestive and immune system When the body is poised to fight or run away, blood flow is redirected to major muscle groups to give the body a burst of energy to respond to the perceived threat. This means the blood is directed away from areas such as the digestive system and the immune system – both of which play a part in the condition of the skin. A poorly functioning digestive system can cause or exacerbate a myriad of skin issues including acne, rosacea and eczema, as well as causing less serious problems such as blemishes and a dull complexion. If there’s not enough blood flowing to the digestive system then this can result in a decrease in the amount of nutrients being absorbed by the body.12 Nutrients such as vitamin A, B and C, omega-3 fatty acids and the antioxidant beta-carotene are vital for healthy skin, and, if the digestive system is compromised, it’s very difficult for the body to absorb these. Long-term high levels of cortisol can also weaken the immune system.13 This can cause problems for people who suffer from chronic skin conditions such as eczema, which can be exacerbated by allergens, which the immune system fights off.14 If the immune system is weakened then allergens can more easily trigger histamine, which increases itchiness and therefore aggravates the itch-scratch cycle associated with eczema.15 Detecting levels of stress in patients Sometimes stress presents itself clearly on the skin in eczema, acne or psoriasis flare-ups, but in many cases the effect of stress on the skin is much more subtle and is visible in wrinkles, a sallow complexion or dry patches. It’s important to take a holistic approach to identifying stress as the cause of skin problems by discussing common symptoms of stress with a patient, including:16 • Sleep problems • Headaches • Palpitations

Reproduced from Aesthetics | Volume 3/Issue 6 - May 2016

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• Stomach problems • Low energy • Frequent colds • Reduced appetite • Restlessness • Itchiness If a number of these symptoms are present then, in my professional opinion, it’s highly likely stress could be causing problems with the patient’s skin as well.

How to treat stress-induced skin conditions The best ways to treat skin conditions that are caused by or aggravated by stress is to identify what triggers stress in the patient and then work to manage this accordingly. Once a patient’s stress can be managed more effectively, skin treatments are more likely to be successful.

Managing stress Successful stress management is not a quick fix and often takes a long-term commitment before symptoms improve.

Depending on the cause and the severity of the stress there is a range of management techniques including yoga, meditation, improvements to diet and exercise, which can help a patient to manage moderate stress levels.17 For more severe or long-term cases of stress, patients may consider psychotherapy, cognitive behavioural therapy or medication such as beta-blockers or antidepressants. In some patients, issues such as obsessive-compulsive disorder or anxiety disorders can cause compulsive skin picking or scratching, so psychological treatment alongside dermatological treatment may help reduce symptoms.

Taking action to manage stress can often make patients feel more in control of their skin conditions, which in itself can help to reduce symptoms.

REFERENCES 1. Pyschosocial (US: National Eczema Association, 2016) <https:// nationaleczema.org/eczema/related-conditions/psychosocial/> 2. Understanding the stress response (US: Harvard Health Publications, 2011) <http://www.health.harvard.edu/stayinghealthy/understanding-the-stress-response> 3. You & Your Hormones (UK, Your Hormones, Corticotrophinreleasing hormone, 2013) <http://www.yourhormones.info/ hormones/corticotrophinreleasing_hormone.aspx> 4. Why stress causes people to overeat (US: Harvard Health Publication, 2012) <http://www.health.harvard.edu/newsletter_ article/why-stress-causes-people-to-overeat> 5. Understanding the stress response (US: Harvard Health Publications, 2011) <http://www.health.harvard.edu/stayinghealthy/understanding-the-stress-response> 6. Stress and Blood Glucose Levels, Diabetes, the global diabetes community (UK: Diabetes, 2016) <http://www.diabetes.co.uk/ stress-and-blood-glucose-levels.html> 7. Bruna Romana-Souza, Gracineide Santos Lima-Cezar, Andréa Monte-Alto-Costa, ‘Psychological stress-induced catecholamines accelerates cutaneous aging in mice’, Department of Histology and Embryology, (2015).

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Creating healthy skin habits Habits such as itching, picking and rubbing can make many skin conditions worse, particularly conditions such as eczema, psoriasis and acne. Not scratching a condition such as eczema is easier said than done, but cultivating better skin habits can help to reduce these urges over time. In many cases itching, picking and rubbing are self-soothing techniques, which patients have developed as a way to cope with stress and anxiety. As well as identifying the cause of stress and anxiety, patients can make small changes, which should help them to control compulsive picking and itching by gradually unlearning the habits: • Ask patients to be aware of what situations trigger the need to scratch or pick. In some cases it might be something as simple as removing tweezers or a mirror from their bathroom if these trigger the urge to pick when stressed, for example.

• Patients should be aware of the time they spend ‘scanning’ the skin for dry patches, spots, bumps or scabs, which they may be tempted to pick or scratch. Increasing awareness of negative behaviour is often the first step in taking action to decrease this behaviour.

• Encourage patients to use the time normally spent itching or picking to do something soothing for their skin instead, such as a facemask or a warm bath.

Medication The third approach to combating skin conditions caused by stress is medication.

As previously mentioned, in some patients, anxiety, depression or conditions such as OCD can exacerbate skin conditions. If this is the case then these conditions can be treated with appropriate medication, such as antidepressants, to help control a patient’s need to aggravate the skin. As well as medication to treat psychological conditions, 8. Karyn Repinski, Face Facts About Sugar (US, Prevention, 2011) <http://www.prevention.com/beauty/natural-beauty/how-sugarages-your-skin> 9. Kris Campbell, Glycation and the Skin (US, Skin Inc., 2013) <http:// www.skininc.com/skinscience/physiology/Glycation-and-theSkin-230102271.html> 10. What is glycation? (US, Sharecare, 2016) <https://www.sharecare. com/health/healthy-skin/what-is-glycation> 11. How to Reduce the Effects of Stress on Your Skin (US, Skyn Iceland, 2016) <http://www.skyniceland.com/beauty-guides/howto-reduce-the-effects-of-stress-on-your-skin> 12. Sharon Feieresisen, Why improper digestion might be screwing up your skin (UK, The Fashion Spot, 2013) <http://www. theukfashionspot.co.uk/beauty/326385-digestion-and-skin/> 13. Michael Randall, The Physiology of Stress: Cortisol and the Hypothalamic-Pituitary-Adrenal Axis (US: Dartmouth Undergraduate Journal of Science, 2011) <http://dujs.dartmouth. edu/2011/02/the-physiology-of-stress-cortisol-and-thehypothalamic-pituitary-adrenal-axis/#.VvPB6eKLSUk> 14. Atopic Dermatitis/Eczema (UK: Allergy UK, 2016) <https://www. allergyuk.org/skin-allergy/atopic-eczema> 15. Dr Victoria Lewis, The immune system and the skin (UK:

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patients can also be prescribed medication to tackle skin conditions as a two-pronged approach. Topical creams such as steroid cream for eczema and psoriasis, and retinoids and antibiotics for acne, are just some of the medications that can help control flare-ups.18,19 Caring for the skin An effective skincare routine can help to reduce the impact of stress on the skin, from helping to manage chronic conditions, to reducing the effects of ageing: • Fragrance free products – hypoallergenic products with a low or neutral pH level can help prevent inflammation by reducing irritation caused by harsh chemicals drying the skin.20 • For conditions that cause redness such as rosacea, anti-inflammatory creams such as those containing extract of liquorice root or allantoin can help alleviate redness.21 Conclusion Treating skin problems that are caused by or exacerbated by stress has to be managed holistically, so that the root cause of the stress is tackled alongside an effective skincare routine. Without adopting this approach, we can treat problems with the skin but the results are unlikely to be as effective unless the cause of the stress is managed too. By encouraging patients to effectively deal with stress in their lifestyle, they should have much more noticeable, long-term results than if you were to simply treat the skin alone.

Mr Stephen McCulley is a consultant plastic, reconstructive and aesthetic surgeon. He is based at City Hospital in Nottingham where he is a specialist in the treatment of breast cancer and breast reconstruction. Mr McCulley also runs a private practice that offers both surgical and non-surgical procedures.

netdoctor, 2014) <http://www.netdoctor.co.uk/conditions/skinand-hair/a3653/the-immune-system-and-the-skin/> 16. 50 Common Signs and Symptoms of Stress, (US: The American Institute of Stress, 2016) <http://www.stress.org/stress-effects/> 17. Rick Nauert, Stress Management Improves Skin Conditions, (US: Psych Central, 2015) <http://psychcentral.com/news/2011/08/09/ stress-management-improves-skin-conditions/28458.html> 18. Mild Psoriasis: Topical Steroids (US, National Psoriasis Foundation, 2016) <https://www.psoriasis.org/about-psoriasis/ treatments/topicals/steroids> 19. Treating acne (UK, NHS Choices, 2016) <http://www.nhs.uk/ Conditions/Acne/Pages/Treatment.aspx> 20. Best sensitive skin care products you must have – creams, moisturisers, lotions (US, skincarederm.org, 2016) <http://www. skincarederm.org/sensitive-skin/best-sensitive-skin-moisturizercreams-lotions-anti-aging-facial-masks-deodorant-fragrancesand-sensitive-skin/> 21. Dr Jeanette Jacknin, Rosacea Series: Licorice – a sweet solution for rosacea and melasma (US: Curezone, 2016) http://www. curezone.org/forums/am.asp?i=1857181

Reproduced from Aesthetics | Volume 3/Issue 6 - May 2016

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Mesotherapy for Cellulite Treatment Dr Philippe Hamida-Pisal details the aetiology of cellulite and advises on treatments using mesotherapy Cellulite is a concern that many of our aesthetic patients are likely to present with. While there are a variety of treatment options available, including skincare, laser or LED treatments, electrotherapy, lymphatic drainage and injection lipolysis, this article will focus on the use of mesotherapy, examining its efficacy as a successful method of managing cellulite.

Definition and cause While most people will be familiar with the term ‘cellulite’, it is important that practitioners thoroughly understand its meaning before offering treatment.

‘Cellulite’ or ‘superficial lipodystrophy’ is a cluster of hypodermic fat. Its scientific name is panniculopathy oedematous-fibro-sclerosis (PEFS), which corresponds to different states of the advancement of cellulite.1 PEFS is an increase in thickness of the hypodermis combined with an increase in thickness of the dermo-hypodermic panniculus, and an excessive local thickening of the superficial adipose tissue. Cellulite is characterised by a padded cutaneous appearance, commonly known as ‘orange peel’.1 The more excess fat is stored as triglycerides, the greater the swelling of adipocytes filled with fat will be, as adipocytes can grow up to 50 times their original volume.1 As such, cellulite becomes more visible making it a greater aesthetic concern for our patients.

Three indications characterise cellulite: adipose, water retention and fibrosis. To target these issues using mesotherapy, we have to choose the appropriate medicines.

Classification and history In 1978, Nurnberger and Muller proposed a classification based on the appearance of the skin (Figure 1).3 Through biopsies, they demonstrated the existence of cellulite adipose lobules. In the case of female patients, the adipose tissue is contained in chamber-like structures that favour the expansion of adipose tissue into the dermis. Conversely, men have a network of criss-crossing, connective tissue architecture, forming smaller polygonal units that allow for subcutaneous fat deposits to expand laterally and internally, but with little protrusion into the dermis.3 This explains the ‘orange peel effect’, which is often present in women.

In 1979, Curri and Merlen were the first to explain the physiopathology of cellulite using video capillaroscopy, allowing direct observation of the blood flow between the adipocytes and highlighting the essential role of microcirculatory failure. They proposed a classification split into four phases:6 Phase 1: Decrease and loss of mucopolysaccharides with increased permeability and plasma exudation, which leads to water retention.

Phase 2: Formation of collagenous fibres that encapsulate clusters of adipocytes.

Phase 3: Formation of a capsule of connective fibres enclosing adipocytes.

Phase 4: Formation of micro-cellulite nodules (30 to 50 adipocytes) surrounded by collagen fibres evolving towards macro-nodules

Nurnberger-Muller Scale Stage 0: smooth appearance of the skin when standing and when pinched Stage 1: smooth appearance of the skin but ‘orange peel’ effect evident when standing and lying Stage 2: smooth appearance of the skin when lying, however padded appearance when standing Stage 3: padded appearance in all positions Figure 1: Nurnberger and Muller’s cellulite classification scale

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causing micro-diffuse sclerosis.

Since the early 1980s, researchers and practitioners have jointly agreed on the multi-factorial origin and pathophysiological mechanisms of cellulite:7

• Hypertrophy of fat lobes in the hypodermis slows down the microcirculatory function • Dilated capillaries cause interstitial fluid infiltration • A slowdown in the lymphatic circulation prevents the removal of tissue oedema • Fatty lobes are grouped into nodules encapsulated in a fibrous shell, causing a disturbance in the adipocyte metabolisms • Connective tissue between fat lobes thickens, hardens and shrinks giving a dimpled appearance to the skin (orange peel effect), accompanied by disruption of tissue metabolism and circulatory exchanges In 2000, Dr Philippe Blanchemaison, repeating this classification, proposed a new type of cellulite called R-FAT: water retention, fibrosis and adipose tissue.1,6 This classification is based on the development of an index of water retention (IRE) quantified by the use of high-frequency ultrasound.

According to Blanchemaison, each of the three factors of cellulite (R-FAT) can therefore be defined in terms of the physiopathology.

Mesotherapy treatment is based on this triple notion: Adipose cellulite: lipodystrophy Cellulite water retention: hydrolipodystrophy Fibrous cellulite: fibrolipodystrophy

Using mesotherapy When considering using mesotherapy as a cellulite treatment, the practitioner should consider the following questions: Which drugs?

This is the most important question to answer, as the practitioner will have to recall the previous notions of physiopathology. They should look at the properties of each drug and choose the most appropriate: Medicines for circulation • Pentoxifylline (Trental): peripheral vasodilator with arterial vasodilator effect demonstrated. Greater use of pentoxifylline causes a slight decrease in fibrinogen and changes in erythrocyte deformability.1,3 • Papaverine: a musculotropic spasmolytic.

In mesotherapy it acts on the

Reproduced from Aesthetics | Volume 3/Issue 6 - May 2016

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Various treatment mixtures The information below details various mixture recommendations for the treatments of adipose, water retention and fibrosis. This is by no means a comprehensive list of the options available, however it should serve as a helpful tool when considering adopting mesotherapy as a treatment option for your cellulite patients.

Adipose treatment Primary medicine: Base xanthan: theophylline aminophylline, euphylline Secondary medicines: vasodilator: papaverine, silica: conjonctyl, magnesium

Before

After

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Mixture: • Lidocaine 2ml • Euphylline 2ml • Papaverine 2ml • Conjonctyl 2ml

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• Conjonctyl 1ml • NCTF 135 1ml

Water retention treatment Main medicine: Etamsylate: dicynone Secondary medicine: papaverine, vitamin C, conjonctyl, magnesium Mixture: • Lidocaine 2ml • Dicynone 2ml • Papaverine 2ml

Fibrosis treatment Main medicine: Calcitonin Secondary medicine: Vasodilator: papaverine, silica, vitamin C Mixture: • Lidocaine 2ml • Calcitonin 50U.I • Papaverine 2ml • Conjonctyl 1ml • NCTF 135 1ml

Before

After

Before and after 12 sessions of mesotherapy treatment. Images courtesy of the Society of Mesotherapy and Dr Philippe Hamida-Pisal.

microcirculation by promoting capillary vasodilation.1,6 • Etamsylate (Dicynone): used in functional manifestations of venolymphatic insufficiency, impaired capillary fragility. Mesotherapy using etamsylate promotes drainage of the connective tissues and improves the state of the capillaries.1,6 Medicines for the connective tissue • Organic Silica (Conjonctyl): a 1% solution of sodium monomethyl trisilanol orthohydroxybenzoate. The active ingredient is conjonctyl salicylate monomethyltrisilanol, a digestible and bioavailable organic silica. This rebuilds the inner lining of the blood vessels and improves blood circulation. Silica used in mesotherapy implements the reorganisation of the architecture of the dermis. Conjonctyl will boost the synthesis of elastic tissue and thereby improve circulation.1,6 • Synthetic salmon calcitonin (Miacalcin): widely used in mesotherapy. It has a stimulating effect on the microcirculation

within the cellulite. However, practitioners need to be aware of potential side effects such as nausea and hot flushes, if the dosage is too high or if the vascular passage is fast.1 • Nutritional cocktail (NCTF 135): made-up of vitamins, minerals, amino acids and nucleic acids.

• Magnesium: for its nutritional and antioxidant properties.

Medicines for the lipolysis • Xanthine bases (Aminophylline): inhibitors of phosphodiesterase and thus act on lipolysis.7 • Caffeine: the use is dependent on each individual. During consultation the practitioner should find out if the patient has a known reaction to caffeine and advise accordingly. When using caffeine, always start with a low dose and only increase this if the patient does not have an adverse reaction.

How much and what percentage?

In most cases, the same quantity of each drug has to be mixed when the rules of

pharmacology permit. Calcitonin, the only hormone used in mesotherapy, is used with caution (50 international units in general) so as not to cause side effects associated with the molecule.6 The amount must be carefully calculated according to the surface area to be treated, usually 10ml.1 Where to inject?

Injections should occur in the areas that are normally affected by cellulite which are the stomach, upper thighs, inner areas of the upper thighs, inner knees and buttocks.

Practitioners should be aware that some areas where the skin is very thin may be sensitive and should be treated with caution.

What technique and how deep?

The injection is always intradermal and hypo i.e. between 3-6mm. The intradermal technique is most often used. In case of severe pain at the point of injection, the ‘point-by-point’ technique may be an alternative. Point-by-point is the technique to inject 0.05 to 0.1ml, meaning that there are less points of injection, less pain for the patient and generally produces

Reproduced from Aesthetics | Volume 3/Issue 6 - May 2016

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good diffusion. The use of an injector (for example, the mesogun) may aid the technique as it can offer more direct placement.

this often prevents us from achieving a good result. It is now widely acknowledged that stress can be a cause of cellulite and inhibit a good response to a treatment.1,3,6

How often?

The patient should be treated weekly for 10 to 12 weeks. The results are patient dependent, but usually seen at approximately the fifth week, with optimum results visible at the tenth or twelfth session. We advise our patients to undergo a maintenance treatment every six months.

Mesotherapy is not only a therapeutic treatment, but also a preventative technique for cellulite. Don’t hesitate to involve other means of mesotherapy because, as mentioned earlier, no effective technique is used in isolation.

Conclusion

Therapeutic protocols Firstly, it is important to remember that any cellulite treatment must have a treatment for general circulation, which needs to be performed every two weeks. On some occasions, it is also useful to treat the patient for stress, as an aggravating factor such as

Cellulite is not a disease but a chronic dysfunction and the reasons for its existence are multi-factorial. Mesotherapy is an effective treatment for cellulite and has been used for more than 50 years. The results are pleasing, however it is necessary to combine it with other treatments to achieve the best results.

These are selected based on the specific case of cellulite in each patient and the doctor’s knowledge and resources at their disposal. Performing mesotherapy requires precise technique and the practitioner needs to fully understand the procedure. As far as I am aware, all accidents referenced to date (including infection) are commonly due to negligence or malpractice of the practitioners and the methods they adopt. Finally, it is essential that the patient maintains a healthy lifestyle, participates in regular physical activity and eats a balanced diet in order to achieve optimal results each time.

Dr Philippe Hamida-Pisal is an aesthetic practitioner working in London and Paris. As well as being the president of the Society of Mesotherapy of the UK, the society partner of Euromedicom and IMCAS Paris, Dr Hamida-Pisal is a key note speaker at major industry events around the world; discussing the concept of beauty, the ageing process and ethnic skin.

REFERENCES 1. Le Coz J, Mesotherapy and Lipolysis: a comprehensive clinical approach, Dermatologic Surgery, 35 (2009), p.860.

2. Duncan D, Chubaty R, ‘Clinical safety Data and Standard of Practice for Injection Lipolysis: a retrospective study’, Aesthetic Surgery Journal, 2006.

3. Pinto R, ‘Mesosculpt with Phosphatidylcholine’, US Journal, 6 (2007), p.9.

4. Rotunda A, ‘JAAD 2005’, American Academy of Dermatology Inc. DOI:10.1016-2005.07.068.

5. Le Coz J et al, ‘Mesotherapie et medicine esthetique’, Editions Solal, 1998.

6. Hexsel Doris Maria, ‘Mazzuco Rosemar: surgical rounds; subcision: A treatment for cellulite’, International Journal od Dermatology, 39 (2000), pp.539-544.

7. Uzunov, P and Weiss, ‘Separation of multiple molecular forms of cyclic adenosine 3,5 monophosphate phosphodiesterase in rat cerebellum by polyacrylamide gel electrophoresis’, Biochim. Biophys. 284 (1972), pp.220-226.

FURTHER READING • Silva J, Update in mésocellulite. 9e congrès international de mésotherapie, Paris, 2000.

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The Role of Antioxidant Skincare in Post-Procedural Wound Healing Dr Firas Al-Niaimi is a leading Consultant Dermatologist and Laser Surgeon.

His most recent clinical research has focused on integrating cosmeceutical skincare to improve patient outcomes following laser skin rejuvenation treatment. Here, Dr Al-Niaimi gives some insight into the potential benefits: “Laser treatments are increasingly popular for skin rejuvenation, but what are some of the post-procedure challenges faced by practitioners?”

Whilst practitioners have seen around a 30% increase in popularity of laser treatments just within the last year,1 there remain significant post-procedural challenges – namely the length of post-operative downtime and potential unwanted complications, which can be a challenge in today’s busy society. Ablative laser treatments use high temperatures to vaporise unwanted tissue and can be very effective, however they usually require a lengthy recovery time. Non-ablative laser treatments are popular for skin rejuvenation and can help address photo-ageing and specific skin disorders. Average downtime is around three to five days with common side-effects including redness and swelling, which prevent patients from immediately resuming normal daily activities and can in some individuals have a major impact. Given that fractional lasers substantially deplete cutaneous antioxidants to a degree well beyond normal daily conditions, it may be impactful to deliver a greater amount of Vitamin C deeper into the skin in order to promote and accelerate proper wound healing and reduce recovery time.

“What is SkinCeuticals’ C E Ferulic and how does it address these concerns?”

C E Ferulic is a patented triple antioxidant formulation containing L-Ascorbic acid, vitamin E and Ferulic acid, designed to neutralise free radicals and protect against oxidative stress. It works by boosting the skin’s natural antioxidant defences and has antiinflammatory effects. L-Ascorbic acid inhibits ultraviolet and infrared radiation-induced damage and has shown in studies to reduce its associated erythema. I recently published all the evidence on the effects of topical vitamin C on the skin.2 Additionally, because Vitamin E has a lipophilic base it works together with the glycerine and sodium hyaluronate for a humectant effect, leading to increased skin hydration.3 For me, these properties make C E Ferulic a natural choice for post-procedural care following both ablative and nonablative laser treatments, as the versatility of this treatment and the high-potency ingredients can help accelerate skin repair and effectively reduce downtime for my patients without skin irritation.

“Has there been any research to show the efficacy of antioxidant cosmeceutical skincare in accelerating wound healing following laser treatments?”

Absolutely! A 2012 study by Kalista et al. initially demonstrated the efficacy of C E Ferulic in combination with a non-ablative laser in generating a more rapid healing response, with minimal downtime and efficacious clinical outcomes seen up to three months after a series of treatment.4 On average, redness and swelling resolved 29% faster compared to the laser alone group.4 In March this year, my team and I published a paper investigating the efficacy of C E 52

Ferulic in wound healing following a fractional ablative CO2 laser treatment.3 For the first time, we demonstrated that post-operative treatment with C E Ferulic resulted in accelerated wound-healing, with patients able to return to work and social activities at day five, as opposed to the typical seven to ten-day recovery timescale. Postoperative use of C E Ferulic resulted in decreased swelling at day seven, and decreased redness on days three and five, compared to vehicle. A significant increase in basic fibroblast growth factor (bFGF) at day five also highlighted a new biomarker to indicate the up-regulation of wound-healing factors in the skin. We were able to translate scientific research into daily clinical practice.

Figure 1: Laser Treatment Alone (Group 1)

Baseline

After treatment

Photos courtesy of Solta Medical

Figure 2: Laser + Topical Treatment Alone (Group 2)

Baseline

After treatment

Photos courtesy of Solta Medical

“How could these findings be used to improve clinical practice?”

I believe we now have sufficient published data, as well as a wealth of hands-on clinical experience to recommend that high-potency antioxidant cosmeceutical skincare, such as C E Ferulic, should be delivered as standard practice following both ablative and nonablative laser procedures. Concerns about extensive downtime and ability to resume daily activities are of pivotal importance to my patients, so I feel it is important to have a validated process in place to help accelerate wound healing and post-operative recovery. By including C E Ferulic as an immediate post-treatment intervention, I can reassure my patients that they should experience reduced swelling, redness and overall downtime, enabling them to get back to daily life more quickly. At the end of the day, happy patients are the lifeblood of my practice!

C E Ferulic from SkinCeuticals. RRP: £129 – 30ml SkinCeuticals Stockist Enquiries: www.skinceuticals.co.uk REFERENCES 1. LLP, P.M. (2015) Popularity of non-surgical cosmetic procedures soars as demand for cosmetic surgery falls. http://www.penningtons.co.uk/news-publications/latest-news/popularity-of-non-surgicalcosmetic-procedures-soars-as-demand-for-cosmetic-surgery-falls/ (Accessed: 22 March 2016).

2. Al-Niaimi F. The effects of topical vitamin C on the skin. PRiME January 2016.

3. Waibel, Mi, Ozog, Qu, Zhou, Rudnick, Al-Niami, Woodward, Campos, Mordon. Laser-Assisted Delivery of Vitamin C, Vitamin E, and Ferulic Acid Formula Serum Decreases Fractional Laser Postoperative Recovery by Increased Beta Fibroblast Growth Factor Expression. November, 2015.

4. Kalista, Oresajo, Guest, Loncaric, Struck. Clinical Results of Clear + Brilliant™ 1927 nm Laser Treatment Used with a Topical Skincare Regimen. May, 2012.

Aesthetics | May 2016

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Abstracts Clinical Papers

A summary of the latest clinical studies Title: Intense pulsed light versus photodynamic therapy using liposomal methylene blue gel for the treatment of truncal acne vulgaris: a comparative randomized split body study Authors: Moftah NH, Ibrahim SM, Wahba NH Published: Archives of Dermatological Research, March 2016 Keywords: Acne vulgaris, IPL, PDT Abstract: Acne vulgaris is an extremely common skin condition. It often leads to negative psychological consequences. Photodynamic therapy (PDT) using intense pulsed light has been introduced for effective treatment of acne. The objective was to study the effect of PDT in truncal acne vulgaris using liposomal methylene blue (LMB) versus IPL alone. Thirty-five patients with varying degrees of acne were treated with topical 0.1 % LMB hydrogel applied on the randomly selected one side of the back, and after 60 min the entire back was exposed to IPL. The procedure was done once weekly for three sessions and patients were re-evaluated 1 month after the third session by two independent dermatologists. Acne severity was graded using the Burton scale. Patient satisfaction using Cardiff Acne Disability Index (CADI) was recorded before and after treatment. On LMB-pretreated side, inflammatory acne lesion counts were significantly decreased by 56.40% compared with 34.06% on IPL alone. Marked improvement was seen on LMB-pretreated side in 11.5% of patients compared with 2.8% on IPL alone. There was a correlation between CADI score and overall improvement. Our study concluded that LMB-IPL is more effective than IPL alone, safe with tolerable pain in the treatment of acne vulgaris on the back.

Title: Combination of microneedling and 10% trichloroacetic acid peels in the management of infraorbital dark circles Authors: Kontochistopoulos G, Kouris A, Platsidaki E, Markantoni V, Gerodimou M, Antoniou C. Published: Journal of Cosmetic and Laser Therapy, March 2016 Keywords: Microneedling, skin peel, dark circles, periorbital area Abstract: Dark circles (DC), seen in the periorbital area, are defined as bilateral, round, homogeneous pigmented macules whose aetiology is thought to be multifactorial. Available treatments include bleaching creams, topical retinoic acid, chemical peels, lasers, autologous fat transplantation, injectable fillers and surgery (blepharoplasty).

Objective: to evaluate the efficacy and safety of a combination of microneedling and 10% trichloroacetic acid peels in the treatment of DC. Materials and methods: thirteen female patients with mild to severe infraorbital DC were included in the study. The patients were aged between 21 to 61 years. They were treated with Automatic microneedle therapy System-Handhold (AMTS-H, Mcure, Co.,Ltd) and topical application of 10% trichloroacetic acid solution to each infraorbital area for five minutes. The effect was photo-documented and a Patient and Physician Global Assessment was evaluated. Safety was assessed by evaluating early and delayed adverse events. Results: almost all patients showed significant aesthetic improvement. Both Physician and Patient Global Assessment rated a fair, good or excellent response in 92.3%. The procedure was well-tolerated. Mild discomfort, transient erythema and oedema were quite common during or immediately after the procedure. The patients were followed up regularly every month for four months, and no recurrence was recorded. Conclusion:

microneedling and 10% trichloroacetic acid constitute an innovative combination treatment for DC with encouraging results and minor side-effects.

Title: Key importance of compression properties in the biophysical characteristics of hyaluronic acid soft-tissue fillers Author: Gavard Molliard S, Albert S, Mondon K Published: J Mech Behav Biomed Mater Keywords: fibroblasts stimulation, hyaluronic acid, rheology, fillers, injectables Abstract: Hyaluronic acid (HA) soft-tissue fillers are the most popular degradable injectable products used for correcting skin depressions and restoring facial volume loss. In this article, three different rheological tests (shear-stress test and compression tests in static and dynamic mode) were carried out on nine CE-marked cross-linked HA fillers. Corresponding shear-stress (G’, tanδ) and compression (E’, tanδc, normal force FN) parameters were measured. We show here that the tested products behave differently under shear-stress and under compression even though they are used for the same indications. G’ showed the expected influence on the tissue volumising capacity, and the same influence was also observed for the compression parameters E’. In conclusion, HA soft-tissue fillers exhibit widely different biophysical characteristics and many variables contribute to their overall performance. The elastic modulus G’ is not the only critical parameter to consider amongst the rheological properties: the compression parameters E’ and FN also provide key information, which should be taken into account for a better prediction of clinical outcomes, especially for predicting the volumising capacity and probably the ability to stimulate collagen production by fibroblasts.

Title: Skin Remodeling Using Hyaluronic Acid Filler Injections in Photo-Aged Faces Authors: França Wanick FB, Almeida Issa MC, Luiz RR, Soares Filho PJ, Olej B. Published: Dermatologic Surgery, March 2016 Keywords: Hyaluronic acid, dermal filler, injection Abstract: Hyaluronic acid (HA) filler is an important dermatological procedure. Although many studies have reported clinical improvement with this procedure, histology with morphometric evidence is not well documented. Objective: evaluate the clinical and histological results of a HA filler injection and to quantify dermis remodeling at 3 and 9 months after HA injections into aged faces. Materials and methods: twenty patients were enrolled in this study. Hyaluronic acid filler was injected into the nasolabial folds and preauricular regions of the patients. Skin biopsies of the preauricular regions were performed before the procedure and at 3 and 9 months after the procedure.

Results: sixteen women (aged 40-50 years) completed the clinical study and demonstrated improvement for 12 months. Twenty patients completed the histologic studies. Morphologic evaluation showed increases in the epidermal layers. The morphometric study showed a statistically significant increase in collagen fibers at 3 and 9 months after the procedure (34.2% ± 31.5% and 39.5% ± 39.7%, respectively, p<.05). Conclusion: Sustained clinical results for HA filler can be explained not only by the presence of HA gel on the dermis but also by the dermal remodeling induced by HA filler injected into the face.

Reproduced from Aesthetics | Volume 3/Issue 6 - May 2016

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Entry for the Aesthetics Awards 2016 is now open Aesthetic professionals from across the UK are invited to submit their entry for the most prestigious awards ceremony in the medical aesthetic calendar The Aesthetics Awards is the perfect opportunity to celebrate the developments and achievements of our unique specialty in 2016.

Finalists and winners will be recognised for their services to the industry in 24 renowned categories, with awards presented to those who have worked hard to represent the highest standards in clinical excellence, product innovation and practice achievement.

Following much success last year, the ceremony will once again be held at the Park Plaza Westminster Bridge Hotel in central London on Saturday December 3.

The unmissable evening will consist of a drinks reception, entertainment from a top comedian and a delicious three-course

dinner before the main awards presentations take place, which will then be followed by music and dancing late into the night.

Why should I enter?

Entering the Aesthetics Awards is an excellent opportunity to celebrate the successes and achievements of your business. Being shortlisted as a finalist or chosen as a winner of an award is a great marketing tool, enabling you to show potential and existing clients why you stand out from your competitors in this fast-growing sector. Entry will be open until June 30, with finalists announced on September 1 on the Aesthetics Awards website and in the Aesthetics journal.

The Aesthetics Awards 2016 categories Cosmeceutical Range/Product of the Year This award will be given to the manufacturer or UK distributor of the best cosmeceutical product or product range, retailed in UK medical aesthetics clinics.

The judges will select finalists who show evidence that their product is effective, safe, easy-to-use and well accepted by patients.

Treatment of the Year This award will be given to the manufacturer or supplier considered to offer the best medical aesthetic treatment in the UK. The category is open to any treatment offered in UK medical aesthetic clinics. Finalists will be able to demonstrate a wide range of indications, evidence of good safety and efficacy, optimum duration and tangible benefits over similar treatments on the market.

Best Treatment Partner The Sterimedix Award for Injectable Product of the Year This award will be given to the manufacturer or UK distributor of the injectable product deemed to be the best-in-class available on the UK market.

Finalists will be chosen from products that support a wide range of indications and can show evidence of good safety and efficacy, optimum duration and tangible benefits over similar products on the market.

This award is for the manufacturer or UK distributor of the product or device deemed to offer the best support for medical aesthetic treatment. The judges will look for those who can show evidence that their product is effective, safe, well accepted by patients and enhances or prolongs the effect of aesthetic treatment.

Equipment Supplier of the Year This award is for the manufacturer or UK distributor of the product or device deemed

to offer the best support for medical aesthetic treatment. The judges will look for those who can show evidence that their product is effective, safe, well accepted by patients and enhances or prolongs the effect of aesthetic treatment.

Distributor of the Year This award acknowledges the vital role played

by UK distributors who bring new, international products and treatments to the UK medical aesthetic market. Finalists will be selected on the basis of their customer service, product range and services to the industry.

Best Customer Service by a Manufacturer/Supplier This award acknowledges the manufacturer or supplier that has offered outstanding customer service and aftersales support in the last 12 months. In choosing finalists, the Aesthetics team will look for specific examples of outstanding customer service, as well as initiatives aimed at improving and maintaining customer service, consistent supply and aftersales support.

Reproduced from Aesthetics | Volume 3/Issue 6 - May 2016

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Association/Industry Body of the Year This award recognises the important role that professional associations and industry bodies play in supporting the development of their members and the profession as a whole.

In selecting finalists, the Aesthetics team will look for tangible member benefits and evidence of strong activity designed to support members and the profession/industry as a whole.

The Healthxchange Pharmacy Award for Sales Representative of the Year

This category is designed to recognise the valuable contribution that sales representatives make to their industry, their customers, and, ultimately, their patients. Finalists will be able to show outstanding levels of support for their customers, a strong commitment to their industry and a proven ability to assist clinics in supporting patients and growing sales of their products.

duction Fat Re

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

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Skin Tighten

Cellulite

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

The award for Best New Clinic is open to any clinic in the UK and Why choose after 3D-lipo?1 January 2015. The best new Ireland that was established clinic will be judged on initiatives designed to promote growth, evidence of commitment to customer service, patient care and patient safety, and good feedback from customers/patients.

Aesthetics

How to enter All entries must be made via the Aesthetics Awards website. You can enter in as many categories as you wish but you may only enter yourself, a company you work for, an employee who works for your company or a product made or distributed by your company. Entries made on behalf of a third party will not be accepted. You may only enter each category once. Multiple entry forms for the same clinic, company, individual, treatment or product will be disregarded. All entries must be accompanied by the supporting evidence requested in the entry form. The information provided will be used to choose the lists of finalists and by the judges when voting on a winner. Late entries will be charged with an administration fee at £100 plus VAT per entry. Amendments to existing entries will also be subject to a charge of £100 plus VAT. Additions and amendments will only be accepted if the shortlisting process has not already begun and the decision of whether to accept these is at the organiser’s discretion.

How will winners be selected?

Entries will close on June 30, with the finalists announced online and in the September issue of the Aesthetics journal. A process of voting and judging will take place to select the winners. Aesthetics journal reader votes will constitute a percentage of the final score for each finalist in the following categories: • • • • • • • •

Cosmeceutical Range/Product of the Year The Sterimedix Award for Injectable Product of the Year Treatment of the Year Best Treatment Partner Equipment Supplier of the Year Distributor of the Year Best Customer Service by a Manufacturer/Supplier The Healthxchange Pharmacy Award for Sales Representative of the Year • Association/Industry Body of the Year

Cavitation

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Cryolipolysis

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

Radio Frequency Skin Tightening

Focus Fractional RF is the 3rd generation of RF technology. It utilises three or more pole/electrodes to deliver the RF energy under the

skin. This energy is controlled and limited to the treatment area. Key advantages of this technology are high treatment efficacy, no pain as less energy is required, shorter treatment services and variable depths of penetration.

3D Dermology Combines pulsed variable vacuum and skin rolling for the effective treatment of cellulite.

Best Clinic Awards What the experts say...

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

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The results of these votes will be combined with scores from an expert judging panel, selected by Aesthetics, to decide the winner.

Winners in the following categories will be decided by assessment from the judging panel alone:

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Best Clinic categories at the Aesthetics Awards are awarded regionally. These awards are open to any clinic in the UK & Ireland that has been open for more than 12 months and will be judged on commitment to excellence in customer service, patient care and patient safety, and evidence of good feedback from customers/patients.

The SkinCeuticals Award for Best Clinic Ireland

The Med-fx Award for Best Clinic London

The Lynton Lasers Award for Best Clinic South England

The Wigmore Medical Award for Best Clinic North England

• • • • • • • • • • • • • •

The 3D-lipo Award for Best New Clinic, UK and Ireland Best Clinic Scotland The Wigmore Medical Award for Best Clinic North England The Lynton Lasers Award for Best Clinic South England The Med-fx Award for Best Clinic London Best Clinic Wales The SkinCeuticals Award for Best Clinic Ireland The AestheticSource Award for Best Clinic Group UK & Ireland (3 clinics or more) The Swisscode Award for Best Clinic Group UK & Ireland (10 clinics or more) Clinic Reception Team of the Year The Enhance Insurance Award for Training Initiative of the Year The Institute Hyalual Award for Aesthetic Nurse Practitioner of the Year The Dermalux Award for Aesthetic Medical Practitioner of the Year The Barry Knapp Award for Product Innovation, supported by Oxygenetix

The winner of The Schuco International Award for Special Achievement will be selected by Aesthetics and will be announced on the night without an entry process.

Reproduced from Aesthetics | Volume 3/Issue 6 - May 2016

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Best Clinic Scotland Best Clinic Wales

Best Clinic Group UK & Ireland These prestigious awards are open to any clinic group in the UK and Ireland with either more than 3 clinics (but less than 10) or 10 clinics or more. The group will be judged as a whole on commitment to excellence in customer service, patient care and patient safety, and evidence of good feedback from customers/patients.

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

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

Clinic Reception Team of the Year This award is open to reception teams of any size working in a clinic in the UK or Ireland. In selecting finalists and a winner, the judges will look for evidence of ongoing, outstanding customer service, a continuous training programme, strong practitioner support and effective teamwork for the benefit of the clinic and it patients.

The Enhance Insurance Award for Training Initiative of the Year

Enhance Insurance

|

Advice

|

Support

This award will be presented to the training provider or individual trainer whose training programme is considered to have advanced the education of medical aesthetic professionals most effectively during the last 12 months. Judges will look for engaging methods of delivery, a high-quality, relevant, generic programme, a continuous development and improvement system, and achievement of measurable outcomes by delegates.

last 12 months. The winner will be judged on their clinical expertise, continuous professional development, commitment to patient safety and the difference they make to their patients, clinic and the profession as a whole.

The Dermalux Award for Medical Aesthetic Practitioner of the Year

This award will recognise the aesthetic doctor, dentist, dermatologist or surgeon who is deemed to have contributed most to the profession and/or has provided the most outstanding care and treatment to their patients in the last 12 months. The winner will be judged on their clinical expertise, continuous professional development, commitment to patient safety and the difference they make to their patients, clinic and the profession as a whole.

The Barry Knapp Award for Product Innovation, supported by Oxygenetix

This award recognises the most innovative and dynamic products on the market. Eligible products must have been launched into the UK market after January 1 2015. The judges will look for genuine innovation or product advancement leading to treatment for new indications, quicker or easier treatments, better treatment outcomes, enhanced patient safety, all backed up by sound evidence.

The Schuco International Award for Special Achievement

The Institute Hyalual Award for Aesthetic Nurse Practitioner of the Year

This award will recognise the aesthetic nurse who is deemed to have contributed most to the profession and/or has provided the most outstanding care and treatment to his or her patients in the

This award recognises the outstanding achievements and significant contribution to the profession and industry by an individual with a distinguished career in medical aesthetics. The Aesthetics team will select the winner of this category. Individual entries are not accepted.

WWW.AESTHETICSAWARDS.COM Reproduced from Aesthetics | Volume 3/Issue 6 - May 2016

Silkann.

Aesthetic cannula innovations from Sterimedix. A world leader in single-use surgical products Silkann is a comprehensive range of twin-packed Sterimedix flexible aesthetic cannulas and sharp needles - designed for operational efficiency and with your patients’ comfort in mind.

Each cannula with screw thread polycarbonate hub, is supplied with a slightly larger sharp pre-hole needle, giving practitioners the perfect match between cannula and needle to ensure maximium accuracy whilst maintaining optimum patient comfort.

• A new and unique screw type hub manufactured using polycarbonate to reduce the risk of cannula detachment.

• Indicator on the hub to show orientation of the port during injection.

Aest hetic Cann ula a nd Sh arp N eedle Sets Fat T ransf er Ca nnula s

• The best port quality and consistency of port position, to remove risks during procedures.

• Ports designed to optimise the flow and performance of fillers whilst reducing injection forces.

• The highest quality of packaging to maintain the integrity of the cannulas at all times.

Available to buy online

www.AestheticCannula.com Shar p Ne edles

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Entering Awards Clinic operations director Amanda Elbourn details the value of entering industry awards and shares her tips for creating a successful entry The multi-billion pound medical aesthetics industry encompasses a complex array of businesses, clinics, products, treatments and individual professionals under one deceptively simplistic term. The popularity of the industry has risen exponentially in the past two decades and, as a result, recognised regulations and guidelines have been established to ensure higher standards of safety and efficacy for the benefit of both the patient and the professional. Although these regulations have revolutionised general practice, it is the use of industry awards that have further cemented the quality of medical aesthetics in the UK as we know it today.

There are numerous nationally recognised awards bodies that celebrate the most accomplished businesses within medical aesthetics, including MyFaceMyBody, the Professional Beauty Awards, the Aesthetic Dentistry Awards and the Aesthetics Awards. The Aesthetics Awards is an annual event that had 24 awards categories in 2015, including best clinic, best product, best supplier, best sales representative, best training initiative and best practitioner. It is a renowned honour to win within the industry and can be incredibly beneficial for the recipient.

Our experience With eleven clinics nationwide, Courthouse Clinics was entered into the award categories for 2015 that recognised our chain as a whole with a focus on two particular campaigns: the MyFaceMyBody Awards and the Aesthetics Awards. It was a combined effort of the whole group, for which we maintained weekly updates of our voting progress so that the staff could regularly communicate with our patients regarding the awards. It is testament to the dedication and hard work of all of our staff, including front-of-house, medical aestheticians, clinic managers, nurses and doctors that Courthouse Clinics managed to secure these two national awards.

Courthouse Clinics was successful in winning both The Swisscode Award for Best Clinic Group UK and Ireland (with ten clinics or more) at the Aesthetic Awards and Best Clinic Chain at the MyFaceMyBody Awards. Aesthetics is all about repeat business and winning awards cements trust, which is proven by our high number of returning patients. The awards event itself is an exciting evening filled with great anticipation and anxiety, the industry recognition is wholeheartedly demonstrated, and it was with great pride that we could inform all of our staff that we were winners.

The stress and hard work dissolves into a distant memory when you are holding up your industry trophy and we are now proudly displaying the awards in our flagship Wimpole Street clinic with certificates at all sites.

Why should I enter?

There is enormous value in being nominated for an award and, of course, even more so, in winning. On a personal level it brings unity to your team as your hard work

Aesthetics aestheticsjournal.com

has been officially recognised, it builds confidence in performance and is a positive confirmation that you are successful in a highly competitive industry. On a larger scale, awards ceremonies are an opportunity to showcase your business to the industry, an opportunity for free PR and the ultimate trust builders for new and current patients.

Different awards will of course bring different benefits to your company. Some awards may even prove to be relatively ineffective to your business on the whole, so before you put together a campaign ensure that you determine what exactly you want to achieve with the award: • Why and how will it benefit you as a company?

• What are you seeking to achieve with the use of awards?

• Is the award prestigious enough to impact you?

Awards categories tend to cover all areas of the industry and include products and equipment, treatments, practitioners and representatives, suppliers and manufacturers, clinics, teams and training – plus a special recognition award.

It is also beneficial to consider what the award might be able to do for your company in terms of revenue and reputation; is the awards body well respected within the industry? Will they support you with winners’ marketing material, so you can showcase your win to patients and industry professionals following the ceremony?

If you decide that the award is worthwhile, always read the rules and regulations of the entry before taking any further steps. Breakdown each requirement so that you are sure that you will be able to fulfil the criteria sought by the awards body. Once this is established, you must consider whether you are able to take on the challenge of competing for an award. How much workload will it create and will you be able to cope with this on top of your day-to-day tasks? Specifically, is this manageable for your marketing team or your staff if there is to be a mystery shop? I would recommend delegating one person to marketing the awards and, ensuring all voting links provided by the awards body are shared with the relevant people.

When entering awards it is also important to consider your staff; ensure that they understand the importance of winning the award, and what it means to them and to the company. Let them know that each and every one of them pays a vital role in securing not only an awards win, but also ensuring the day-to-day success of the clinic. You will need a well-communicated plan and must also consider the cost of entering the awards. This goes beyond the entry itself – will you be able to attend the award ceremony? Who will go the event? Can you justify the time spent on managing the award campaign? Once you have considered all of the above, and decided upon which awards ceremonies and categories you’re going to enter, you can confidently move forward with the entry process.

Reproduced from Aesthetics | Volume 3/Issue 6 - May 2016

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Entering When entering awards it is important to spend time and deliberate carefully over the application process for each one you enter. Your successes will not represent themselves, so this is an ideal task for your marketing team to be able to verify your expertise and your uniqueness as a business in a succinct and clear manner. It is important to discern how you want to portray your business and to ensure this is achieved confidently and professionally. Perhaps the most important first stage of this is to formulate the key achievements that your business has had over the past twelve months and to use these points as a basis for your application. It is integral that you understand and appreciate the judging criteria for the award you are entering. Consider: • What are the judges asking from you?

• What are they looking for?

• What would they be impressed with from your achievements that would beat the competition?

In addition, do not forget to research the previous year’s winner as well to see what tactics they used to help secure their win.

Consider the judging process There are many formats in which an award can be judged but, primarily, a panel of experts, some form of voting system or a combination of the two will be used. If the award you are campaigning for requires votes, you will need to focus your efforts heavily on industry support, patient feedback and social media outlets. If the awards ceremony you are entering relies on patient votes, you need to inform your patients that you have been shortlisted for an award and encourage them to vote for you by providing them with as much information and support as possible, to ensure the process is quick and simple. It may be worth creating an incentive such as a prize draw for your patients that all voters will be entered into – rewarding patients for their loyalty is a great way of building your reputation in the run up to an award ceremony. Other awards ceremonies, particularly the Aesthetics Awards, rely on judging from people working within the medical aesthetics industry. As such, it is essential to inform your suppliers and industry peers that you have been shortlisted for an award, as it is an opportunity to use successful partnerships to progress yourselves in this industry. The simplest way in which to do this is via email, perhaps with reference to a more detailed page on your website concerning the award, as well as logos within email signatures and banners on your website. For some categories in certain awards ceremonies, there will be the possibility of a mystery shop. There are many ways that you can effectively prepare in advance for this to ensure that you and your staff are well represented. Initially, discussing the prospect of a mystery shop with your staff is a must to determine expectations and to iron out any problems you might expect. Performing in-house mystery shops as a form of practice will be a great experience and preparation for the real thing, which is something that is hugely beneficial to ensure your patient experience is achieving the desired level. Managing this at multiple sites requires the support of local managers and their teams to ensure that each clinic or site is prepared, and is delivering gold standard care.

Use examples When formulating an award-winning campaign, the judges’ time is an important factor that should mould your strategy almost completely.

You want to be able to deliver a lot of information quickly that is both

Aesthetics

interesting and intriguing. There are many ways that you can do this, the most obvious of which is to use everyday examples of your achievements to add a human element to your application. If the category you are entering relates to the success of your clinic or your work as a practitioner, use as many of your patients’ personal stories as possible to express the difference your business has made to the lives of those you treat. Alternatively, if you are entering a category that relates to internal work within the industry, such as the launch of a new skincare range, product innovation, training course or your work as a sales representative, use the same formula, but instead consider how your work has benefitted the industry. Have your clients retained more patients since incorporating your treatment or product into their clinic? Have your students gone on to build successful practices after attending your training course? Using examples is an excellent way to ensure your winning value gets across to the judges.

Incorporate data Providing substantial data can also make your application stand out, whether that be the percentage rise of returning patients, data from patient or client satisfaction surveys, or an increase in revenue. It is an uncomplicated and incontestable approach to showing positive improvement in your business. You need to be able to strongly demonstrate how you stand out from your competitors.

Share the news Social media is an integral tool that has almost become the most important form of communication for businesses, particularly for the aesthetic industry. These platforms share information instantaneously to its users in a way that nothing before it has, enabling businesses to keep their clients up to date with anything they may need to know. When it comes to awards, particularly if they are determined by customer votes, the information provided must be as direct and simplistic as possible. A curt ‘please click here to vote for us’ is more likely to earn a vote than a lengthy letter or telephone call. Emails and newsletters are similarly useful to earn votes, although these are typically less engaging than Facebook or Twitter. The most important point is that the information about the award you are shortlisted for is provided to your customers in a form that is easy to find, easy to understand and easy to act upon.

Value of entering If you have the time and resources to allocate to the task, winning an award is an incredibly beneficial asset for any business. Simply being able to state that your business is award-winning can increase interest and is an ideal trust builder for new patients. Suppliers recognise your commitment to the industry and actively seek to continue partnerships and strengthen relationships. This is a clear opportunity to showcase your clinic or clinics, the treatments you offer, treatment results, patient satisfaction, recognition of standards and compliance. Staff morale is increased and you will develop a robust reputation with increased attraction when recruiting new staff to work for an award-winning chain or team. In my personal experience with Courthouse Clinics, I can safely say that it is well worth the effort!

Amanda Elbourn is the RGN/RSCN operations director for Courthouse Clinics. She has worked in the aesthetics industry for 12 years, initially as a nurse practitioner before moving toward the management sector of the industry. Presently she is responsible for the day-to-day running of all clinics within the Courthouse group.

Reproduced from Aesthetics | Volume 3/Issue 6 - May 2016

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Skin Imaging Dr Anita Sturnham discusses the benefits of incorporating surface imaging technology in a clinic for help with medical assessments and treatment plans During my journey as a skin specialist and general practitioner over the last 12 years, I have practised evidence-based medicine, always believing that assessing and monitoring a patient’s progress throughout their treatment plan is an essential and important part of any medical practitioner’s role.

I have always followed an analytical approach in my medical practice, with the use of blood tests, scans and x-rays to follow a patient’s journey. However, in my previous skin clinics, both in the NHS and in private settings, my ability to diagnose and monitor skin conditions had been limited by a lack of diagnostic equipment and technology, preventing me from accurately recording, assessing and followingup my patients. When launching my clinic, Nuriss Skincare and Wellness Centre, I wanted to create an advanced skincare and wellness centre that reflects this same methodology, using cutting-edge technology to aid diagnosis and patient care. I wanted to introduce a reliable imaging system, which would allow me to monitor a patient’s baseline skin condition and, in turn, use this data to assess progress throughout their treatment course. Many of my peers in the UK were not using imaging devices in their practice, but from my time spent researching in the US, it seemed to be common place, as well as beneficial, to have this technology in-house.

Using surface imaging Surface imaging enables the possibility to capture high quality, consistent and repeatable facial images and provides an insight into your patient’s skin. The images provide information that routine examination alone would not be able to establish (Figure 1).4

Figure 1: Standard photography imaging positions for skin assessment, showing frontal, left and right sided facial views4

When a patient comes to see me for their initial skin consultation, after taking a full medical history and assessing their diet and lifestyle factors, all patients have a skin scan. The process is quick, taking a matter of minutes to complete. The results provide me with the information needed to design a tailor-made homecare and clinic treatment programme, to suit their specific skin needs. The system I use utilises a patented comparison for analysis (Figure 2).4 By inputting your patient’s age, sex and skin type details into the system, their results are compared to the world’s largest skin database. This allows me to grade my patient’s skin relative to others of the same age and skin type and therefore enables me to establish their skin strengths and weaknesses. My patients love this personal Figure 2: Discussion of scan results in a skin consultation

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and bespoke approach. The process also allows me to really engage with my patients, and provides the opportunity for me to educate and empower them, so that when they leave my clinic, they are armed with the information they need to understand their skin better and look after it appropriately moving forwards.

There are several features of surface imaging that I use regularly and find extremely helpful. These include the skin scanner, skin analyser feature, the simulator mode, and the personalised information printout, which are features only found in the particular device I chose to incorporate in my clinic.

The skin scanner My philosophy at Nuriss focuses on the importance of feeding the body and the skin with the right nutrients it needs to be healthy. Our skincare plays an important role in the appearance of our skin.

As part of my treatment plans, I therefore design a ‘day’ and ‘night’ skincare regimen for my patients, which targets their skin concerns and the issues identified in their scan.7 The skin scan also gives the opportunity to assess a patient’s progress at various stages of their treatment plan, allowing adjustments in their programme if the desired improvements haven’t been noted. The system enables me to take identical images at return visits, resulting in a reliable assessment tool that can provide ‘side-by-side’ results comparing past with present.

The skin analyser The skin analyser enables me to assess the following parameters of skin health (Figure 3): • Spots: assesses superficial brown and red lesions, including acne scars, hyperpigmentation and vascular lesions.

• Wrinkles: assesses folds or wrinkles in the skin, assessing fine and deeper lines.

• Texture: assesses the ‘smoothness’ of the skin.

• Pores: the circular surface openings of the sweat glands.

• UV: assesses UV damage.

• Brown pigment: assesses hyperpigmentation, freckles, lentigines and melasma.

• Red pigment: assesses a variety of conditions such as acne, rosacea, telangiectasia and inflammation.

• Porphyins: assesses bacterial excretions that can be causative factors of conditions such as acne.

The simulator The simulator mode enables me to calculate an individual’s ageing process, creating a predicted image of the patient five to seven years on. This predicts the changes one may expect to see with their pigmentation and wrinkles, assuming no additional skin intervention.

I find this module particularly useful. It highlights the ‘problem areas’ and helps both the clinician and the patient to focus their efforts on treating the key areas of concern. I find it a great tool to boost a patient compliance with a treatment programme.

Reproduced from Aesthetics | Volume 3/Issue 6 - May 2016

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Spots

Texture

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Wrinkles

Pores

UV Spots

Red areas

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Brown spots

Porphyrins

Figure 3: Example of parameters assessed during the surface imaging assessment4

Case Study 1: Patient A 45-year-old female Fitzpatrick 1 Concerns: rosacea and sensitive skin Onset: gradual worsening over the past five years Skincare: a well-known high street brand. Products included a foaming cleanser, alcohol-based toner, oil-based day cream and facial oil, which was used at night • Non-smoker, occasional alcohol, minimal caffeine intake • Medical history: nil else of significance • Surface imaging results: significant redness and pigmentation, increased pores and porphyrin load • • • • •

The results of the surfacing imaging made me feel that Patient A’s daily skincare products were exacerbating her problems. Sometimes, simply altering a patient’s skincare regimen can improve their skin condition, without the need for moving on to more advanced clinic treatments, such as laser. Foaming cleansers, containing sodium laurel sulphate and the alcoholbased toners are common culprits for skin redness and inflammation. My strategy with rosacea and sensitive skin sufferers is to remove any harsh products and common skin irritants and to follow the ‘less is more’ approach. I advised her to stop using her high street brands and switch to using a gentle wheat germ cleanser, a water-based toner and non-comedogenic day cream, containing mineral SPF zinc oxide. It is important to remember that the pathophysiology of rosacea often stems from the pilosebaceous unit, with an overgrowth of the demodex mite seen in the pores.8 I therefore recommended removing any comedogenic, oil-based products and I introduced a gentle retinol and hyaluronic acid formulation to use at night time. Her skin scans were taken at the initial consult and then repeated eight weeks later. Making a simple change to the skincare regimen resulted in a significant reduction in redness as well as reducing the appearance of fine lines and wrinkles. Having the opportunity to reassess the skin in this way, and to show improvement in such a short period of time, fuelled this patient’s motivation to continue her efforts to use the new products. It also enabled me the opportunity to discuss other clinic treatments that could be of benefit. When a patient sees improvements, this cements their trust in my recommendations and they are more likely to return for further treatments.

Personalised reports At the end of the consultation, patients receive a personalised and informative printout of their results. I have programmed my analysis system so that all of our

skincare products are placed into the built-in skincare catalogue. Once I have established a patient’s skin strengths and weaknesses, I can then select the appropriate products, highlighting key active ingredients that may be beneficial for them to use as part of their daily skincare regimen. I have found this to be a great upselling tool. In my opinion, patients don’t just want to be told what their problems are, they also want to know how they can improve things.

Another benefit of using surface imaging is that it acts as a motivational tool and often helps to support my product and clinic treatment recommendations. A new patient may be reluctant to stop using his/her current skincare products, despite the scan results suggesting that they are potentially doing more harm than good. The scan is also a good way of documenting a patient’s skin health for medico-legal reasons before starting a skin programme, to ensure accurate comparisons pre and post treatments. Case Studies 1 and 2 are studies that I have worked on which illustrates how to make use of a skin surface imaging device in a clinic.

Types of imaging devices Various skin imaging devices have been developed to enable photography and assessment of the skin.1 Standard photography imaging systems This uses a camera to deliver visible light to the skin by direct or diffuse illumination.1 Angled lighting is used to generate a gradient of the illuminating field on the skin in order to assess fine lines and wrinkles.5 Polarised light photography This allows assessment of surface and subsurface features of the skin.1 A polarising filter is placed both in front of the flash unit, and in front of the camera. When the polarising filters are in the same orientation with each other, surface features of the skin such as texture, pores, fine lines and wrinkles are visually enhanced.2 When the polarising filters are aligned perpendicular to each other, subsurface features of the skin such as inflammation, red and brown pigmentation and blood vessels are visually enhanced.5 Ultraviolet photography This allows for assessment of pigmentation and bacteria, Propionibacterium acnes. The flash unit is filtered to produce ultraviolet A light and the camera is filtered so that only visible light enters the lens. There are variations of UV photography devices available; some also record the reflected UV light to assess distribution of pigment.2 Choosing a device Looking at the case studies, it should be evident that there is a benefit of incorporating this type of technology into a clinic. Once you have decided

Reproduced from Aesthetics | Volume 3/Issue 6 - May 2016

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Case Study 2: Patient B • 34-year-old female • Fitzpatrick 3 • Concerns: post-inflammatory hyperpigmentation, secondary to acne lesions • Treatments tried: been to various clinics and had chemical peels, with worsening of the pigmentation • Skincare regimen: simple skincare wipes, argan oil at night • No medication, no other significant health problems During my assessment, I established that Patient B’s pigmentation was likely to be secondary to the inflammation triggered by her acne breakouts. My first strategy was to establish the cause for her breakouts and to treat these. Her visual imaging scan provided useful information including an excessive pore count and porphyrin load. I therefore suggested a strategy to target these areas identified: a salicylic acid based cleanser, topical benzoyl peroxide and clindamycin cream, and advised her to stop all facial oils. Her skin analysis also identified both superficial and deep brown pigmentation, allowing me to identify an appropriate strategy to target the different depths of pigment. I designed a homecare skin regimen, which used a twice-daily alpha arbutin treatment to stabilise the melanocytes and a retinol night cream. Retinol provides additional pigment-stabilising properties. To target the deeper pigmentation, we performed a number of laser treatments using a 1064nm laser, every two weeks. After six sessions, I performed two glycolic peels over a two-month period, to target the superficial pigmentation.

Her results at this stage are encouraging, with more than 50% reduction in pigmentation shown in the visual imaging scan results. We will repeat her scan in six weeks’ time.

to introduce a surface imaging device, you must be aware of the different types of devices available. When choosing a surface imaging device, careful research must be conducted to determine which one is best for you. You need to identify the parameters you wish to assess. For example, if you are only interested in assessing UV damage, then a UV Imaging device will suffice. If you are looking to assess epidermal and sub-epidermal factors, you will need a more advanced polarised and UV imaging system. When choosing my device, I decided I wanted to use it for all new skin consultations to ensure uniform assessment of my patients and to allow the opportunity to design tailor-made skin treatment plans to suit an individual’s skin needs. Skin scans also provide an excellent way of monitoring a patient’s progress throughout their treatment programme. My choice was based on many factors, including peer reviews and my own testing of various devices on the market.

I selected the The Visia analysis system, which combines both polarised light photography and UV photography, to photograph, analyse and document parameters relating to the skin’s health.4 This system also comes with a selection of advanced 3D visual tools, eyelash analysis, side-by-side comparisons, skin simulation and a ‘Tru skin age’ module,4 which estimates the approximate age of the patient’s skin, based on their results. In my opinion, this provides a revolutionary new metric to guide the selection of skincare products and treatment options.4 Other popular devices on the market include Beauvisage and Image Pro.6

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When choosing my device, I decided I wanted to use it for all new skin consultations to ensure uniform assessment of my patients and to allow the opportunity to design tailor-made skin treatment plans to suit an individual’s skin needs A place for surfacing imaging in aesthetic clinics I believe surface imaging systems to be a useful adjunct to any dermatology or medical aesthetics clinic. Not only does surface imaging allow me to carefully assess and document a new patient’s skin health, it allows me to formulate tailor-made treatment programmes to target key problem areas. It also enables me to monitor patients’ progress throughout their treatment programme.

In addition, I find the scan results to be a great motivational tool for my patients. My advice to any clinician considering the introduction of a skin analysis system into their clinic, is to do your research, invite sales representatives to visit your clinic and trial a few devices before purchase.

Dr Anita Sturnham is a GP and specialist dermatologist.

She is an ambassador for Unilever skincare and a medical expert for Superdrug, previously appearing on television to share her expertise. She currently works as a general and aesthetic practitioner, combining NHS duties with private practice at her clinic, Nuriss Skincare and Wellness Centre in London.

REFERENCE: 1. Merola,K, Kollias, N, Pote, JS, Payonk, G, Method of promoting skin care products, (2005) <http:// www.google.com/patents/US6922523> 2. Kligman, A, Fulton, J, ‘Ultraviolet Photography Serves as Both Predictor and Educator,’ Cosmetic Dermatology 10(1997), pp.31-33.

3. Lucchina, L, Kollias, N, Gillies, R, et al ‘Fluorescence photography in the evaluation of acne,’ Journal of the American Academy of Dermatology 35(1996), pp.58-63.

4. ‘Redefining the Vision of Skin Care,’ Canfield Imaging Systems, (2016) <http://www.canfieldsci.com/ imaging-systems/visia-complexion-analysis> 5. Muccini J, et al. ‘Polarized light photography in the evaluation of photoaging’ Journal of the American Academy of Dermatology, 33(1995) pp. 765-769.

6. Image Pro I: Our Most Affordable Skin Imaging System, IMAGE Innovative imaging solutions <http:// www.emagemedical.com/image-pro-i/> 7. ‘The Patient Journey,’ NURISS, <https://www.nuriss.co.uk/clinic/patient-journey/> 8. Cribier B, ‘Pathophysiology of rosacea: redness, telangiectasia, and rosacea,’ Ann Dermatol Venereol (2011).

Reproduced from Aesthetics | Volume 3/Issue 6 - May 2016

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Personal Wellbeing Education Independent nurse prescriber Jodie Grove details the benefits of offering patients psychological referrals in aesthetic clinics Treating patients in the aesthetic world is all about correcting the physical appearance of an individual, however, it is also important to consider the psychological reasons that patients may seek aesthetic treatments. In my clinic, I have recently introduced personal wellbeing care to my patients in order to further support them on their aesthetic journey. Many of our patients will be seeking aesthetic treatment to not only enhance their appearance, but to address deeper psychological issues. From my experience as a nurse, much like most of you reading this article, I have developed the ability to understand and empathise with people who are suffering from low self-esteem and lack of confidence. As medical professionals, I believe it is our duty to manage these concerns and offer appropriate treatment and support. In this article I will discuss exactly what personal wellbeing in a clinic environment entails, along with the benefits, the challenges, and the importance of educating both practitioners and patients in this approach to patient care.

Importance of personal wellbeing for patient health The Department of Health states that:1 • Personal wellbeing is associated with a 19% reduction in all-cause mortality in healthy populations • Individuals with high personal wellbeing are more likely to recover and survive from illness

• Personal wellbeing can add 4-10 years to life Taking these facts into consideration, when a patient comes to my clinic for aesthetic treatments, during the first consultation I will spend considerable time not just talking about the treatments that they want, but, most importantly, identifying what has made them walk through my door.

In many instances, during this one-toone discussion, I find that the patient has underlying reasons that have made them seek aesthetic treatment. In addition to issues such as lack of confidence, selfesteem and low self-worth, other triggers include people who are unhappy with their appearance due to age, weight gain or weight loss and relationship break-ups. In these circumstances, I take time to consider whether the patient’s wellbeing will improve with aesthetic treatment or if they need more specific support to deal with emotional issues.

The consultation During the initial consultation, discuss the reason for your patient’s visit; use the listening skills you have picked up over the years as a practitioner. The detail the patient goes into can often involve them disclosing the deeper triggers for treatment, which can lead them to require emotional support, hence the approach needs to be gentle. I recommend drawing upon personal experiences to relate to the patient. Strive to

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open an honest and sympathetic discussion about the reasons they are seeking treatments and then introduce the concept of personal wellbeing as an addition to seeking physical improvements, if appropriate. It is important to ensure that you do not make your patient feel uncomfortable or that they are psychoanalysed when they come to see you through ‘inappropriate interrogation’. When talking to my patients, I will often say things like ‘we all need a bit of help and support at times, life can be tough’. If patients talk about being on anti-depressants, I will make them feel more comfortable about this and the stigmas that surround them.

Introducing personal wellbeing Upon deciding to offer wellbeing support in your clinic, it is essential that you consider how it will be offered to ensure it is suitable for the aesthetic patient. If you do not already have the experience, knowledge and credentials, then it is essential that you partner with a wellbeing therapist. I have chosen to work with David Rahman, whom I first came across when I was looking for a therapist for my own personal wellbeing.

David is the founder of Start Smiling Again and the developer of Blueprint Therapy and Coaching, an approach that focuses deeper into thought generators and discovers what makes an individual feel and think the way they do. David is the official provider of stress and anxiety management training for the UK Government Department for Work and Pensions and he provides seminars to local GPs on stress and anxiety. As I have been a patient of David’s, and, considering his extensive experience, I have the utmost confidence in referring my patients to him.

Wellbeing seminars Within the past year, David and I have launched a series of wellbeing seminars aimed at patients who prefer to get support in a group setting. When I discuss wellbeing therapy with my patients, I give them information about working with David on a one-to-one basis as well as group sessions.

I explain that at the group seminars, no one is asked to share their story. David simply delivers a programme that gives details of the blueprint therapy he has developed and the tools you need to help combat psychological concerns. The sessions last between three to six hours, depending on what the focus is on; our most popular session topic is about confidence issues and lack of self esteem, and we have just

Reproduced from Aesthetics | Volume 3/Issue 6 - May 2016

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The care and support offered to that patient often means they are happy to recommend your services

introduced a session aimed at women in business or high-power positions. This can encourage wellbeing patients, who I may have already referred to the sessions, to come back and talk to me about any issues or concerns they have. I talk about how visible concerns such as poor skin or acne scarring can have a direct effect on people, and I often gain new patients this way.

Cost At my clinic, the first wellbeing session is always free. I find that this encourages attendance and allows aesthetic patients to see first-hand why personal wellbeing is so important, helping them to understand the role it can play in improving their lives. There are some patients that come to the free session and don’t take up any further support, however I have estimated that around 70% either book sessions with David on a one-to-one basis or attend a further group session that requires them to pay. For some wellbeing patients, one session may have been enough to get the clarity they needed. We generally get lots of patients attending a second event and bringing family or friends. We also open the paid seminars to the general public, which don’t have to be existing patients of David’s or mine. This is also great marketing for my clinic, as some of these people, who may have family or friends that I referred in the first place, have the opportunity to meet me and discuss any issues they may have and how I can potentially help.

Promotion To promote personal wellbeing, I ensure that my current patients can see this service exists in my clinic with effective marketing techniques such as posters, leaflets and my own verbal promotion.

I also recommend utilising your digital presence to promote your wellbeing services. As well as posting updates to my new website, I am very active on social media, in particular Facebook, which is where my target audience is particularly engaged. Regular newsletters, sent to your patient database, featuring case studies and updates on treatments are also extremely helpful. It is also important that you are confident in sharing your own experiences to connect with patients and put them at ease.

In addition, I have launched a ‘personal wellbeing referral system’, which more than 50% of my patients have taken up. The referral system simply involves either giving the patient one of David’s business cards or asking them if they would like me to pass their number on to David. I explain everything is confidential and reassure them that I don’t receive any feedback or information regarding what they discuss with David.

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Response So far I have received positive responses from my wellbeing patients and most are very thankful that I have taken the time to understand their issues, without pushing treatments upon them. In some cases, the issues are resolved with the wellbeing therapist and the patient will, in fact, not undergo any aesthetic treatments at all. It may sound like I am turning patients away, but because of this approach, all patients who are referred will nearly always come back to me if and when they are ready for treatment; others have both the wellbeing and aesthetic sessions at the same time. My word-of-mouth referrals are also very high because of my clinic’s reputation for offering such a pro-active holistic service. The care and support offered to that patient often means they are happy to recommend your services to friends or family seeking treatment, or potentially write a review for your clinic’s website and marketing materials. As such, you have not only hugely benefited the patient by putting their care first; your actions may also have an impact on your future business.

There are some negative perceptions when it comes to introducing personal wellbeing support to a clinic. Some people think that we are trying to influence patients’ lives and challenge their mental stability, even though this is not the case. To avoid this, it is crucial that the initial consultation is conducted sensitively and sympathetically. Also keep in mind that there is always a percentage of patients that don’t need this level of support. Many are simply looking to make changes to their appearance for purely aesthetic reasons. Ensure you are competent in recognising who to offer personal wellbeing support to, and the most appropriate time to do so.

Conclusion Personal wellbeing education, in my opinion, is an approach that all aesthetic practitioners should consider to ensure that wellbeing issues are automatically addressed with all patients. When I first established The Grove Skin Clinic, my aim was to deliver the best aesthetic treatments possible. Little did I know that I would be in a position to offer hugely beneficial support to my patients through my association with David, allowing me to introduce personal wellbeing as a valuable, patient-centred service. It pains me to hear of inexperienced practitioners simply delivering treatments without thought or care for their patients. I cannot advocate strongly enough the benefits that personal wellbeing support has brought to my business and would encourage other clinicians to seriously look at this option to help set their clinics apart from the competition. It also brings great personal satisfaction when you see the benefits it brings to your patients. Even if you do not choose to incorporate this in your clinic, prior to any aesthetic treatment it is important to always keep the patient’s personal wellbeing in mind, and ask yourself, why are they actually seeking this treatment?

Jodie Grove is an independent nurse prescriber and founder of The Grove Skin Clinic in Swansea, south Wales. She has worked alongside some of the industry’s leading plastic surgeons and is a member of the British Association of Cosmetic Nurses and the Royal Collage of Nurses. Grove takes a holistic approach to her practice and aims to offer a bespoke and personal service to her patients.

REFERENCES 1. Department of Health,Wellbeing: Why it matters to health policy, (2014) <https://www.gov.uk/ government/uploads/system/uploads/attachment_data/file/277566/Narrative__January_2014_.pdf>

Reproduced from Aesthetics | Volume 3/Issue 6 - May 2016

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“For beautiful eyes, look for the good in others” Mrs Sabrina Shah-Desai explains her love of treating the periorbital area and why teaching is a vital part of her career “I come from a family of doctors; we have a dentist, ENT surgeon, thoracic surgeon, onco-surgeon and gynaecologist,” explains consultant ophthalmic plastic and reconstructive surgeon Mrs Sabrina Shah-Desai, “But I am the first to work in cosmetics.”

While Mrs Shah-Desai decided to become a surgeon at an early age, it was an enjoyment of art that led her into aesthetics, “For me, aesthetics is art, science and imagination and I think that captures what I love about practicing it.” But this wasn’t the path her family would have assumed, “My father was a thoracic surgeon and when I began doing oculoplastics, he would say to me, ‘Why don’t you do cataracts?’ But to me, cataract surgery was repetitive and dull – I wanted to do aesthetics.”

Mrs Shah-Desai completed her degree in Ophthalmology in India in 1994 and travelled to England in 1995 to complete her Fellowship of the Royal College of Surgeons (FRCS). She trained at many prestigious units and after spending eight years at Moorfields Eye Hospital, she became an NHS consultant in 2010, “Whilst at Moorfields, I trained under Mr Richard Collin, one of the world’s oculoplastic legends. He used to do a lot of toxin injections, which were just getting into the market at the time and I learnt a lot about aesthetics from him.”

In 2012, Mrs Shah-Desai set up her London practice, Perfect Eyes Ltd, whilst still working in the NHS. Then in 2015, after spending almost 20 years working for the NHS, she decided it was the right moment to spend more time focusing on what she enjoyed the most, “I worked so hard in the NHS looking after people who had disfiguring functional problems.

The only time I looked after patients with aesthetic problems was in my private practice – so something had to give. I did not want to give up on the aesthetic side because I enjoyed it so much.” In her NHS and private career Mrs Shah-Desai has always made time for teaching, something she says is a huge part of her career, “I love training and teaching, it keeps my brain young; enthuses me and I have met some of my best friends through doing so. When you teach somebody you learn yourself, you see conditions in a different way from revisiting form and function. As a Hindu, I’m a great believer in karma, destiny and the cycle of life and I believe this is my way of giving back.”

She continues, “You never stop learning, I learn everyday and I am so grateful that I do. It’s an evolving field and medicine is changing so fast; twenty years ago we were going overseas to learn how to use dermal fillers and up until six years ago we were pretty much just treating localised areas. Then we realised we could use fillers like structural pillars to support the face, and achieve amazing aesthetic results. You can do a lot with fillers that you can’t achieve easily with surgery, in a manner in which the patient benefits with highly aesthetic outcomes achieved with minimal risk and downtime.”

Mrs Shah-Desai enjoys the challenge in working on such a delicate area of the face, “I think the eye area is one of the most demanding surgical areas because it’s a functioning anatomy. If you do a plastic surgical procedure on the arm or abdomen, you can hide it easier if the results are not optimum. But when you do a procedure around the eye, there is nowhere to hide – it is there for the world to see. It is a very high-intensity, unforgiving area, both surgically and non-surgically and that’s what I love about it, the fact that you really have to be at the top of your game.” When asked what her biggest achievement is so far, she replies, “When I worked in the NHS I set up a skin cancer MOHs service which took three years to do, but it helped a large population in Essex, so that was a professional achievement. In terms of my aesthetic career, my big achievement is yet to come – you’ll have to watch this space!”

Do you have an ethos or motto?

Keep it simple, be generous and grow people with you.

As a person, I don’t believe in growing alone and trampling on everybody around me; I believe in empowering people, especially women. My philosophy is, ‘for beautiful eyes, look for the good in others’.

What’s the best piece of career advice you’ve ever been given?

Don’t chase success. Do the best you can do and success will follow.

Do you have an industry pet hate?

As a confident female role model I find it disconcerting to come to aesthetic conferences and find that many women (in the industry) have become so dysmorphic about their looks.

What aspects of the industry do you enjoy?

I love how welcoming it is, it is so nice to be a part of this group. I debuted on the aesthetic conference circuit last year and everyone has just opened their arms and embraced me.

Reproduced from Aesthetics | Volume 3/Issue 6 - May 2016

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The Last Word PR and social media consultants Tingy Simoes and Nikki Milovanovic argue why its time to clamp down on cosmetic games aimed at children On April 1, the British Association of Aesthetic Plastic Surgeons’ (BAAPS) press office engaged in the time-honoured tradition of spaghetti trees and flying penguins by launching an April Fools’ Day prank through social media. The stunt took the form of an image of a plastic doll accompanied by syringes and surgical instruments, marketed as a toy for girls. Whilst clearly meant to be light-hearted, the reasoning behind it was anything but.

The ‘doctored’ image, posted through the BAAPS press office Twitter account, had the express purpose of shocking the aesthetics sector into realising there is a very real problem with a new spate of cosmetic surgery and non-surgical ‘games’ aimed at children. The post managed to ‘fool’ and sparked hot debates on body image, psychologically vulnerable groups and advertising.

As absurd as it might seem, the pretend toy is sadly only one small manufacturing step away from the games already deemed marketable in a sector with little statutory controls – a sector that quite often sees untrained practitioners performing injectable treatments on young patients.

In the aftermath of the prank, when (according to custom) the BAAPS media team came clean at noon, we followed up with a series of actual, real ‘games’ we’d found online and through app stores in order to raise awareness of the problem. Marketed as girls’ games designed for ages nine and above, they had slogans such as ‘a game for beauty and skin operations to make princess look beautiful’ and ‘little boys and girls it’s your chance to become an expert doctor’. An even more graphic pastime marketed at girls aged 12+ showed cartoon patients undergoing rhinoplasty, accompanied by the message ‘every girl dreams of [sic] delicate face and stunning figure. If makeup can’t give the beauty you want...turn into a Victoria’s secret [sic] model at once!’ Players of the game can also alter ‘unsatisfactory’ boyfriends, who will become ‘a handsome male model immediately!’

Some of the apps even went so far as to pirate highly recognisable Disney characters from the movie Frozen, with the protagonists discussing liposuction due to ‘being fat’. Perhaps in today’s society one could argue children are hardly unaware of the term fat – but why introduce them to a ‘need’ for liposuction so early in life?

Whilst the jury is still out on whether toys and games can actually ‘force’ behaviour in children, researchers from the American Psychological Association (APA) conducted a comprehensive review of research literature published between 2005 and 2013 which was focused on violent video game use. It claimed that there was ‘a consistent relation between violent video game use and increases in aggressive behaviour, aggressive cognitions and aggressive affect, and decreases in pro-social behaviour, empathy and sensitivity to aggression’.1 Specifically targeting the young and vulnerable to feel bad about their looks is nothing short of aggressive bullying on a massive scale. Whilst teens may regularly be exposed to unrealistic images

Aesthetics

through magazines and fashion, further inducing them to consider irreversible surgical procedures are approaches the BAAPS has previously decried as socially irresponsible. In early 2012, the All Party Parliamentary Group (APPG) on Body Image revealed that girls as young as five now worry about their size and appearance.2 Over the past decade the BAAPS has campaigned to tackle this, singling out trends of youthful celebrities promoting cosmetic procedures, as well as ads on billboards, buses, TV and social media as contributing to the problem. The organisation has many times proposed banning cosmetic surgery advertising outright, or at the very least keeping it out of public spaces where it is likely to be absorbed by impressionable children. In 2012, the BAAPS explicitly addressed the issue through their news release ‘Mary Had a Little Lipo’, which garnered wide media attention, including on BBC’s Radio 1 Newsbeat. The aim was to protect children from surgery advertisements by submitting a new, strict advertising code to the Committee of Advertising Practice (CAP).3 Research by Ofcom suggests one in three children aged 5-15 have their own tablet computer.4 With this technology playing such a huge role in society, it is impossible to imagine the trend of children routinely being exposed to unrealistic body image expectations going away any time soon; this only reinforces the need for public education.

Although this toy was a ruse, it was an effective strategy in uniting the many (traditionally disparate) disciplines of the sector in collective outrage, so we can further examine how to bring about change through discussion, petitions, complaints, joint condemnation and above all, cohesion – rather than dissension.

It is essential that practitioners work together and use every platform possible to disrupt the status quo that has encouraged the marketing of psychologically destructive materials – the very same conditions that have enabled young reality stars to be used in cosmetic surgery advertising campaigns; allowed surgical and non-surgical prizes given by companies who are well aware they’re abusing loopholes; and contributed to damaging the reputations of those who do adhere to ethical codes.

At the BAAPS we do not think this is a laughing matter, but the ‘joke’ has served its purpose – the sector has once again been shaken wide awake to the larger impact of allowing the current state of affairs to flourish unchecked. Now it is time that we act in solidarity, to put these ‘games’ where they belong: out of reach of children.

Tingy Simoes and Nikki Milovanovic run the BAAPS Press Office through PR agency Wavelength Marketing Communications Tingy Simoes is owner and managing director of award-winning public relations agency Wavelength Marketing Communications, specialising in the health and medical sectors and representing some of the bestknown entities in the field. Co-author Nikki Milovanovic is Wavelength’s Head of Social Media and runs the BAAPS Press Office.

REFERENCES 1. American Psychological Association, APA Review Confirms Link Between Playing Violent Video Games and Aggression, (2015) <http://www.apa.org/news/press/releases/2015/08/violent-videogames.aspx> 2. YMCA, Reflections on body image: All Party Parliamentary Group on Body Image <http://www.ncb. org.uk/media/861233/appg_body_image_final.pdf> 3. BAAPS, Mary had a little lipo? Protect children from surgery ads, (2012) <http://baaps.org.uk/about-us/ press-releases/1420-mary-had-a-little-lipo-protect-children-from-surgery-ads> 4. Ofcom, One in three children now has their own tablet computer, (2014) <http://media.ofcom.org.uk/ news/2014/media-lit-audit-oct2014/>

Reproduced from Aesthetics | Volume 3/Issue 6 - May 2016

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