Aesthetics November 2017

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VOLUME 4/ISSUE 12 - NOVEMBER 2017

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Treating the Chin CPD

Nurse prescriber Anna Baker explores considerations for chin augmentation

Facial Assessment and Treatment Three practitioners discuss how they assessed and treated patients at ACE 2017

The Male Mid-face

Dr Tahera BhojaniLynch details considerations for midfacial filler treatments

Christmas Marketing

PR consultant Charlotte Moreso provides tips to boost sales over Christmas

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Contents • November 2017 06 News

The latest product and industry news

14 Conference Reports

Highlights from the BCAM 2017, ABC and IAPCAM conferences

16 News Special: Regulation of Hair Restoration Surgery

Aesthetics investigates the standards and guidelines for hair restoration surgery

18 Conference Preview: ACE 2018

A look at the Elite Training Experience and free content available at ACE 2018

Special Feature Facial Assessment and Treatment Page 25

20 Advertorial: Meet the Trainer with Dr Ryan Hamdy

Find out more about the courses available at the Aesthetics Academy

CLINICAL PRACTICE 25 Special Feature: Facial Assessment and Treatment

Practitioners explain how they assessed and treated patients at ACE 2017

31 CPD: Augmenting the Chin

Aesthetic nurse prescriber Anna Baker explores the considerations for non- surgical injectable augmentation of the chin

Clinical Contributors

35 Hair Loss and Nutrition

Dr Martin Godfrey discusses nutritional supplements for hair loss

40 Case Study: Treating the Tear Trough

Dr Munir Somji presents a case study of treating a tear trough deformity

43 Contouring the Male Jawline

Dr David Jack studies the anatomy of the male jawline and explains how to contour the area using injectables

46 Treating the Male Mid-face

Dr Tahera Bhojani-Lynch details the treatment considerations of the male mid-face

49 Wrinkle Severity Scales

Dr Rupert Critchley explains the use of wrinkle severity scales

54 Case Study: Concealing Scars

Paramedical tattooist Hina Solanki discusses examples of scar concealment

56 Advertorial: iS Clinical Fire & Ice

Harpar Grace International presents the iS Clinical Fire & Ice resurfacing treatment

57 Abstracts

A round-up and summary of useful clinical papers

IN PRACTICE: MARKETING SPECIAL 59 Avoiding Email Marketing Mistakes

Marketing consultant Adam Hampson discusses 10 common email marketing mistakes and advises on how to avoid them

63 Christmas Marketing

In Practice Christmas Marketing Page 63

PR consultant Charlotte Moreso provides tips on increasing sales over the Christmas period

Anna Baker is a qualified tutor, cosmetic and dermatology nurse prescriber who has been involved in developing the award-winning Dalvi Humzah Aesthetic Training. She is the coordinator and a faculty member for this teaching.

Dr Martin Godfrey is head of research and development at MINERVA Research Labs Ltd. A trained medical practitioner, Dr Godfrey has experience in health and nutritional product marketing. He oversees MINERVA’s clinical trials.

Dr Munir Somji is the chief medical officer for DrMedispa, specialising in facial aesthetics and hair restoration surgery. Dr Somji has performed numerous tear trough deformity corrections, utilising a variety of different techniques.

Dr David Jack is an aesthetic practitioner based between his clinics in Harley Street in London and Scotland. Dr Jack trained in the NHS until 2014, mostly in plastic surgery, before leaving to establish his nonsurgical aesthetic practice.

Dr Tahera Bhojani-Lynch is a doctor and surgeon specialising in ophthalmology and has more than 20 years’ experience in medical aesthetics. She was the first female British graduate LASIK surgeon in the UK. Dr Rupert Critchley is the lead clinician and director of Viva Skin Clinics and clinical lead at The VIVA Academy Harley Street. He is a qualified GP, attained MRCS part A and has completed many courses in advanced non-surgical aesthetics.

Hina Solanki is a permanent makeup artist, scar medical tattooing specialist and author of the Permanent Make Up Guide. Patients of all ethnicities from across the world seek her expertise to camouflage scar tissue.

67 Utilising Facebook Adverts

SEO consultant Callum Daly explains how to use Facebook advertising

71 In Profile: Dr Andrew Weber

Dr Andrew Weber describes his career journey and how he combines his general practice with medical aesthetics

72 The Last Word

Ms Priyanka Chadha, Miss Lara Watson and Mr Nihull Jakharia-Shah debate the pros and cons of simulation training in aesthetics

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Editor’s letter Well, we are well and truly into autumn and with Christmas parties coming up the desire for the perfect, smooth, contoured complexion is high!

But before all of that is the Aesthetics Awards Amanda Cameron 2017 on December 2, the social event of the Editor Aesthetics calendar. Book your seat soon – tickets are selling fast! The next exciting event on our agenda is ACE 2018 on April 27 and 28, which you can register for now! ACE 2018 promises to be the biggest and best so far, with an unsurpassed quality of education and practical training. We are delighted to introduce a brand new agenda – the Elite Training Experience – which will give you a taste of some of the best training programmes available in medical aesthetics (p.18). Re-live the highlights of the ACE 2017 conference in our Special Feature on p.25; three practitioners explain the assessment and treatment of their models and showcase their incredible before and after photographs.

This month in the journal we focus on treating men. According to the British Association of Aesthetic Plastic Surgeons, men account for 8% of cosmetic procedures carried out in the UK, but, in many practitioners’ experience, treatments are certainly becoming more popular. When treating men, it’s important that the differences in anatomy are understood – Dr David Jack explains the anatomical considerations in his article on contouring the jawline on p.43, while Dr Tahera Bhojani-Lynch shares her case study on a male mid-facial treatment on p.46. Our CPD article this month by nurse prescriber Anna Baker (p.31) focuses on the anatomical considerations for treating the chin, which will also be of great use to your male patients.

We hope you enjoy our In Practice section, which is a marketing special with three fantastic articles on how you can improve your strategies to connect with your patients and improve your business.

Turn to p.59 to find out how to avoid common email mistakes, p.67 to learn how to use Facebook Adverts and p.63 to find out how to market for the Christmas period.

Editorial advisory board

We are honoured that a number of leading figures from the medical aesthetic community have joined the 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 aesthetic surgeon with over 20 years’ experience. He is an international presenter, as well as the medical director and lead tutor of Medicos Rx. Mr Humzah also runs the multi-award winning Dalvi Humzah Aesthetic Training courses. He is a founding member of the Academy of Clinical Educators at the Royal College of Physicians and Surgeons of Glasgow.

Dr Raj Acquilla is a cosmetic dermatologist with more than 12 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 Cosmetic Nurses (BACN) and the UK lead on the BSI committee for aesthetic non-surgical medical standards. She is a registered university mentor in cosmetic medicine and currently a second year student on the Northumbria University Masters course in non-surgical cosmetic interventions.

Bennett has been developing her practice in aesthetics for 25 years.

Dr Tapan Patel is the founder and medical director of PHI Clinic. He has more than 16 years’ clinical experience and has been performing aesthetic treatments for more than 14 years. Recently, he was listed in Tatler’s Top 30 Anti-Ageing Experts. Dr Patel is passionate about standards in aesthetic medicine and ensures that along with day-to-day clinic work he also attends and speaks at numerous conferences.

Mr Adrian Richards is a plastic and cosmetic surgeon with 12 years of specialism in plastic surgery at both NHS and private clinics. He is a member of 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 Maria Gonzalez has worked in the field of dermatology 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.

Dr Sarah Tonks is a cosmetic doctor, holding dual 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.

Dr Stefanie Williams is a dermatologist with special interest in aesthetic medicine. She is the founder and medical director of the multiaward winning EUDELO Dermatology & Skin Wellbeing in London. She lectures in the Division of Cosmetic Science and has published more than 100 scientific articles, book chapters and abstracts. Dr Williams is also author of Amazon-No-1 Bestseller ‘Future Proof Your Skin’.

Dr Christopher Rowland Payne is a consultant 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.

Dr Souphiyeh Samizadeh is a dental surgeon with a Master’s degree in Aesthetic Medicine and a PGCert in Clinical Education. She is the clinical director of Revivify London, an honorary clinical teacher at King’s College London and a visiting associate professor at Shanghai Jiao Tong University. Dr Samizadeh frequently presents at international conferences and is passionate about raising industry standards.

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

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Botulinum toxin

Talk #Aesthetics Follow us on Twitter @aestheticsgroup #Conference BCAM @BCAM01 @DrNestorD demonstrating how to achieve a neck lift with suspension threads #BCAMconference2017 #education #threads #Training S-Thetics @MissBalaratnam Enjoyed a full day delivering #dermalfiller training to fellow colleagues in the South West and introducing them to the latest #MDCodes for full face rejuvenation #Launch DHAesthetic Training @mdhtraining Mr Dalvi Humzah @pdsurgery recently chairing the Benelux launch of Cellfina in Holland #TutorsOnTour #NewBook Dr Stefanie Williams @DrStefanieW So proud to see my new book on how to best look after your skin – from skincare to non-surgical cosmetic treatments

#Lecture Clinetix @clinetix Mr Simon Ravichandran lectured to a full house on ‘All you need to know about anatomy and safety in aesthetic medicine’ #IAPCAM #Marketing Truly Content Ltd @TrulyContentLtd We loved filming promo videos with the wonderful @JRKendrick last week! #Marketing #KendrickPR #ContentMarketing #Aesthetics

FDA approves Botox for forehead lines Global pharmaceutical company Allergan has announced that Botox Cosmetic (onabotulinumtoxinA) has been approved by the US Food and Drug Administration (FDA) for its third indication. The prescription-only medicine is now approved for the temporary improvement in the appearance of moderate to severe forehead lines, associated with frontalis muscle activity in adults. It has previously been approved for lateral canthal lines and glabella lines. “Allergan recognises that forehead lines are a top area of concern for patients,” said David Nicholson, chief research and development officer at Allergan. “Our goal in pursuing a third indication for Botox Cosmetic, for the temporary improvement in the appearance of moderate to severe forehead lines, was based on our desire to study the patient selection, dosing and injection pattern to help provide optimal treatment outcomes,” he added. According to Allergan, in its clinical trials, Botox Cosmetic was found to be more effective for reduction in the severity of forehead lines than placebo, and has been described as safe in nearly 500 peer-reviewed articles in scientific and medical journals.

Skincare

ZO Skin Health launches Pore Refiner Aesthetic skincare provider ZO Skin Health has released a new product aimed at reducing enlarged pores. The Ossential Instant Pore Refiner is designed to reduce pore size, skin surface oil and improve skin texture. Ingredients in the product include rosa canina fruit extract, which the company claims helps to balance oily skin and minimise the amount of oil on the skin’s surface; salicyloyl phytosphingosine, which aims to exfoliate dead cells around pores and prevent congestion; and ZO’s antiinflammatory and antioxidant complexes ZO-RRS2 and ZOX12, which, according to the company, aid in the defence against harmful extrinsic factors, including pollutants. “The social impact of enlarged pores is that skin appears oily, shiny and uneven in texture due to the raised outer edges of every enlarged pore,” said Rick Woodin, vice president of global research and development for ZO Skin Health. “Upon our recent discovery of two leading-edge, clinically proven biotechnologies we, at ZO, designed a synergistic formulation that we felt confident could most effectively address the diversity of biological factors that cause enlarged pores,” he said, continuing, “The combination technology model we used is proven to suppress excess sebum production and accumulation by limiting differentiation of sebocytes, the skin cells primarily responsible for sebum production.” ZO Skin Health is available exclusively in the UK through Wigmore Medical.

Reproduced from Aesthetics | Volume 4/Issue 12 - November 2017

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Pharmacy launch

Church Pharmacy opens premises near Harley Street Medical supplier Church Pharmacy has opened a new premises on Little Portland Street, which is a four-minute walk from Harley Street. According to the company, the private pharmacy will be catering only for the aesthetics market and will be offering a one-hour delivery service to Harley Street and the surrounding areas, for all customers who order through the online prescription service, DigitRx. For areas in Greater London, goods will be delivered within two to three hours. A full range of products can be ordered through the pharmacy, including popular dermal fillers and botulinum toxins.

The company states that the new project is due to customer demand.

Founder of Church Pharmacy, Zain Bhojani, said, “It’s exciting to be able to operate full-time out of a space in London and be closer to our customers.

We like to think the experience people will receive will be very relaxed and smooth. We welcome people to visit us and have a chat and a coffee in our waiting area – we look forward to building and strengthening the relationships that we’ve had for years.” The pharmacy will be sharing exclusive launch offers during the month of November.

ACE 2018

Enhance Insurance confirmed as ACE 2018 Business Track sponsor For the second year, Enhance Insurance will sponsor the business agenda at the Aesthetics Conference and Exhibition (ACE) 2018. At the Business Track, practitioners, clinic managers, marketing staff and other aesthetic professionals can gain valuable business tips and insights from experts throughout the aesthetic specialty. Topics covered on the CPD-verified agenda will include how to start your own business, managing and training staff, standing out from your competition, PR and marketing, and updates on regulatory bodies such as the General Medical Council. Director of Enhance Insurance, Martin Swann, said, “We, at Enhance, think that ACE 2018 is a fantastic event for all kinds of professionals who are part of the aesthetics specialty. The Business Track is a great forum for practitioners, clinic managers, and others within aesthetics to obtain some valuable information outside of their technical clinical skills to improve the running of their business.”

He added, “We will also be presenting two sessions at the Business Track to give delegates the latest information on topics such as how to mitigate risks and data protection. We are really looking forward to attending next year’s conference to meet and connect with existing and potential clients.”

ACE 2018 will take place at the Business Design Centre in London on April 27 and 28. To find out more about the Business Track and register for free for ACE, visit www.aestheticsconference.com.

Aesthetics

Vital Statistics In a Facebook survey of 580 men, 51.6% said they would never remove their leg hair, 15.3% said they shave their legs frequently and the remainder said they use a trimmer (Men’s Health, 2015)

In a survey of 2,497 men and women, 43% believed if they were better looking they would be more likely to get a promotion (Allure, 2016)

In 2016, 28,341 non-surgical cosmetic procedures were carried out on women in the UK, a fall of 39.1% from 2015 (BAAPS, 2017)

More than 2 billion adults and children globally are overweight or obese and suffer health problems because of their weight (New England Journal of Medicine, 2017)

Americans spent more than $15 billion dollars on combined surgical and non-surgical aesthetic procedures in 2016, up 11% from 2015 (The American Society for Aesthetic Plastic Surgery, 2017)

According to digital analytic company comScore, almost 80% of time spent on social media platforms happens on mobile (comScore, 2016)

Reproduced from Aesthetics | Volume 4/Issue 12 - November 2017

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Events diary 29th November - 1st December 2017 British Association of Plastic Reconstructive and Aesthetic Surgeons Winter Scientific Meeting 2017, London www.bapras.org.uk

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Awards

Last chance to book for the Aesthetics Awards 2017

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

1st - 3rd February 2018 IMCAS Annual World Congress 2017, Paris www.imcas.com

1st - 5th March 2018 American Academy of Dermatology Annual Meeting, Washington DC www.aad.org

4th - 7th April 2018 Aesthetic & Anti-aging Medicine World Congress, Monte Carlo www.amwc2018.org

27th – 28th April 2018 The Aesthetics Conference and Exhibition 2018, London www.aestheticsconference.com Clinic launch

Due to popular demand, more tables have been added for the Aesthetics Awards 2017, which will take place at the Park Plaza Westminster Bridge hotel in London on December 2. With just one month to go until the most recognised awards event in medical aesthetics takes place, guests are being urged to book now as limited tickets are available. The 700-plus guests will enjoy the biggest celebration in medical aesthetics through a bustling drinks networking reception and laugh-out-loud entertainment from stand-up comedian Stewart Francis, who is a regular panellist on TV programme Mock The Week. Additionally, guests will be treated to a delicious three-course meal before watching the presentation of Commendations, High Commendations and trophies to the 2017 Winners. For the first time ever, the evening celebrations will also include a live performance from a six-piece pop and rock band.

Additionally, a new sponsor has been announced; Dalvi Humzah Aesthetic Training will be sponsoring the Award for Best Supplier Training Provider. To book your ticket before it’s too late visit www.aestheticsawards.com/booking.

Skincare

Dr Raj Acquilla opens new clinic Aesthetic practitioner Dr Raj Acquilla has officially launched his new clinic in Cheshire, YUVA Medispa. The clinic is offering an extensive range of treatments, including botulinum toxin and dermal filler injections, The Liquid Facelift, Hydrafacial, skin peels, body shaping and skin tightening with Exilis, photorejuvenation with IPL, CO2RE fractional laser resurfacing treatments and a variety of other body treatments. Dr Acquilla said, “Our philosophy at YUVA is to make our patients not only look, but feel better about themselves through proven, safe and effective procedures. We pride ourselves on listening to their needs so that we can tailor and deliver a treatment plan that suits their individual goals.” He continued, “We understand the emotions that are attached to age-related changes in appearance and endeavour to make all our patients’ experiences and journeys with us memorable and positive.” The clinic is a finalist for The AestheticSource Award for Best New Clinic, UK and Ireland at the Aesthetics Awards 2017, which takes place in London on December 2.

Image Skincare launches 13 new products

Skincare company Image Skincare has added 13 new products to its portfolio.

Among the products included in the range, which is named Image MD, is a facial cleanser and a youth serum, as well as a retinol booster, which contains omega 3 and omega 6 oil infused with retinol, aiming to hydrate the skin. Also featured in the range is a collagen eye gel, which targets wrinkles, puffiness and dark circles, alongside a post-treatment scar gel, which aims to reduce the thickness and roughness of scars.

The company states that the range is formulated by plastic surgeons, and active ingredients in the products include retinol, alpha hydroxy acids (AHAs), aromatase inhibitor androstatrienedione (ATD) and plant-derived stem cell technology.

Reproduced from Aesthetics | Volume 4/Issue 12 - November 2017

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Conference

sk:n Medical Convention preview Some of the UK’s leading dermatologists, plastic surgeons and aesthetic practitioners will be meeting on November 10 in Birmingham to explore the latest in new skin treatments and technologies. The Medical Convention 2017, which is in its 13th year, will be held at The Vox Conference Centre, Resorts World Birmingham and is expected to draw up to 200 delegates. The event, which includes a conference and exhibition, aims to provide delegates with a hub of industry expertise and a chance to gain a better understanding of new treatments and emerging technologies. The one-day convention will consist of medical seminars and will provide attendees with networking opportunities, an aesthetics and skincare exhibition, CPD points, as well as lunch and refreshments. It aims to harness knowledge and experience from across the aesthetics sector with the hope of inspiring industry-leading care and improving patient outcomes. “Anyone who’s interested in skin treatment, whether they’re a dermatologist, nurse, or a professional interested in aesthetic practice, I would definitely recommend attending this event,” said previous delegate, consultant dermatologist Dr Irshad Zaki, adding, “It’s a good way of learning new things, networking and meeting people who deliver similar treatments.” The programme will include talks on: patient consultation, treatment planning using Allergan’s MD Codes, a review of data on the nutraceutical Fernblock, advancements in skincare, supplements for skin health, skin peels, treating female facial hirsutism, acne scarring, laser technology and a panel discussion on how to avoid complaints and litigation, chaired by group medical director at sk:n and consultant dermatologist Dr Daron Seukeran. Dr Seukeran said that the seminar topics chosen for the event are selected with the specific challenges of aesthetics practitioners in mind, “What is really important is for us to have a programme that is relevant to consultant dermatologists, consultant plastic surgeons and doctors in aesthetic medicine – and also to nurses, therapists and clinic managers.” According to sk:n, there are a limited number of spaces available at the conference so delegates are encouraged to book now to ensure they do not miss out.

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

BACN STRATEGY The 2014-2017 strategy cycle is now coming to a close, and the BACN has developed a comprehensive outlook of actions and objectives for 2017-2020, focusing on member engagement, industry standards, and our commitment to ensuring nurses’ voices are heard at all levels. Members have each received a copy via email, and the strategy can be read by all members in the BACN members’ area.

BACN CONFERENCE 2018 Although the BACN Autumn Aesthetic Conference 2017 feels like yesterday, we are already gearing up for next year! The BACN Board met in October to confirm details for our Conference in 2018. All details will be released before the New Year for prospective delegates and exhibitors!

REGIONAL MEETINGS After a fantastic attendance at our Autumn Aesthetic Conference in September, we are looking forward to our next round of Super Group Regional Meetings throughout the UK. With demos from our strategic partners and networking with other aesthetic nurses, attending is a great benefit of being a member of the BACN. To book, just go to the events page of the BACN website. For a full list of 2017 meetings see below: 3rd Nov: Newcastle 6th Nov: Leeds 10th Nov: Cardiff 13th Nov: Belfast 20th Nov: Southampton 24th Nov: Birmingham 27th Nov: London 1st Dec: Glasgow 4th Dec: Manchester 8th Dec: Bristol

Skin regeneration

Energist launches nitrogen plasma device Aesthetic manufacturer Energist has introduced a new device that uses nitrogen gas to treat a variety of cosmetic and medical skin conditions. According to the company, the NeoGen Evo device delivers a controlled pulse of nitrogen plasma to the skin, to stimulate a physiological response, without creating an open wound. The company claims the stimulation of neocollagenisis within the epidermal and dermal layers provides improvement to the skin for more than a year. According to Energist, the aesthetic indications include the treatment of striae, wrinkles, pigmented lesions, photodamaged skin and pore size reduction, while the medical indications include the reduction of active acne, scarring (acne, surgical and burns) and melasma. Energist also says that the nitrogen plasma enables the increased uptake of topical drug therapies.

MEET A MEMBER Lisa Niemier has been working in aesthetics for eight years and opened her clinic four years ago. She has been involved in education and research throughout her nursing career and has a passion for teaching. Lisa has been a regional lead representative for the BACN for a number of years. Her current positions as a business owner and for the BACN give her experience on a practical level to understand the issues around aesthetic nursing and challenges within the industry.

This column is written and supported by the BACN

Reproduced from Aesthetics | Volume 4/Issue 12 - November 2017

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LMEDAC announces new training dates London Medical Education Academy (LMEDAC) has revealed new dates during November, December and February for its hands-on cadaver training course. According to the academy, the course – entitled Facial Anatomy: Dissect and Inject – aims to provide attendees with an understanding of the basics of facial anatomy. Sessions on the upper face, mid-face and lower face will take place throughout the one-day course. LMEDAC states that the course will include dissection of facial muscles, nerves and arteries, as well as an injection demonstration with dyed filler in selected locations. Members of the faculty at LMEDAC include specialist consultant plastic surgeon Mr Taimur Shoaib, maxillofacial plastic surgeon Mr Colin Macive and anatomists Dr Matthew Szarko and Dr Michael Rittig. The courses will take place in Glasgow on November 3, Nottingham on December 11 and 12, and Edinburgh on February 19 and 20.

Hair transplants

BAHRS develops guide to improve patient safety The British Association of Hair Restoration Surgery (BAHRS) has assisted the Care Quality Commission (CQC) in creating an inspection guide to promote the safety of patients in hair restoration surgery. The guide aims to help CQC advisors to make a correct assessment when inspecting clinics that do hair restoration surgery, to ensure they meet the CQC’s guidelines. The BAHRS also believes there has been an increase in unethical advertising in the sector, including offers of financial incentives, and pressurised sales tactics, which potentially endangers patient safety. One of the issues the association highlights are websites that do not explicitly list the surgeons who do the surgery, along with a description of their qualifications and experience.

The BAHRS will be working with the Advertising Standards Authority (ASA) to ensure marketers of hair transplant surgery comply with regulations.

Hair restoration surgery is one of the modalities for which standards for both training and practice are being set by the Cosmetic Practice Standards Authority (CPSA).

Conference

New sponsors revealed for ACE 2018 New sponsors have been announced for the Aesthetics Conference and Exhibition (ACE) 2018. Sponsors of sessions within the Expert Clinic agenda will include UK skincare distributor Unique Skin and laser manufacturer Cutera Medical Ltd. Medical aesthetics distributor AestheticSource will be holding two sessions at the Expert Clinic agenda and has also been announced as the sponsor for the delegate bags. Meanwhile, energy-based medical device company Lumenis and global cosmeceutical skincare company SkinCeuticals will host a Masterclass session each and pharmaceutical company Galderma will be holding two sessions.

Galderma and UK distributor of IBSA Farmaceutici Italia, HA-Derma, will also showcase their company’s KOLs at the event through live interviews, which will be broadcast around the exhibition. Director of AestheticSource, Lorna Bowes, said, “We’re so looking forward to having the wonderful platform at ACE for a significant new launch with the support of leading international speakers.” ACE 2018 will take place on April 27 and 28 in London and free registration is now open.

Visit www.aestheticsconference.com to find out more.

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Lucy Dowling, Senior Brand Manager at Merz Aesthetics Tell us about the new Own Your Beauty campaign?

Own Your Beauty (#OYB) with Belotero® is the new emotive and engaging patient centric campaign designed to enable aesthetic practitioners to empower their patients to own their beauty. Patients today don’t want a filler that ‘owns’ them, they want a filler that naturally integrates into their tissue, so that they can retain their identity and express their emotions. To own your beauty is to take control over how you project your image, and the decisions which you make to achieve that. To own your beauty is to have the confidence to show your emotions.

How can patients own their beauty with Belotero®?

Belotero® is not about painting by numbers for a generic look; it’s a palette of HA fillers that enables a practitioner to tailor a treatment by analysing the face and using the correct tools and techniques to respect individuality, so that every patient can feel empowered to own their age, and own their beauty. Belotero® is differentiated in science, rheology and technique. True Belotero® artists understand the Belotero® difference, to achieve natural looking results.

What’s the future of Belotero®?

Marching through the medical aesthetic industry is an ‘Army of Artists’, Belotero® Artists. With the #OYB campaign at the heart of it, aesthetic practitioners are invited to be a part of the journey to be a ‘master of their art’. The community of Belotero® artists is growing fast, it is a desirable place for aesthetic practitioners to be and belong to, where they can gain the support and partnership from Merz Aesthetics, plus guidance, education, and networking. This community supports professional goals, with patients at the heart of it. By choosing the Belotero® journey and to be part of the Army of Artists, aesthetic practitioners can aspire to grow in confidence and expertise. This journey is aspirational and we welcome aspiring aesthetic practitioners to be a part of it.

If you could describe the campaign in three words, what would they be?

Distinctive, engaging, aspirational.

This column is written and supported by

Reproduced from Aesthetics | Volume 4/Issue 12 - November 2017

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Cosmetic surgery

Surgeons report rise in ‘botched’ cosmetic procedures New data released by the British Association of Aesthetic Plastic Surgeons (BAAPS) states that four in five surgeons have recorded a rise in revisions for ‘botched’ cosmetic procedures. The findings come from an internal survey of 230 association members, of which 80% revealed that they have had an increase in requests from patients, to correct failed cosmetic surgery procedures, during the last five years.

In the poll, surgeons identified that the main reasons for revisions were incorrect patient selection for surgery (40%), the original procedure had been carried out by an inadequately trained practitioner (30%) and that the procedure was carried out via a cheap deal abroad (30%). “I have seen many people who were clearly not appropriate for surgery – ranging from unrealistic expectations, to the more extreme body dysmorphia, contraindicated medications, smokers, and pre-existing medical conditions, which should have ruled them out. And yet, unscrupulous practitioners have endangered their health entirely for profit,” said consultant plastic surgeon and BAAPS president Mr Simon Withey, who noted that around 40% of his work last year was revisional procedures. He added, “This has directly led to an increase in the number of reported cases of people returning to the UK with serious complications after receiving cosmetic surgery abroad.”

Distributor

New distributor arrives in the UK Aesthetic distributor MedAesthetics Ltd has launched in the UK. The company, founded by Dr Maria Toncheva and medical director George Brankov has been active in the EU for the last 12 years, but is now aiming to break into the UK market.

MedAesthetics, whose tagline is ‘medical science and aesthetic solutions’, manufactures and distributes products, which aim to complete the treatment of the practitioner’s patients from start to finish. Products the company will be distributing include platelet rich plasma (PRP) kits, platelet rich fibrin (PRF) kits, and food supplements.

Mesotherapy

Naturastudios releases Dermatic Aesthetic equipment supplier Naturastudios has launched a new mesotherapy gun.

The Dermatic device uses compressed air to deliver a high-injection speed to open up a possibility of therapies, including skin rejuvenation, antiageing and collagen stimulation. According to the company, the device delivers consistent and effective results, which the company states can be achieved by adjusting various settings on the machine, such as speed of burst, injection depth and quantity of liquid to inject, to tailor patients’ needs and reduce product waste. Naturastudios states that the device uses very thin needles, coupled with compressed air, for deep penetration into the epidermis. The device is now available to order.

News in Brief BAS announces 2018 conference date The British Association of Sclerotherapists (BAS) will hold a conference next year on May 15 at the Dorney Lake Conference Centre, near Windsor. Dr Martyn King, BAS board member and aesthetic practitioner, said, “In the past we’ve held meetings every two years, but the 2017 meeting was so successful that we are breaking tradition and holding another conference next year. Dorney Lake is a beautiful venue, and so close to Heathrow, meaning that we will again be well supported by delegates from Scotland and Ireland.”

Schuco International appoints Kendrick PR UK distributor Schuco International has partnered with aesthetic public relations consultancy, Kendrick PR. The PR firm will now manage the communications for its aesthetic product portfolio, which includes the Princess dermal filler range, the PLASMA non-invasive sublimation device and cosmeceutical skincare brand Universkin.

Ed Fox, marketing manager at Schuco International, said, “We are delighted to be working with Kendrick PR to grow our existing strong presence in the aesthetic market.“ Consentz become Save Face’s preferred software partner Independent accreditation body Save Face has selected Consentz as its preferred software partner. The collaboration aims to promote shared safety standards in the aesthetics specialty. Clinical director of Save Face, Emma Davies, said, “Save Face has selected Consentz as it supports practitioners in keeping good electronic records, which are necessary to be compliant with data protection requirements.”

Harpar Grace becomes distributor of CODAGE Aesthetic distributor Harpar Grace has been appointed as the UK and Ireland distributor of the French bespoke skincare range CODAGE. Founder and director of Harpar Grace, Alana Chalmers, said, “CODAGE is an exciting brand to work with – especially with all the opportunity within the professional aesthetic sector. CODAGE really offers a luxury, upmarket professional skincare concept, which is perfect for the new generation mediaesthetic clinic concept without compromising on results.”

Reproduced from Aesthetics | Volume 4/Issue 12 - November 2017

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On the Scene

Out and about in the specialty this month

Integrative Beauty skincare launch, London On October 12, aesthetic practitioner Dr David Jack launched his new skincare programme Integrative Beauty to the press in Mayfair, London. Guests were greeted with champagne and were treated to a three-course meal, whilst Dr David Jack discussed the new skincare concept, which has the tagline ‘beauty from the inside and the outside’. The event showcased Dr Jack’s new range which is designed for people with an active lifestyle. Three topical skincare products are included within the range, including Good Morning!, a vitamin C serum with a neroli scent; All Day Long, an SPF50 moisturiser with antioxidants; and Good Night!, a retinol night cream with jasmine and mint. Also included in the range are two oral supplements, a vegan protein shake named SkinShake; and SkInfusion; a micronutrient drink designed to be taken during exercise, when blood flow to the skin is at its highest.

Additionally, two special teas, and capsules to help sleeping and skin, hair and nail quality are also featured in the range. Following the event, Dr Jack said, “I was overwhelmed with the turnout and support at my launch dinner for my Integrative Beauty range at George in Mayfair. I am looking forward to launching the range to the public later this month and launching the brand with some large retail partners very soon.”

JCCP Stakeholder Council launch, London Guests from a range of backgrounds and companies in aesthetics were invited to attend the Joint Council of Cosmetic Practitioners (JCCP) Stakeholder Council launch at Chandos House in London on September 20. The aim of the launch event was to introduce the Stakeholder Council and showcase the core purpose and mission of both the JCCP and the Clinical Practice Standards Authority (CPSA).

JCCP inaugural chair Professor David Sines said, “The Stakeholder Council has been created by the JCCP Board of Trustees to provide the Board with advice, opinion, guidance and recommendations from a variety of informed perspectives about the operations of the JCCP in pursuit of its mission. The Council’s members reflect diverse experiences, geographies and interests in relation to the work of the JCCP.” Part of the Council’s advice will include policy development, application of the JCCP/CPSA’s standards, the operation of the JCCP Registers and raising public awareness about patient safety in aesthetics. Paul Burgess, executive support to the JCCP, said, “By establishing the Stakeholder Council, we are extending an invitation to all stakeholders to join with us to contribute purposefully to the work of the Council. By engaging and sharing positive contributions, the Stakeholder Council will seek to become a powerhouse for change within the sector.”

iConsult Discovery Day, Birmingham On September 25, clinic management software developer iConsult held a business workshop at the Hilton Hotel in Birmingham to provide aesthetic professionals with new strategies to help take their businesses to the next level.

The event opened with a video and presentation by founder and creator of iConsult Interactive Client Management System, Richard CrawfordSmall. Also speaking at the event was brand and design specialist, Russell Turner; and Ruth Zawoda, founder and managing director of aesthetic content marketing service Truly Content. Sharon Allen, business development executive of Enhance Insurance, who attended the event as a delegate, said, “It was extremely inspiring and insightful to learn more about how you can make sure your business is the best it can possibly be.”

Crawford-Small said of the day, “The right kind of exposure and marketing plan for a start-up brand or clinic in this industry is not easy. Our Discovery Days are an entry level stepping stone, that can help new and established businesses launch a product or service into the aesthetics market.” He added, “We hope our delegates learnt how to create a clear, effective and easy to implement sales and marketing plan that reflects their unique selling points.” The next Discovery Day will be on November 15 at the Dallas Burston Polo Club in Worcestershire.

IBSA International Masterclass, Pavia UK distributor of IBSA Farmaceutici Italia, HA-Derma, invited guests to travel to the picturesque Italian town of Pavia for two days of learning on September 14 and 15. IBSA’s dermoaesthetic business unit manager, Tania Pirazzini, and international sales manager, Leo Magnani, welcomed practitioners from the UK, Belarus, Israel, Lithuania, Spain and Ukraine to the IBSA International Masterclass. The two-day programme began with an introduction to IBSA and its product portfolio, with the first day dedicated to combination protocols of Aliaxin dermal filler and Profhilo HA hybrid for skin remodeling. Pirazzini explained the key features of both products and why they are ‘different and unique’. Attendees also enjoyed theory presentations, which were complemented with numerous live demonstrations.

Professor Daniel Cassuto shared advice on face reframing and periorbital rejuvenation, while Dr Antonello Tateo demonstrated injection techniques for hand and neck rejuvenation. Dr Gabriel Siquier Dameto presented on how to achieve ‘the perfect lip’ and Dr Giovanni Salti demonstrated non-surgical rhinoplasty. On the second day, attendees heard talks about IBSA’s multi-level tissue regeneration concept and learnt about recommended protocols and clinical studies for the products. These talks were complemented with live demonstrations of the appropriate injection techniques.

Reproduced from Aesthetics | Volume 4/Issue 12 - November 2017

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Conference Reports

Aesthetics reports on the highlights of the latest conferences in the specialty

IAPCAM Symposium, London

Aesthetics Business Conference, London

Delegates attended the International Association for Prevention of Complications in Aesthetic Medicine’s (IAPCAM) symposium in London on September 21. Held at the Church House Conference Centre in Westminster, London, the symposium attracted 125 delegates and provided them with the some of latest information on the management of complications on a range of aesthetic procedures. After a welcome from conference director Dr Beatriz Molina, there was an anatomy session held by Dr Simon Ravichandran, who reminded delegates of the danger and safe zones the face. Oculoplastic surgeon Mr Phillippe Berros discussed how to safely inject and manage complications in the periocular area, while Dr Tahera Bhojani-Lynch presented her cases of delayed hypersensitivity due to dermal fillers and how she handled them. Dr Patrick Treacy discussed a case study using his HELPIR technique to restore tissue after vascular occlusion, while Dr Max Malik talked about body dysmorphic disorder (BDD) and the questions practitioners should ask to diagnose patients and avoid complications later. Dr Beatriz Molina said of the symposium, “The conference went really well, I was pleased at the large number of people that attended and the high quality of the speakers. Delegates were able to take something away from each talk.”

The first ever Aesthetic Business Conference (ABC) hosted by Hamilton Fraser and Church Pharmacy took place at The Royal Society in London on September 25. The conference aimed to equip practitioners and clinic managers with business knowledge through numerous presentations and networking. A variety of sessions were held, which were hosted by Hamilton Fraser Cosmetic Insurance, Galderma, Church Pharmacy, AestheticSource and the JCCP. Sessions included a talk on technology in aesthetics with co-director of Church Pharmacy, Zain Bhojani, and managing director of CRM software company Pabau, Billy Brandham. This was followed by a talk on delivering patient-centered consultations with Dr Ravi Jain, who discussed the importance of providing excellent patient service, and advised on how to increase customer satisfaction. Additionally, aesthetic nurse prescriber and trainer Lorna Bowes presented on the value of long-term patient relationships, which was followed by a talk from aesthetic insurance and claims manager, Naomi Di-Scala, who detailed how to deal with regulatory requirements and retain patients in clinic. Director of Cosmetic Digital, Adam Hampson, led the final session on improving digital marketing. The conference ended with a panel discussion on the future of the industry and saw industry leaders debating critical themes set to affect the aesthetics specialty.

BCAM Conference 2017, London

On Saturday September 23, 260 medical aesthetic practitioners gathered at the Church House Conference Centre in London for the British College of Aesthetic Medicine’s (BCAM) annual conference. The day began with a welcome from conference director Dr Ruth Harker, who said that the aim of the conference was for doctors to confer with each other, as it is essential in aesthetics to share information and be involved in a network. Two agendas took place over the course of the day along with an exhibition. In the Main Lecture Programme, delegates heard about infection control from Dr Bela Horvath, while consultant plastic surgeon Mr Nigel Mercer discussed how practitioners can work with surgeons for a blendedskill approach. A popular topic of the day was threads; a panel of six practitioners discussed the development and popularity of the treatment, before demonstrating their use to the audience. Among other topics highlighted in the Main Lecture Programme were, fat grafting, cryolipolysis and different types of body sculpting, as well as

how to diagnose dermatology conditions.

In the Business and Clinical Forum Programme, BCAM board member Dr Uliana Gout, Dr Lauren Jamieson and Dr Xavier Goodarzian presented individual sessions on topics concerning skincare and considered best practices for chemical peels, hair and skin health in a panel discussion. Dr Goodzarian showcased a complication case study of post-inflammatory hyperpigmentation (PIH) due to chemical peels, and explained how he managed it effectively. “You can reverse PIH, but if you are doing a chemical peel treatment you need to know how to manage it as you have to deal with it very quickly,” he said. In the afternoon, Dr Emma Ravichandran performed a live lip augmentation demonstration, to a full audience, which was followed with advice from Dr Anusha Govender on dealing with patients with BDD. The programme ended with the launch of the BCAM Academy, which is targeted towards doctors who do not yet fulfil the criteria to become BCAM members. BCAM president Dr Paul Charlson and BCAM board member Dr Chrissy Coffey explained that the academy will help educate doctors in all areas of aesthetics, from training and complication management to professionalism within the field. Dr Charlson said of the day, “It’s been fantastic. We have tried to make it more scientific and evidence-based with serious discussions; all the talks have been excellent and there have been so many good speakers. We have had great feedback on the quality of the meeting and the networking opportunities for both colleagues and exhibitors alike.” The 2018 BCAM conference will take place at Church House in Westminster on Saturday September 22.

Reproduced from Aesthetics | Volume 4/Issue 12 - November 2017

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scope, and I think that this was partly to do with a lack of understanding of what HRS entails,” says Dr Williams. He explains the importance of understanding the definition of HRS, which is detailed in the guide, saying, “There are two types of HRS – the first is hair transplant surgery and the second is prosthetic hair fibre implantation. For the purposes of the CQC, it does not include hair-bearing flap surgery or non-surgical forms of hair restoration such as platelet rich plasma injections, mesotherapy or microneedling.”

He continues, “There has also been a lack of clarity as to whether or not hair transplantation is surgery; there are two techniques for harvesting donor hair to transplant – the first being strip follicular unit transplantation (FUT), which involves an incision in the skin and is clearly surgery, and the second being follicular unit extraction (FUE), which some practitioners claim isn’t surgery because it involves multiple small round punch incisions. However, as the total cross-sectional area of the round incisions is large, there is potential for significant bleeding, and there can be serious complications. The newly formed Cosmetic Aesthetics looks at the confusion surrounding Practice Standards Authority (CPSA) has clearly acknowledged both techniques as Level 1b standards and guidelines for hair restoration invasive surgical procedures.” surgery, and examines how some practitioners The uncertainty as to whether hair may be putting themselves at risk transplantation was deemed as ‘surgery’ also came up after the Keogh review. Following Last month, the British Association of Hair Restoration Surgery Keogh, the Royal College of Surgeons (RCS) took ownership of the (BAHRS) announced it had contributed to the development cosmetic surgical treatment recommendations and Health Education of a Care Quality Commission (CQC) inspection guide on hair England (HEE) did the same with non-surgical procedures. But, restoration surgery (HRS), with the aim of promoting patient according to Dr Williams, there was a dilemma about where HRS safety in the HRS field. The guide – which is not available for public should go, as he says the majority of HRS procedures are carried out viewing – is said, by BAHRS President and hair transplant surgeon by doctors who do not have a surgical qualification.

Dr Greg Williams, to provide CQC specialist advisors with clear In Phase One of the HEE Final Report (2014), it is stated, “HRS is guidance when inspecting clinics that provide HRS, to ensure they classed as a Level 1b invasive surgical procedure usually done under meet CQC standards. Aesthetics speaks to Dr Williams to ask why local anaesthetic and is delivered in the UK and internationally by he believes the inspection guide was necessary and how patient doctors from a variety of medical backgrounds, not limited to those safety is being put at risk. with formal surgical training. The Cosmetic Surgery Inter-speciality Committee (CSIC) has taken the view that hair restoration surgery The guide would fit better with work on non-surgical cosmetic interventions By law, clinics offering surgical procedures must register with the (NSCIs) led by HEE, given the non-surgical background of the majority CQC.1 Some time after registration, a CQC team, including specialist of practitioners who currently perform this procedure.”2 advisors, should inspect the clinic to ensure that it meets CQC Although HRS now comes under the authority of the Joint Council for standards. The new HRS guide aims to assist the specialist advisors, Cosmetic Practitioners (JCCP), Dr Williams explains that the CQC has who are unlikely to have specific knowledge on professional areas now recently clarified that all hair restoration surgery procedures are such as HRS, to make a proper and valid assessment. According indeed ‘in scope’, and therefore all clinics offering these procedures to Dr Williams, it will give the advisors a general description on the must be registered with the CQC.1 different types of hair restoration surgery procedures and the areas of Due to the lack of understanding over the years on whether HRS patient care that need extra scrutiny. should be CQC registered, some practitioners may be putting themselves at risk of breaching the law by not being registered. “I Lack of clarity believe that there are a large number of clinics offering HRS that Dr Williams explains that one of the main issues with CQC registration are not CQC registered,” says Dr Williams. He explains, “Some is the confusion that has existed with regards to HRS. “In the past, practitioners may have misinterpreted the scope, some may have there have been some inconsistencies in the information that was realised it was vague and therefore chosen to interpret it differently, given out by the CQC about whether or not HRS was in the CQC’s and others may have been told they did not need to register.”

Standards and Regulation of Hair Restoration Surgery

Reproduced from Aesthetics | Volume 4/Issue 12 - November 2017

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Dr Williams explains that the BAHRS will be reporting all clinics it is aware of, that are offering HRS but are not registered. Once reported, it is up to the CQC to take steps to stop clinics operating until they are registered.

Dr Williams further clarifies, “Any service provider offering hair transplant surgery or prosthetic hair fibre implantation must be registered with the CQC. A service provider can be an individual, a partnership or an organisation [such as companies, charities, NHS trusts and local authorities]. A service provider, which is a subsidiary of another company that is CQC registered must still, itself, be registered.”3 He adds that, “A service provider can use or rent an operating theatre of another service provider but both providers must be CQC registered. The location may not need to be registered but the provider must be.”4

The future Two new HRS standards are due to be released in early 2018 by the CPSA – one on hair transplant surgery and one on prosthetic hair fibre implantation.5 For practitioners who practice HRS, to be included on the JCCP register, they must meet the standards of the procedures they offer to patients. Dr Williams, who has worked with the CPSA on these standards, explains, “We can certainly say at this stage, it is proposed that only GMC registered doctors should perform the surgical steps of hair transplantation procedures, which includes making FUE incisions to harvest donor hair, and that only GMC registered doctors who are also hair transplant surgeons should offer prosthetic hair fibre implantation.” The standards will

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also reiterate that both forms of HRS must be undertaken by CQCregistered service providers.3 However, Dr Williams says patients need to be made more aware of the dangers, “I think there needs to be wider public awareness campaigns about HRS, who can offer it, and the type of facility where it should be performed. I also believe patients and practitioners should not hesitate to report any clinics to the CQC that offer HRS and are not registered.” Dr Williams concludes, “If you are operating on patients in a non-CQC registered hair transplant clinic then you are operating illegally.”

REFERENCES 1. CQC, Regulated activities, Care Quality Commission, <http://www.cqc.org.uk/guidance-providers/ registration/regulated-activities> 2. HEE, Review of qualifications required for delivery of non-surgical cosmetic interventions, Phase 1, (2014) <https://hee.nhs.uk/hee-your-area/north-west-london/our-work/attracting-developing-ourworkforce/qualification-requirements-non-surgical-cosmetic-procedures> 3. CQC, Scope of registration, <http://www.cqc.org.uk/sites/default/files/20150428_scope_of_ registration_independent_medical_practitioners_working_in_private_practice.pdf> 4. CQC, What is a location guidance, <http://www.cqc.org.uk/sites/default/files/20160211_300900_ v6_00_what_is_a_location_guidance.pdf> 5. CPSA, Hair Restoration Surgery <http://www.cosmeticstandards.org.uk/hair-restoration-surgery.html>

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Develop vital commercial skills at the Business Track

Introducing ACE 2018 Registration for the leading medical aesthetic conference and exhibition in the UK is now open! Find out more about the huge variety of free content on offer, as well as the unique Elite Training Experience The time to register for the unmissable medical aesthetic event of the year has arrived! Once again, aesthetic professionals from across the UK will meet at the Business Design Centre in London on April 27 and 28.

Delegates will enjoy two days of education delivered by leading speakers, have the chance to explore the 2,500m2 Exhibition Floor and discover all the latest products and services, as well as the unique opportunity to network with professionals from across the specialty. Whether you are new to aesthetics or have years of experience, if you’re a doctor, nurse, surgeon, dentist, clinic owner, manager, aesthetician or any other professional working within aesthetics, there will be something for you to gain at the Aesthetics Conference and Exhibition (ACE) 2018!

Gain key product knowledge at the Masterclasses

The Masterclasses, held in private rooms in the gallery, offer the chance to gain insight into how the UK’s key opinion leaders get the best results from the products and treatments they use. These in-depth, interactive 60 to 90-minute sessions will be run by 12 prominent aesthetic companies, which so far include Galderma, SkinCeuticals and Lumenis, with more to be announced in the coming months. Topics covered will include, the mechanism of action of products, administration techniques, patient assessment, side effects and complication management.

Whether you’re new to the specialty and looking to grow your business or just hoping to brush up on various aspects of running a clinic, the Business Track, sponsored by Enhance Insurance, is the place to be. Across the 18 sessions set to take place, delegates can learn about opening a new clinic, tax and VAT, PR, marketing, regulation, training, insurance, building a brand, and so much more! Martin Swann, divisional director of Enhance Insurance says, “I think the Business Track offers delegates a really good opportunity to plan their knowledge around topical subjects that are going to help them in business. Anyone that’s going to come to the Business Track will learn valuable tips to take home to their practice.”

Meet aesthetic professionals at the Exhibition

The ACE Exhibition Floor will become home to more than 80 leading aesthetic distributors, suppliers and manufacturers.

All the latest products and services will be showcased, with live demonstrations on stands taking place, allowing delegates to discover all the latest innovations. ACE programme organiser Amanda Cameron said, “ACE 2018 will be bigger and better than ever before. As always, we have an abundance of free educational content on offer, more than 40 CPD points to gain, the best speakers in the specialty and a huge number of exhibitors offering essential products and services to suit all your clinic’s needs. Everyone working within aesthetics should be a part of this valuable event that is dedicated to supporting the growth of the specialty.”

Watch live demonstrations at the Expert Clinic A favourite amongst delegates – the Expert Clinic – will be situated on the Exhibition Floor and will feature 17 sessions, each 30-minutes in length. They will be sponsored by leading aesthetic companies, which will equip practitioners with all the latest technique advice, treatment overviews and product knowledge to truly enhance their clinical offering. Live demonstrations will take place and topics will cover injectables, skin rejuvenation, body contouring and much more. So far, sponsors include AesthetiCare, mesoestetic, Cynosure UK Ltd, Needle Concept, HA-Derma, AestheticSource, Unique Skin and Cutera Medical.

Reproduced from Aesthetics | Volume 4/Issue 12 - November 2017

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Led by consultant plastic and aesthetic surgeon Mr Dalvi Humzah and featuring an expert national and international faculty, this session will deliver practical and interactive expert tips on how to enhance your skills using cannulas, anatomical details of product placement and how to address specific skin and facial concerns.

Aesthetic practitioner Dr Tapan Patel will lead this in-demand session that will see live demonstrations of filler and toxin procedures, as well as high-definition animated videos to explain key anatomical features and detail skilful injection techniques.

Dr Kate Goldie will bring a taster of her popular course on Saturday morning, which will see her conduct live demonstrations and discuss the art of individualised cheek/mid-face treatments, lip sculpting, facial assessment, periorbital rejuvenation and combining treatments.

Dr Raj Acquilla, supported by nurse prescriber Jane Wilson, will present and perform live demonstrations on the ‘total face approach’. The highly-sought after training will focus on facial aesthetic ideals, facial anatomy for hyaluronic acid and botulinum toxin injection, risk avoidance and complication management.

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Meet the Trainer Aesthetic practitioner Dr Ryan Hamdy is the founder of the Cheshire International School of Cosmetology (CISC) and runs the Aesthetics Academy. He talks training days and after-course support.

Tell us about your experience. How did you become an aesthetic trainer?

I qualified from Manchester Medical School as a medical practitioner in 1987. For about 20 years of my career I worked in general practice, where I also spent time as a clinical assistant at my local dermatology department, primarily removing skin cancers and lesions. About 10 years ago I Dr Ryan Hamdy decided to complete my first aesthetic training course to collect CPD points. I attended Cosmetic Courses, which is run by consultant plastic surgeon Mr Adrian Richards, where I learnt how to administer botulinum toxin and dermal fillers. I have since completed numerous other training courses to update my skills and learn new techniques. Following the initial course, I didn’t practise for about three or four months, however that changed when a local beauty salon with a large client base and good reputation came up for sale. I took that over, which really propelled my aesthetic career as I now had an instant potential patient base. After growing the business, I eventually left the NHS in 2010 to practise aesthetics full-time in Nantwich, Cheshire. In terms of training, I’ve always enjoyed teaching. As a GP, I often taught junior doctors and supported nurses doing their prescribing course. I began running one-toone confidence building workshops as I realised that a number of practitioners still sought support after completing their training. After doing this for a couple of years, I opened the Cheshire International School of Cosmetology (CISC) training facility in Chester last year.

What are the main training opportunities at the Aesthetics Academy?

Training takes place at our 3,500ft2 facility, which comprises a conference room, three spacious self-contained training rooms, clinical room and break-out area. Our excellent facilities offer an alternative to training that is run in a smaller clinic/meeting room environment. We offer foundation and advanced training in the use of botulinum toxin and dermal filler. Training groups are small – usually comprising between five and six practitioners – and consist of day-long courses. We also offer bespoke training, where practitioners can basically create their own agenda. They can bring their own models and we will tailor their training to their exact requirements.

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Who would benefit most from attending your training sessions?

We only train medical professionals – so doctors, nurses and dentists – and all medical registers are checked to confirm this prior to training. We want to help people who aren’t confident to start, so try to make the training as user-friendly and useful as possible. Our foundation course trains those with no experience in aesthetics, as well as practitioners wanting to brush up on their basic skills. To be accepted on the advanced course, delegates will need to have undergone previous training. This can be a slightly grey area, as some people may have been trained more than a year ago, but won’t have practised at all during that time, while others may have undergone training just six months ago but have a lot more practical experience. We do get some people who are perhaps trying to run before they can walk, so we will recommend further foundation training if it is needed. We ask questions to try and get an idea of each person’s experience when they book, so we can tailor sessions to suit each of our trainees.

The key thing for potential delegates to know is that they will feel 100% comfortable from the moment they start. They won’t feel under pressure or embarrassed – we give each trainee personal attention, while supporting and encouraging practitioners throughout.

How is a typical training day structured?

The day will begin with a theory lesson, where we will explore the history of botulinum toxin/dermal filler, brand awareness, anatomy and physiology, dosing, preparation and marketing. The afternoon will then consist of live demonstrations and handson training on patient assessment, skin preparation, injection technique and aftercare. We also talk about indications, side effects, potential complications and how to successfully manage these.

For us, getting people to have as much hands-on experience as possible is essential. If you don’t practise injecting under supervision, you’re unlikely to do it when you’re not being supervised and/or will face more challenges when you do start.

What support do you offer once a practitioner’s training has been completed?

I’m a big advocate of post-course support. Following our training, delegates can join the Aesthetics Academy forum, which is a peer-to-peer support network that meets once a month to discuss recent cases, as well as share advice on both the clinical and business sides of running an aesthetic practice.

Last month, Sally Taber from Treatments You Can Trust attended and gave a talk on developments within the Joint Council of Cosmetic Practitioners.

We also have an active WhatsApp group in which we share useful tips and talk about our experiences.

People tend to have their phones on all the time, so

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are generally very good at responding on WhatsApp, meaning each question or request will be responded to with an appropriate answer.

Members also have access to a range of anatomical resources and how-to videos, which are particularly useful to practitioners wanting to refresh their knowledge following training. We have lots more exciting educational activities planned for the next 12 months!

Advertorial Meet the Trainer

K E Y STATS 30 years’ clinical experience 10 years in medical aesthetics 5-6 delegates per class going away. Members love this support, as there’s someone else who can keep an eye on things and give the practitioner peace of mind while they’re away. Finally, all trainees are encouraged to speak to me directly. They will not be put through to a receptionist if they have a question following their training – I happily support, and always have time, for all my trainees. We’ve got to have new people entering the specialty, otherwise it runs out of steam, but I know that if something goes wrong, it could put practitioners off injecting again and can almost ruin a career before it’s started. Being able to speak to a mentor during that formative stage of your career is hugely important.

Are there any other benefits of training with the Aesthetics Academy?

Yes! All delegates receive post-training mentorship and, if a delegate chooses to become a member of the Aesthetics Academy forum following their training, they will have access to our ‘Prescribing Buddies’ database, which they can use to pair up with an appropriate prescriber within their local area. In addition, most clinicians practise in isolation, yet they will have other commitments or need a holiday once in a while. As such, the network’s members support each other with holiday cover. They can use the network to find a suitable practitioner within their area who will cover their patients’ concerns, if they are

TES T IM O NIA L S “Best aesthetics course I have ever attended.

Don’t usually do A+P first which really helped my understanding. Handouts were also fantastic. Will be back for more training!”

Ross Needham, nurse prescriber

“I was considering providing dermal filler treatments at my clinic and this course gave me the impetus I was looking for. I felt as though I was in safe hands throughout the course and the practical sessions were helpful rather than daunting.”

Peter Forest, nurse prescriber

“I made great progress attending the foundation Botox and dermal filler courses at CISC, but I felt that I needed a little more tuition before I started offering the treatments at my own clinic. The bespoke training was perfect – there were lots of opportunities to practise injecting and ask questions. Dr Hamdy put me at complete ease and I feel so much more confident now.”

Annabel Hardy, nurse prescriber

What are the measurable outcomes for trainees and how are they assessed?

We provide certification that will allow delegates to obtain relevant insurance once they have successfully completed the course.

Everyone gets certification and can practise on the strength of what they’ve learnt – if we have any concerns over a delegate’s ability, then we will address these privately prior to issuing certification. We are also looking towards Level 7 accreditation in the near future.

What is the key message that practitioners should take away from your training?

You won’t become an expert after one day of training, but we offer a training template that, at the very least, allows you to be safe when treating patients. The Aesthetics Academy offers good quality training, personal service, and excellent after-training support!

UPCOMING TRAINING DATES • Foundation Filler Course: Nov 4th, Dec 6th, Jan 20th • Lip Filler Masterclass: Nov 5th, Jan 31st • Tear Trough Masterclass: Nov 13th • Foundation Toxin Course: Nov 25th, Jan 10th • Advanced Toxin Course: Dec 13th For 1-2-1 training, please contact us directly.

E enquiries@cisc-training.co.uk T 0800 161 3250

For a comprehensive range of facial aesthetics training, look out for the new Med-fx training portal – launching in November at medfx.co.uk Aesthetics | November 2017

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Terms and conditions apply, and are available upon request. Offers are only valid on a single order taken between Wednesday 1st November until Wednesday 15th November 2017.

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Facial Assessment and Treatment Aesthetics speaks to three practitioners who discuss how they assessed and treated patients at last year’s Aesthetics Conference and Exhibition As everyone knows, it’s very difficult to learn a new practical skill, or to improve upon one that you already have, by simply studying a textbook. To be completely competent in medical aesthetic treatments, practitioners must ensure they receive sufficient practical training for each and every procedure. This training, many practitioners note, is ongoing and essential for safe practice and effective treatments. There are many different ways to learn or stay updated with current practice, but one way is to hear different practitioners with unique experiences

speak about their patients to a live audience. It is useful to watch others assess different faces, discuss their most challenging cases, answer audience questions and perform live demonstrations. A perfect opportunity to get this valuable experience is at congresses. With registration for the Aesthetics Conference and Exhibition (ACE) 2018 now open, we re-live just a few of the highlights from last year and take a look at the premium live facial assessments and demonstrations to showcase the outstanding content that was presented on stage.

integrate well within the tissue and not attract too much water, which could result in oedema. When choosing products for the eye My patient, a 49-year-old male, thought that he area you need to consider the G prime, or elasticity, of the product looked tired around the eyes and described himself and how it will behave, because some HAs are not suitable for the as ‘haggard’ in appearance. In my assessment, eye area. If the patient has thinner skin you need a softer product, I noticed that he had deep grooves around the eyes, quite while with thicker skin you can afford to have a higher G Prime. noticeable perioral lines and under-eye bags. As men have thicker Your product also needs to have a lifting capacity, but it can’t be skin than females, they can be more difficult to treat as the grooves too hard because the eye tissue is very thin, so the product choice around the eyes often become much deeper. Although you could is dependent on the patient. I have traditionally used Restylane address the eye grooves using a toxin, I wanted to demonstrate Refyne or Defyne in this area, which give brilliant results; however, the results that can be achieved using only dermal filler. When for this live demonstration, I used Aliaxin SR. injecting around the eyes, I would definitely recommend using I began by making an injection point at the very end of the tear a hyaluronic acid (HA) filler because it’s such a high-risk area. trough in the mid-face, about 2cm below the orbital rim using a You need to make sure that you have a product that is going to 23G needle. I then used a 25G cannula and injected deep to the bone and pointed upwards behind the tear trough area, Before After but didn’t go above the bone, and placed some product in the tear trough to soften it. Then I injected directly onto the orbital rim and went perpendicular onto the bone using a 30G needle, placing deposits of product along the whole of the rim on top of the bone. In total, we used 1ml of product per side.

In terms of potential complications for this treatment, there is a high risk of bruising in the periorbital area and there is a possibility of oedema if you don’t inject onto the bone. You must mention the risk of blindness to the patient, but, in my experience, if you inject on the bone this risk is really low Before After because there are no blood vessels here. I recommend that anyone treating the periorbital area go to an advanced masterclass to get the appropriate training before they attempt this procedure. It looks very easy when you see it, but you really need to observe and practise a lot; an anatomy masterclass is essential. Considering we used quite a small amount of product, the thickness of the skin and the age of the patient, I thought the results were good and I was very impressed. You can see the difference in volume quite well as the depression was Figure 1: A 49-year-old patient before and immediately after a perioral treatment by Dr Molina using very deep. The patient was happy and said he thought 1ml of Aliaxin SR dermal filler on each side. Images courtesy of Surface Imaging Solutions using the he looked natural and refreshed.

VECTRA H1 3D camera.

Male perioral rejuvenation

Aesthetic practitioner Dr Beatriz Molina

Reproduced from Aesthetics | Volume 4/Issue 12 - November 2017

AVAILABLE IN 4 PACK SIZES

Bocouture® (Botulinum toxin type A (150 kD), free from complexing proteins) 50/100 unit vials. Prescribing information:M-BOCUK-0067. Please refer to the Summary of Product Characteristics (SmPC) before prescribing. Presentation: 50/100 units of Clostridium Botulinum Neurotoxin type A, free from complexing proteins as a powder for solution for injection. Indications: Temporary improvement in the appearance of moderate to severe upper facial lines (glabellar frown lines, crow’s feet lines, horizontal forehead lines) in adults ≥18 and <65 years when the Xseverity of these lines has an important psychological impact for the patient. Dosage and administration: For intramuscular use only. Unit doses recommended for Bocouture are not interchangeable with those for other preparations of Botulinum toxin. Bocouture may only be used by physicians with suitable qualifications and proven experience in the application of Botulinum toxin. The intervals between treatments should not be shorter than 3 months. Reconstitute with 0.9% sodium chloride.

Horizontal Forehead Lines: The recommended total dose range is 10 to 20 units; a total injection volume of 0.25 ml (10 units) to 0.5 ml (20 units) is injected into the frontalis muscle in five horizontally aligned injection sites at least 2 cm above the orbital rim. An injection volume of 0.05 ml (2 units), 0.075 ml (3 units) or 0.1 ml (4 units) is applied per injection point, respectively. Glabellar Frown Lines: Total recommended standard dose is 20 units. 0.1ml (4 units) into 5 injection sites (2 injections in each corrugator muscle and 1 injection in the procerus muscle). May be increased to up to 30 units. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. Crow’s Feet lines: Total recommended standard dosing is 12 units per side (overall total dose: 24 units); 0.1ml (4 units) injected bilaterally into each of the 3 injection sites. Injections too close to the Zygomaticus major muscle should be avoided to prevent lip ptosis.

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

may not respond to Botulinum toxin products. Should not be injected into a blood vessel. Not recommended for patients with a history of dysphagia and aspiration. Caution in patients with amyotrophic lateral sclerosis, peripheral neuromuscular dysfunction, or in targeted muscles displaying pronounced weakness or atrophy. Bocouture should be used with caution in patients receiving therapy that could have an anticoagulant effect, or if bleeding disorders of any type occur. Too frequent or too high dosing of Botulinum toxin type A may increase the risk of antibodies forming. Should not be used during pregnancy unless clearly necessary. Should not be used during breastfeeding.

Interactions: Concomitant use with aminoglycosides or spectinomycin requires special care. Peripheral muscle relaxants should be used with caution. 4-aminoquinolines may reduce the effect. Undesirable effects: Usually, undesirable effects are observed within the first week after treatment and are temporary in nature. Undesirable effects independent of indication include; application related undesirable effects (localised pain, inflammation, swelling), class related undesirable effects (localised muscle weakness, blepharoptosis), and toxin spread (very rare exaggerated muscle weakness, dysphagia, aspiration pneumonia).

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

Common: Hypoaesthesia, injection site haematoma, application site pain, eyelid ptosis, dry eye, facial asymmetry, sensation of heaviness, nausea. Glabellar Frown Lines: Common: Headache, Muscle disorders (elevation of eyebrow). Crow’s Feet Lines: Common: Eyelid oedema, dry eye, injection site haematoma. For a full list of adverse reactions, please consult the SmPC. Overdose: May result in pronounced neuromuscular paralysis distant from the injection site. Symptoms are not immediately apparent post-injection. Legal Category: POM. List Price: 50 U/vial £72.00, 50 U twin pack £144.00, 100 U/vial £229.90, 100 U twin pack £459.80. Product Licence Number: PL 29978/0002, PL 29978/0005 Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer Landstraße 100,60318 Frankfurt/Main, Germany.

Date of Preparation: February 2017. Further information available from: Merz Pharma UK Ltd., 260 Centennial Park, Elstree Hill South, Elstree, Hertfordshire WD6 3SR. Tel: +44 (0) 333 200 4143

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

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

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

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

2. Bocouture® 100 units Summary of Product Characteristics (SmPC).

September 2016. Available from: https://www.medicines.org.uk/ emc/medicine/32426 3. Kerscher M, et al. Efficacy and Safety of IncobotulinumtoxinA in the Treatment of Upper Facial Lines: Results From a Randomized, Double-Blind, Placebo-Controlled, Phase III study. Dermatol Surg 2015;41:1149-1157 Bocouture® is a registered trademark of Merz Pharma GmbH & Co, KGaA. M-BOC-UK-0107 Date of Preparation October 2017

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Aesthetics Journal

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the side profile. I also wanted to make her mouth fit with the jawline so that it runs like a smooth curve from the cheek, right across the lower part of her lip without the little marionette line, which would As my 53-year-old patient’s main concern was the give her a more harmonious lower face. lower part of her face, I concentrated on examining In the mandibular region, there are three areas that we usually this area in detail, rather than doing a full facial assessment. What need to address: the bone, the soft tissue and the skin. In this you need to look for is how the lower facial shape fits in with patient, I wanted to correct the boney area of the jawline and the the rest of the face, what the structural changes are, and what soft tissue area around the mouth, so for this demonstration we treatments would be needed to achieve a more harmonious face. used Radiesse (+) dermal filler. It has a good firmness when you I noticed that although the patient’s skin was of good quality, it was inject it, so it feels hard like bone, which is what you want, and you a little lax and there was disproportion to the shape of the face. can also use it within the soft tissue. It has the ability to stimulate the From the frontal view, you can see that, to the side of the chin, she skin, so if you have any problems with the skin laxity it will allow for has a jowl and it curves inwards quite noticeably. From the side, it’s skin collagenase to occur, which will lift and firm the skin.

I decided to use a technique that we developed, Before After the Hammock-Lift, to give the patient more shape to her jawline. The Hammock-Lift technique aims to rebuild the boney tissue and then revolumises and repositions the soft tissues, addressing the changes in the mandibular region using a layered approach.

Using a 25G 38mm cannula, I injected down onto the supra-periosteal layer and layered some product along the edge of her mandible to increase her mandible height. I used a cannula because it allows me to easily get into different layers and due to the fact that it is generally less painful when injecting deep. Radiesse (+) contains local anaesthetic, which Before After also helps to reduce the pain. I then injected onto the anterior part of the chin and at the back of her jawline to give it more of an angle. Following that, I placed filler within the soft tissues of her jaw to give the patient a straighter jaw. I also placed product in the soft tissues and skin just around the under-lip to marionette line for some added support. For the whole area, we used about 2.8ml of filler.

When performing treatments in the mandibular region, practitioners must know where they are placing the products, particularly when injecting Figure 2: A 53-year-old patient before and immediately after a lower facial treatment by Mr Dalvi Humzah deep in the lower part of the face. They need to using 2.8ml of Radiesse (+). Images courtesy of Surface Imaging Solutions using the VECTRA H1 3D camera. know where the inferior mental nerve is, which lies clear her jawline has lost definition and the back of her jaw shape just below the canine teeth in the lower jaw, and where the gums is angulated, rather than a nice 90 degrees.1 I also noticed that she are because it’s very easy to inject too deeply and closely to the had a downturned mouth, giving her a slightly sad appearance. oral sulcus. Practitioners also need to know where the bone is in I wanted to focus on changing the lower facial profile and give it relation to the gingival sulcus, where the lips and gum join up, and more of a V-shape from the front view and define her jawline from they must watch out for complications such as vascular problems.

Practitioners should specifically know the anatomy in the lower face and the location of the facial artery and vein before performing treatments in these areas.

You can see that in the ‘after’ photo there is a nice lower face improvement, however, if you look around the eye, the patient has a developing tear trough and the brow is also dropping slightly, so she might benefit from further treatment. This patient has looked after her skin very well so there’s not a lot more I’d want to do for her as it would make her look over-treated.

However, she has a bit of sun damage so I’d be offering her some sort of skin revitalisation, for example Profhilo, an injectable HA that stimulates collagen and elastin, or some chemical peels to improve the skin texture and quality, which will aim to give her skin a bit more ‘sparkle’.

Lower facial rejuvenation

Plastic reconstructive and aesthetic surgeon Mr Dalvi Humzah

You can see that, to the side of the chin, she has a jowl and it curves inwards quite noticeably

Reproduced from Aesthetics | Volume 4/Issue 12 - November 2017

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Aesthetics Journal

Lip augmentation

Aesthetics

Before

After

Before

After

Aesthetic nurse prescriber Sharon Bennett

In every patient assessment, it is important to explicitly ask patients what concerns them rather than to assume this yourself. This because, I believe, draw attention to something so small that the patient might not have otherwise noticed, or were not bothered about, is unnecessary. With younger patients especially, you can trigger a deep and long-term dissatisfaction in appearance. My patient, a 25-year-old, told me that, overall, what bothered her most was her lips and her skin quality. In my assessment, I noticed that her lips were small compared to her total facial dimension and overall balance. Her face also appeared long; the distance from her nose to the top of her lip was long and her upper lip was lacking. I decided that if I treated her using filler to elevate the lip, it would reduce the nose to lip distance and give a better proportion to both her frontal and profile view. In terms of her skin texture, she had open-pores, some dehydration and small imperfections. She’s Australian and has lived in the sun, so she has had sun damage and she is showing some pigment because of this.

I firstly decided to treat her lips using Restylane HA filler. I don’t always use the same product for the lip, but for young patients wanting something a little more definitive I often choose Restylane, because it has high projection and includes lidocaine for pain reduction. I used a needle on this occasion because I wanted to inject more superficially, giving fine definition. I didn’t use a cannula here, but that’s a personal preference because I work better and more precisely with a needle. Initially, I injected along the vermillion border. I also injected into the red body of the lip to augment, as well as the philtrum to define and elevate it. I almost always inject both the upper and lower lip for balance; as HA also hydrates, if you only treat one lip then it might create an imbalance of hydration. In total, I used 1ml of Restylane. The main precaution I take while injecting, as all practitioners must, is to observe the skin as I inject and ensure that I am avoiding placement near the labial arteries. Anatomically I am familiar with their position, and they tend to lie deeper than my superficial filler placement. However, no two patients are the same and anatomy can differ from patient to patient. This is something we often see in cadaver dissections. To address my patient’s skin quality, I used the HA injectable Xela Rederm, which aims to promote skin hydration, while the added ingredient of succinate acid successfully addresses pigmentation concerns. You can inject this in many ways; I like to use a needle and place it at a superficial dermal level into the skin, but you can also use a meso gun or cannula. I treated her mid-face in lateral rows from the corner of the mouth up to the cheek

See all this and more at ACE 2018!

Hearing how other practitioners conduct their facial assessments and treatments, as well as learning about their unique approaches to different procedures, is extremely useful in further developing clinical skills. At ACE 2018, which takes place on April 27-28 in London, the country’s top expert practitioners will discuss their experiences on the Expert Clinic and Masterclass agendas. Delegates also have the opportunity to engage in anatomy discussions, learn about complication prevention and management, as well as watch facial assessments and demonstrations at the sessions within the exciting, brand

Figure 3: A 25-year-old patient before and immediately after lip augmentation and facial hydration treatment by Sharon Bennett. Images courtesy of Surface Imaging Solutions using the VECTRA H1 3D camera.

bone and along the jawline; afterwards I gently massaged. For the younger patient, I have found that this treatment gives brighter, glowing skin, while lifting and oxygenating the cells.

As the patient had a small asymmetry and her brows were a little uneven, with the left brow sitting higher, I finished off the treatment with some botulinum toxin to elevate the right brow to harmonise them. In terms of future treatments for this patient, she is only 25 years old so I don’t think there are any areas I would necessarily want to change further. We want to refresh and enhance what the younger patient has, and not alter their natural appearance.

However, I think, looking at the profile view, that she would benefit from a little filler in the chin to balance the nose chin proportion better, but I didn’t have time to do that on the day. She also had some minor acne, which we couldn’t address on the day, but I would advise a skincare regime that could include retinols, some AHAs and antioxidants. Sun protection is particularly important because of her pigmentation, and to act as a preventative.

Overall, I think the results I achieved are good; her lips now give her face more balance and it appears slightly shorter. Her face has also lifted and she looks hydrated. Although one usually needs around three of the hydration treatments to see optimum effects, she would have really noticed a difference immediately in her facial hydration and glow.

new, paid-for agenda, the Elite Training Experience.

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There are limited places available and the 10% Early Booking Discount for the Elite Training Experience ends December 31.

To register for free, or to book the Elite Training Experience, go to www.aestheticsconference.com REFERENCES 1. Shaw RB, Katzel EB, Koltz PF, Yaremchuk MJ, Girotto JA, Kahn DM, Langstein HN, ‘Aging of the facial skeleton: aesthetic implications and rejuvenation strategies’, Plastic & Reconstructive Surgery, 2011 Jan;127(1):374-83.

Reproduced from Aesthetics | Volume 4/Issue 12 - November 2017

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1. Sundaram H, et al. Comparison of the Rheological Properties of Viscosity and Elasticity in Two Categories of Soft Tissue Fillers: Calcium Hydroxylapatite and Hyaluronic Acid, Derm Surg 2010;1076-0512 2. Instructions for Use (IFU) Radiesse® 3. Schachter D, et al. Calcium Hydroxylapatite With Integral Lidocaine Provides Improved Pain Control for the Correction of Nasolabial Folds. Journal of Drugs in Dermatology. August 2016; Volume 15. Issue 8. 1005-1011 4. https://www.accessdata.fda.gov/cdrh_docs/pdf5/p050052s049a.pdf

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Aesthetics Journal

Augmenting the Chin Aesthetic nurse prescriber Anna Baker discusses the practical considerations for non-surgical injectable augmentation of the chin The aesthetic appearance of the face is significantly influenced by the underlying skeletal structure. An attractive face requires balance and proportion of a number of facial features,1 which include the nose, lips and neck in the lower face.2 If projection of the chin or width is inadequate, the neck and jowl soft tissues may appear prematurely aged.3 Appropriate aesthetic treatment of the chin can influence the appearance of the face and neck, whilst a number of effective approaches are acknowledged (autologous fat, chin implants and boney osteotomy of the chin).

Whilst surgical techniques are accepted and well established, the use of non-surgical dermal filler is growing in popularity with both men and women as a preferable treatment option. The assessment and analysis of the lower facial region is key to a successful nonsurgical aesthetic outcome. A variety of dermal fillers and associated techniques are described within the literature, underpinned by sound anatomical studies describing the anatomy of this region, to support the clinician in achieving a safe outcome. This article will focus on the practical considerations of the use of dermal fillers, supported by a detailed exploration of the salient anatomy.

Anatomy The anatomy of the face in relation to non-surgical aesthetic procedures is a specialist area of growing interest, owing to the unique senescent changes that manifest across all facial anatomic regions. There is a growing emergence of anatomical literature, underpinned by cadaveric findings that continue to

Mentonian symphysis

Mandibular ramus Mandibular line

Mandibular body

Mandibular ramus Mandibular line

Figure 1: Anatomical features of the mandible5

Aesthetics

shed new light on this developing area, profoundly influencing a clinicianâ&#x20AC;&#x2122;s awareness and understanding of injectable techniques and subsequent choice of product, and/or treatment.4 Skeletal ageing The facial skeletal changes are well established and clearly defined in the literature. Bone is a dynamic, sensitive and changeable tissue, with growth that takes place from birth until the hormonal influence ceases, consolidating at approximately 15-18 years of age.6 Conversely, bone remodelling allows bone architecture to adapt to meet changing mechanical needs, and involves removal of mineralised bone by osteoclasts and formation of bone matrix through osteoblasts.7 Shaw et al. described morphological findings from 120 dentulous Caucasian subjects (60 men and 60 women), demonstrating that the mandibular length and height decreased significantly in both sexes.8 Equally, with the onset of age, the chin becomes more anterior, oblique, and shorter,9 which is significant when analysing the face and planning appropriate treatment, as the boney foundation supports the position of overlying soft tissue. The protrusion of the chin further reduces by approximately 3-4mm by the age of 60 in males and females.1 The most centrally projecting aspect of the chin is the pogonion,3 whereas the menton is the most inferior component of the chin.10 Ligaments The mandibular ligament is one of two major facial ligaments. It supports the facial soft tissues, develops minimal laxity between its origin and connects with the superficial musculo-aponeurotic system (SMAS),8 demarcating the transition from the labiomandibular fold above, and jowl below.9 The jowl develops as a result of distension of the roof of the lower premasseter space with resultant descent of the soft tissues below the body of the mandible.11 The more pronounced the jowl appears, the more apparent the dimpling or tethering may be evident, which is the mandibular ligament. This tethering can be apparent in some individuals in a much younger age group, potentially as young as the mid-twenties,12 owing to anatomical variation, noticeable with mimetic expression.11,12 This is a key concept and essential to recognise as it may affect the aesthetic appearance of the chin. The dimpling and tethering effect cannot be effaced with dermal fillers or botulinum toxin (BoNT-A) and may only be corrected surgically.13 Fat compartments Gierloff et al. describes findings of distinct subcutaneous fat compartments in the mentolabial region, extrapolated from their small cohort cadaveric study, which included nine9 unembalmed specimens (five female, four male) between 72 and 89 years.13 A single layer of fat was identified in the region of the labiomandibular fold, with the labiomandibular crease lying between the labiomandibular fold compartment and the jowl fat.13 Furthermore, the labiomandibular fat pad (medial to the marionette line) undergoes a loss of volume along the lateral edge (parallel to the marionette fold), which can further emphasise the line.14 The medial edge of the depressor anguli oris (DAO) muscle follows the course of the crease, which can be used as a landmark to identify the lateral border of the chin for augmentation.13 In addition, two distinct fat compartments were also identified in the mental region from this study. The superficial chin fat was located; this reaches superiorly, almost to the mentolabial sulcus and is delineated laterally by the labiomandibular fat and inferiorly by the superficial portion of the submentalis fat, which was the second fat compartment found. The submentalis fat consists of a superficial and a deep

Reproduced from Aesthetics | Volume 4/Issue 12 - November 2017

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portion. The deep portion is located along the supraperiosteum and is covered by the mentalis muscle. Topographically, it can be located underneath the mentolabial sulcus, and the superficial, inferior portion of this fat compartment is located immediately under the skin, and accentuates the shape of the mentum.15 Facial muscles-mentum The mental and perioral area is composed of a number of muscles, which closely interdigitate with each other.4 These are described below.

Orbicularis oris The orbicularis oris muscle has a distinctly different morphology to orbicularis oculi, and is much more than a sphincter, consisting of numerous muscle fibres surrounding the mouth.4 It is described in the literature as having two parts, a lower and upper part, which blend to the modiolus.16 It consists partly of fibres derived from the buccinator muscle, and forms the deeper component of the orbicularis, with the medial fibres merging at the angle of the mouth; some of which have arisen from the maxilla, passing to the lower lip, and others from the mandible to the upper lip.16 The most superior and most inferior fibres of the buccinator traverse across the lips, from side to side, without decussation.17 Superficial to this musculature, is a second communication between the levator and the DAO, which cross each other at the corner of the mouth, with those from the levator passing to the lower lip and those from the depressor to the upper lip, to be inserted into the skin near the median line.18 Additional fibres from the zygomaticus major, DAO and levator labii superioris blend with the transverse fibres previously described, travelling in an oblique direction.18 The orbicularis oris closes and projects the lips and is innervated by buccal branches from the facial nerve.14 Depressor anguli oris The depressor anguli oris arises from the inferior border of the mandible where its fibres converge superiorly, inserting into the corner of the mouth.16 It is a large, triangular shaped muscle, which is responsible for pulling the corners of the mouth downwards on contraction and is innervated by the mandibular branch of the facial nerve. At its origin, it fuses with the platysma, and at its insertion with the orbicularis oris and risorius muscle.19 Depressor labii inferioris The depressor labii inferioris (DLI) muscle originates from the line of the mandible, superiorly to blend with the lower lip and helps to depress the lower lip when contracted. The muscle is innervated by the mandibular branch of the facial nerve.16

4mm

Figure 2: Rickettsâ&#x20AC;&#x2122; E-pass line. It should be at least 4mm from the upper lip and at 2mm from the lower lip.23

Mentalis The fibres of the mentalis muscle traverse vertically from the superior deep origin in the mandible to the inferior superficial cutaneous insertion in the medial aspect of the chin.4 The muscle fibres are orientated medially and inferiorly, creating a V-shaped triangle which contains deep fat in its medial

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portion and connects laterally with the DLI.18 The mentalis muscle raises and protrudes the lower lip, and causes adherence of the skin to the subcutaneous tissue, which can create a dimpling effect on the skin of the chin. The dimpled appearance of the chin, which is due to the hypercontraction of the mentalis muscle,9 is often accentuated with age, in part due to the boney changes which show the mentolabial crease becoming pronounced, as the area of attachment for the mentalis reduces. This causes the mentalis to contract giving a dimpled appearance to skin attachments.13 Vasculature Whilst the practitioner is wise to be anatomically aware of the plane and distribution patterns of the labial arteries when treating the lips, the inferior branch of these arteries is important when augmenting the chin. Cotofana et al. noted that the inferior labial artery, in general, runs inferior to the vermillion border of the lower lip,20 which is an important consideration when assessing points of chin augmentation to avoid unnecessary trauma to the labial vasculature.9 Equally, the mental artery, a terminal branch of the inferior alveolar artery which arises from the first part of the maxillary artery, emerges from the mental foramen to supply the chin region.21 In addition, the mental nerve, a sensory branch of the third division of the trigeminal nerve, exits the mandible through the mental foramen which can be located approximately inferior to the first premolar tooth.1

Facial analysis Physical examination of the chin should include clinical assessment and tactile inspection of the chin, lips, nose and teeth.1 The face should be assessed when animated and at rest to closely examine the level of activity evident from the mentalis muscle, and surrounding soft tissue support.11 The chin should be observed and accurately photographed in all dimensions; anteroposterior, superoinferior, transversely, and obliquely, to allow analysis of the contour and projection of the chin as it relates to the lips, nose, marionette region and soft tissues of the neck.1 The mandible may be small or positioned more posteriorly (retrognathia), or the chin itself may be small (microgenia), in the vertical or horizontal dimension.11 In addition, the lower aspect of the face must be analysed with regard to a retropositioned chin and to rule out mandibular dimorphism, such as micrognathia (vertical and horizontal mandibular hypoplasia), as well as retrognathia (retracted mandible relative to the maxilla), that can be associated with dental occlusion abnormalities, most commonly Angle class II dental malocclusion.22 Such cases may potentially require orthognathic surgery.20 A number of chin analysis techniques are described in the literature.22 There is one method that can be used to assess the vertical height of the chin and it determines the ratio between the distances from the subnasal point, upper lip and the chin to lower lip. This ratio should be 1:2.23 The position of the lips in relation to the nose and chin was described by Ricketts through the E-pass line, which is traced through the highest point of the nasal tip, to the most prominent portion of the chin.23 The E-pass line should be at least 4mm from the upper lip and at 2mm from the lower lip.23 Retrusion of the chin is a condition that is commonly encountered in patients requesting rhinoplasty, many of which may be unaware of their microgenia as many individuals view themselves directly in the mirror, rather than obliquely or laterally.24 In individuals with deficient projection of the chin, the nose may appear to overly project, despite appropriate nasal proportion to the face.24 In addition, Anston and Smith propose that individuals may generally

Reproduced from Aesthetics | Volume 4/Issue 12 - November 2017

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manifest a weakness on the left side of the chin, compared to the right.24 The authors suggest possible explanations for this phenomenon can include either genetic transmission, or human masticatory patterns as individuals tend to preferentially chew on the right side of their mouths, irrespective of whether they are right or left handed.24 This could trigger hypertrophy of the right masticatory components, including the mandible.24 The literature is consistent in recommending that to obtain a detailed history of past trauma, orthodontic treatment, temporomandibular joint dysfunction, or prior facial or oral surgery, as patients with underlying skeletal abnormalities may require initial orthodontal treatment.11

Technical considerations Chin projection and shape are generally regarded as key characteristics of facial attractiveness, particularly in men.25 Conversely, when analysing female attractiveness, it is commonly reported that a small or narrow chin may be associated with a more feminine appearance,1 yet, studies demonstrate varying ethnic preferences continue to emerge.5,16 In an Asian population, Liew considers to combine treatment of the chin using dermal filler with the use of BoNT-A on the bulk of the masseter to reduce the width of the lower face. This can facilitate the transition from a short and square face to an oval face, which is usually desired in this population.5 Equally, Braz et al. describes the use of hyaluronic acid dermal filler to the prejowl sulcus with BoNT-A to the depressor anguli muscle, the depressor inferioris labii muscle and the mentalis muscle, to smooth the muscle contraction and restore the contour of the prejowl region with the use of dermal filler.16 The skin of the chin is considered thick, measuring between 2,0002,500μm in most adults,1 which is an important consideration when using a cannula or needle to ensure correct depth placement of injectate. Both 27 gauge needle and 25 gauge cannula for depot placement are described within the literature to achieve a 3D sculpting and shaping of the chin, for example, providing volume to the lateral aspect of the chin (adjacent to the lateral pogonoin).26,27 A volumising dermal filler with a high G Prime, or elasticity, which describes how the filler is able to retain its shape when a force is applied, can effectively shape and contour the chin, which may potentially require restoration to the whole zone, including the lateral oral commissure, marionette zone and prejowl sulcus.28 A dermal filler technique commonly employed to the chin can be made by a bolus injection, on the supraperiosteal plane, often in the medial aspect to give central projection, deep to the mentalis muscle.

This aids the treatment to give deep support to the medial deep and superficial submentalis fat and is favourable in both males and females.16,28 Equally, a superficial, linear approach may be employed to soften the appearance of a defined mental crease. Relaxation of the mentalis muscle initially with BoNT-A will improve the aesthetic outcome as a combined treatment in this indication, prior to placement of dermal filler. An effective example of this combination may be used to project the chin and reduce the depression of the mandibular line in front of the jowl. Use supraperiosteal bolus placement, with the use of cannula from the mandibular line to the commissure with a fan technique, above the muscle in the subcutaneous layer. Some literature advocates product placement within each layer of the chin to increase the lifting effect.4,11 The aesthetic endpoint will be established when the augmentation of the chin appears harmonious to the other anatomical regions of the face. A balanced approach is always required, which may require treatment of more than apparent volume loss of the chin itself, with

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BoNT-A. A useful and effective adjuvant-assessment is key, and will vary significantly between individuals.

Conclusion Effective non-surgical augmentation of the chin requires an advanced and current awareness of the anatomy of the lower face, in conjunction with a detailed analysis of the full face to formulate the most appropriate treatment pathway. Performed correctly, the combination of BoNT-A and/or dermal filler, can create a balanced outcome that complements all aspects of the lower face and neck.

Anna Baker is a qualified tutor, cosmetic and dermatology nurse prescriber who has been involved in developing the award-winning Dalvi Humzah Aesthetic Training with lead tutor, Mr Dalvi Humzah, since 2012. She is the coordinator and a faculty member for this teaching.

REFERENCES 1. Sykes J.M., Fitzgerald R. (2016) Choosing the Best Procedure to Augment the Chin: Is Anything Better than an Implant? Facial Plast Surg 32:507-512 2. Binder W.J., Dhir K., Joseph J. (2013) The role of fillers in facial implant surgery Facial Plast Surg Clin North Am 21(2):201-211 3. Thayer Z.M., Dobson S.D. (2013) Geographic variation in chin shape challenges the universal facial attractiveness hypothesis PLoS ONE 8(4):e60681 4. Trevedic P., Sykes J., Criollo-Lamilla G. (2015) Anatomy of the Lower Face and Botulinum Toxin Injections Plastic and Reconstructive Surgery 136(5s):84s-91s.

5. Liew S (2015) Ethnic and Gender Considerations in the Use of Facial Injectables: Asian Patients Plastic and Reconstructive Surgery 136(5s):22s-27s 6. Rucci N. (2008) Molecular biology of bone remodelling Clin Cases Miner Bone Metab 5:49-56 7. Bartlett S.P., Grossman R., Whitaker L.A. (1992) Age-related changes of the craniofacial skeleton: an anthropometric and histological analysis Plastic and Reconstructive Surgery 90:562-600 8. Shaw R.B., Katzel E.B., Koltz P.F., Yarermchuk M.J., Girotto J.A., Kahn D.M., Langstein H.N. (2011) Aging of the Facial Skeleton: Aesthetic Implications and Rejuvenation Strategies Plastic and Reconstructive Surgery 127(1):374-383 9. Pessa J.E., Slice D.E., Hanz K.R., Broadbent T.H., Rohrich R.J. (2008) Aging and the shape of the mandible Plastic and Reconstructive Surgery 121(1): 196-200 10. Wong C.H., Mendelson B. (2015) Newer Understanding of Specific Anatomic Targets in the Aging Face as Applied to Injectables: Aging Changes in the Craniofacial Skeleton and Facial Ligaments Plastic and Reconstructive Surgery 136(5s):44s-48s 11. Frodel J.L., Sykes J.M., Jones J.L. (2004) Evaluation and treatment of vertical microgenia Arch Facial Plast Surg 6(2):111-119 12. Baker A (2015) Contouring the lower jaw (non-surgical) Pmfa News 1(5):28 13. Gierloff M., Stöhring C., Buder T., Wiltfang J. (2012) The subcutaneous fat compartments in relation to aesthetically important facial folds and rhytides Journal of Plastic, Reconstructive & Aesthetic Surgery 65:1292-1297 14. Marur T., Tuna Y., Demirci S. (2014) Facial Anatomy Clin Dermatol. 32:14-23 15. Romo T., Yalamanchili H., Sclafani A.P. (2005) Chin and prejowl augmentation in the management of the aging jawline Facial Plast Surg 21:38-46 16. Braz A., Humphrey S., Weinkle S., Yee G.J., Remington B.K., Lorenc Z.P., Yoelin S., Waldorf H.A., Azizzadeh B., Butterwick K.J., de Maio M., Sadick N., Trevidic P., Criollo-Lamilla G., Garcia P. (2015) Lower Face: Clinical Anatomy and Regional Approaches with Injectable Fillers Plastic and Reconstructive Surgery 136(5s):235s-257s.

17. Reece E.M., Rohrich R.J. (2008) The aesthetic jawline: management of the ageing jowl Aesthetic Surgery Journal 28:668-674 18. Wu D.C., Fabi S.G., Goldman M.P. (2015) Neurotoxins: Current Concepts in Cosmetic Use on the Face and Neck-Lower Face Plastic and Reconstructive Surgery 135(5s):76s-79s 19. Choi Y.J., Kim J.S., Gil Y.C., Phetudom T., Kim H.J., Tansait T., Hu K.S. (2014) Anatomical Considerations Regarding the Location and Boundary of the Depressor Anguli Oris Muscle with Reference to Botulinum Toxin Injection Plastic and Reconstructive Surgery 134(5): 917-921 20. Cotofana S., Pretterklieber B., Lucius R., Frank K., Haas M., Schenck T.L., Gleiser C., Weyers I., Wedel T., Pretterklieber M. (2017) Distribution Pattern of the Superior and Inferior Labial Arteries: Impact for Safe Upper and Lower Lip Augmentation Procedures Plastic and Reconstructive Surgery 139(5):1075-1082 21. Sinnatamby C.S. (2006) Last’s Anatomy Regional and Applied Churchill Livingstone Elsevier 10th Ed. PP.376 22. Arroyo H.H., Olivetti I.P., Lima L.F.R., Jurado J.R.P. (2016) Clinical evaluation for chin augmentation: literature review and algorithm proposal Braz J Otorhinolaryngol 82(5):596-601 23. Ward J., Podda S., Garri J.L., Wolfe S.A., Thaller S.R. (2007) Chin deformities J Craniofac Surg 18:887894 24. Anston S.J., Smith D.M. (2015) Taking It on the Chin: Recognizing and Accounting for Lower Face Asymmetry in Chin Augmenation and Genioplasty Plastic and Reconstructive Surgery 135(6):15911595 25. Sykes J.M., Suàrez G.A. (2016) Chin Advancement, Augmentation, and Reduction as Adjuncts to Rhinoplasty Clin Plast Surg 43:295-306 26. Anand C (2016) Facial Contouring With Fillers, Neuromodulators, and Lipolysis to Achieve a Natural Look in Patients With Facial Fullness J Drugs Dermatol 1;15(12):1536-1542 27. De Maio M., Wu WTL., Goodman G.J., Monheit G. (2017) Facial Assessment and Injection Guide for Botulinum Toxin and Injectable Hyaluronic Acid Fillers: Focus on the Lower Face Plast Reconstr Surg 140(3):393e-404e 28. Goodman G.J., Swift A., Remington B.K. (2015) Current Concepts in the Use of Vouma, Volift and Volbella Plastic and Reconstructive Surgery 136(5s):139s-148s

Reproduced from Aesthetics | Volume 4/Issue 12 - November 2017

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the head, whereas women lose hair either more diffusely or along the top of the head. Although it’s indicated that male pattern baldness is hereditary, it’s less clear if female pattern is.4 Telogen effluvium Telogen effluvium is a condition where the hairs shift from a growing phase (anagen) to a shedding phase (telogen), and diffuse thinning of the hair then occurs. People can lose up to 70% of their hair very quickly (in a matter of weeks), which is quite common in its milder forms.3 This can be triggered by shocks to the system, such as a high fever, childbirth, crash dieting, stopping or starting of the oral contraceptive pill and life events such as bereavement.4

Hair Loss and Nutrition Dr Martin Godfrey provides an introduction to nutritional supplements for hair loss In today’s evermore appearance conscious world, hair loss can be particularly daunting for some. By the age of 35, approximately 40% of men will have a noticeable level of hair loss. By 65, more than two thirds will.1 Surprisingly, the situation is also bad for women – one in three women will suffer some degree of hair loss or thinning in their lifetime.2,3 I have observed that our attitudes to hair loss, and balding in particular, are changing, with shorter hairstyles and head shaving becoming more popular. I believe this is making baldness far less of a stigma for young men that it once was. However, for many, hair loss is still a massive psychological blow and one that medicine is generally poor at combating.

Not surprisingly, therefore, finding a solution to hair loss has been something of a ‘holy grail’ in the health and cosmetic business. As medical aesthetic professionals, it is useful to know the options available for hair loss, should a patient query this in a consultation.

This article will look at the non-surgical options for managing hair loss that are currently available and in development, particularly in terms of foods and nutraceuticals so that medical aesthetic professionals can share best advice with patients.

Types of hair loss There are three main forms of hair loss that both men and women face and these should be understood by medical aesthetic professionals.

Androgenic alopecia Also known as pattern hair loss, androgenic alopecia is when the hairs in specific areas of the scalp gradually become finer and are eventually lost.4 This type of hair loss is driven not by testosterone itself – which is a common misconception – but by the sensitivity of hair follicles to a metabolite of testosterone called dihydrotestosterone (DHT).3 Androgenic alopecia affects mainly men, but women can also suffer from it due to the same causes. However, the distribution of hair loss is different; men tend to lose hair either in the temples or crown of

Alopecia areata This is the most serious type of hair loss as it can also lead to loss in parts of the body other than the top of the head, such as the eyebrows, and can be linked to other autoimmune diseases, such as vitiligo. Alopecia areata is an autoimmune condition where hair is lost in discrete patches. Sometimes all hair can be lost, including body and facial hair.4,5

Products for regrowth It is important to note that only two products have been clinically proven to regrow hair – finasteride and minoxidil.6 All other products available for hair loss, such as herbal treatments, caffeinebased treatments and nutritional therapies, which are discussed below, just slow down or aim to stop hair loss, but they will not promote growth. The majority of these other products have limited clinical support for their efficacy.

Finasteride Finasteride, which is only approved by the Food and Drug Administration and The European Food Safety Authority (EFSA) for men,7 is used mainly for pattern hair loss and works by preventing the testosterone from being converted to DHT, which allows for hair follicles to regain their pre-shrunk size. Topical formulations are available, but it is mainly taken orally so to guarantee blood levels.8,9 Usually, it takes three to six months of continuously using finasteride (1mg per day) before any effect is seen. The balding process usually resumes within six to 12 months if treatment is stopped.10 Studies have suggested that finasteride can increase hair count as well as improve patient confidence in terms of their appearance.8,9,11 One double blind, randomised clinical trial studied 45 male patients with alopecia who were given placebo, topical or oral finasteride for six months. The results suggested no difference between the two different types of finasteride, but showed a significant increase in hair counts.8 Side effects are uncommon, but can include allergy, breast changes, dizziness, mood changes, testicle pain, loss of libido (sex drive) and erectile dysfunction.7 Just under one in 10 men who take finasteride experience libido or erectile dysfunction,12 which can, in some instances, be permanent.13 This potential long term effect makes many patients very apprehensive about taking this treatment so finasteride could be considered to have a limited role.

Minoxidil Originally minoxidil was (and still is) used as a treatment for high blood pressure, yet numerous studies suggested positive effects for hair growth stimulation.14-18 It is not entirely clear how it works for regrowth, however one study suggests that there is some evidence that it may

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be a result of opening potassium channels.16 Minoxidil is mainly used for male pattern hair loss and is applied to the scalp every day via foam, although tablets are also available, but are mainly used for management of hypertension.16 Results from a systemic literature review suggested that minoxidil is more effective than placebo in promoting total and non-vellus hair growth with a mean difference of 95%.15 Like finasteride, minoxidil usually needs to be used for several months (three to six) before any effect is seen. The balding process will typically resume if treatment with minoxidil is stopped.

Any new hair that regrows will fall out two months after treatment is stopped.14,19 Side effects are uncommon, but can include acne at the site of application, burning, facial hair growth, inflammation or soreness at hair root, reddened skin and facial swelling.20

Food and hair loss Food is, without doubt, incredibly important to hair health. If hair is thinning, becoming brittle, growing slowly and breaking off easily, it may be that the body is not getting the right nutrients or that the patient is not eating enough.21-23 A good, balanced diet to promote healthy hair should contain proteins, carbohydrates, fibres, fats, vitamins and minerals: • Proteins, especially sulphur containing amino-acids such as cysteine and methionine, are beneficial as they are precursors to keratin hair protein synthesis. The amino acid L-lysine, which mainly presents in the inner part of the hair root and is responsible for hair shape and volume, must be included in the diet.24 • Carbohydrates with a low Glycemic Index should be in the diet.24,25 • Fibres regulate carbohydrate-lipid metabolism and are important for hair strength.24 • Fats take part in steroid-hormone synthesis, thus they have an influence on keeping hair healthy.24,26 • Vitamins have an impact on hair health, particularly vitamins C, A and group B vitamins.24,25,27 • Minerals that influence hair growth are: Zn, Fe, Cu, Se, Si, Mg and Ca.24,25,27

Approval of food supplements The EFSA is the risk assessor for any health claim linked to food supplement ingredients.44 The EFSA’s role is to scrutinise any claim and will only substantiate it on the basis of rigorous scientific criteria being met. For example, they might permit that companies can claim that vitamin A is necessary to maintain energy and general vitality. Vitamin C, E and B (including biotin, a vitamin B complex), iron and zinc are seen by the EFSA as components that support healthy hair.45 To date, the EFSA has only supported claims for maintenance of healthy hair, rather than prevention of hair loss or hair regrowth.46 This is because they do not believe there is enough scientific evidence to substantiate these claims. Products can be sold without gaining EFSA approval, however without at least some of the ingredients having EFSA approval, a company cannot substantiate any marketing claims. Approval is difficult for any ingredient and it entails a huge amount of work and expenditure. Pharmaceutical companies can usually afford this, but many nutraceutical companies are small and cannot invest the large sums required to develop large, statistically significant trials across markets. Thus, many commercial products tend to use small, often observational, studies to support their claims.

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Consumption of high fat, fried foods and hydrogenated oils should be avoided. Research has linked monounsaturated and saturated fat to increased testosterone levels, which could potentially lead to elevated levels of DHT and increased hair loss.28 Supplements Scientifically validated, botanical oral treatments include capsaicin, isoflavone, soy, ginseng and saw palmetto.29-32 Herbal mixtures found in Japanese Kampo medicine, which is available at many health food shops, have also shown benefits in preventing hair loss, but these are not scientifically-validated studies.21,33 Vitamin and mineral treatments have demonstrated benefits, particularly those containing zinc, iron, iodine, tocopherol, panthenol and vitamin E, C and B.34 A study of 24 women with fine hair who took 10mg Si/day for nine months suggested that silicone in the form of orthosilicic acid was beneficial.29 Mixtures of vitamin, minerals and amino acids have also been shown to have an effect.35,36 As hair is made up of keratin, protein and collagen supplements have shown to be beneficial, particularly if used in combination with vitamins and minerals such as copper or zinc.26,37-39 Studies have demonstrated that nutraceuticals, which include some of the above ingredients, have been beneficial for hair strength and growth.40-43

Conclusion Many patients experience a real battle against hair loss. I have noticed that despite their efficacy, pharmaceuticals still have a relatively limited role due to worries about the potential side effects and safety if used in the long term. Although nutraceuticals do not have a lot of substantial clinical evidence compared to pharmaceuticals, they have demonstrated some success in managing hair loss. They can therefore be considered as an option in combination with sensible hair care, such as limiting the use of overly hot hair drying for example, and a balanced diet for all those not wanting to lose their hair. Aesthetic professionals should be aware of the nutritional options available to patients and be prepared to refer them to an appropriate specialist if it is outside their clinical expertise.

Disclosure: Dr Martin Godfrey is head of research and development at MINERVA Research Labs Ltd, which manufacturers Gold Collagen beauty supplements. The company is currently researching nutritional solutions for hair.

Dr Martin Godfrey is a medical practitioner with experience 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. Statistic Brain, Hair Loss Statistics from the International Society for Hair Restoration Surgeons, 2016. <http://www.statisticbrain.com/hair-loss-statistics/> 2. Harvard Women’s Health Watch, ‘Treating Female Pattern Hair Loss’, 2009, Harvard Health Publishing, <https://www.health.harvard.edu/staying-healthy/treating-female-pattern-hair-loss> 3. Torres F1, Tosti A2. Female pattern alopecia and telogen effluvium: figuring out diffuse alopecia. Semin Cutan Med Surg. 2015 Jun;34(2):67-71.

4. NHS, Hair Loss, 2017. <http://www.nhs.uk/conditions/hair-loss/Pages/Introduction.aspx> 5. Thomas F Cash, The psychosocial consequences of androgenetic alopecia: a review of the research literature, British Journal of Dermatology, 141 3(1999), pp.398-405.

6. Varothai S, Bergfeld WF, Androgenetic alopecia: an evidence-based treatment update, Am J Clin Dermatol. 2014 Jul;15(3):217-30.

7. Drugs.com, Finasteride 5 mg Tablets, <https://www.drugs.com/cdi/finasteride-5-mg-tablets.html> 8. Hajheydari Z, Akbari J, Saeedi M, Shokoohi L. Comparing the therapeutic effects of finasteride gel and tablet in treatment of the androgenetic alopecia. Indian J Dermatol Venereol Leprol. 2009 JanFeb;75(1):47-51 9. Olsen EA, Hordinsky M, Whiting D, Stough D, Hobbs S, Ellis ML, Wilson T, Rittmaster RS; Dutasteride Alopecia Research Team. The importance of dual 5alpha-reductase inhibition in the treatment of male pattern hair loss: results of a randomized placebo-controlled study of dutasteride versus finasteride. J

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Clinical Practice News

Am Acad Dermatol. 2006 Dec;55(6):1014-23 10. Rossi A, Cantisani C, et al., ‘1 mg daily administration on male androgenetic alopecia in different age groups: 10-year follow-up’, Dermatol Ther, 2011, 24(4), pp.455-61.

11. Keith D. Kaufman, Elise A. Olsen, et al., ‘Finasteride in the treatment of men with androgenetic alopecia’, Journal of the American Academy of Dermatology, 39 4(1998), pp.578-589.

12. Venkataram Mysore, ‘Finasteride and sexual side effects’, Indian Dermatol Online J, 2012 Jan-Apr; 3(1): 62–65.

13. Irwig MS, ‘Persistent Sexual Side Effects of Finasteride: Could They Be Permanent?’, Journal of Sexual Medicine, 2012, 9(11):2927-32.

14. Functional analysis of keratin components in the mouse hair follicle inner root sheath, BJD, Volume 150, Issue 2 February 2004. Pages 186–194.

15. Gupta AK, Charrette A. Topical Minoxidil: Systematic Review and Meta-Analysis of Its Efficacy in Androgenetic Alopecia. Skinmed. 2015 May-Jun;13(3):185-9.

16. AG Messenger, J Rundegren, ‘Minoxidil: mechanisms of action on hair growth’, Br J Dermatol, 2004 Feb;150(2) pp.186-94.

17. Mapar MA1, Omidian M, ‘Is topical minoxidil solution effective on androgenetic alopecia in routine daily practice?’, J Dermatolog Treat, 2007;18(5) pp.268-70.

18. Olsen EA, Dunlap FE, et al., ‘A randomized clinical trial of 5% topical minoxidil versus 2% topical minoxidil and placebo in the treatment of androgenetic alopecia in men’, J Am Acad Dermatol. 2002 Sep;47(3):377-85.

19. Messenger AG1, Rundegren J.Minoxidil: mechanisms of action on hair growth. Br J Dermatol. 2004 Feb;150(2):186-94.

20. Hillmann K, Garcia Bartels N, Kottner J, Stroux A, Canfield D, Blume-Peytavi U. A Single-Centre, Randomized, Double-Blind, Placebo-Controlled Clinical Trial to Investigate the Efficacy and Safety of Minoxidil Topical Foam in Frontotemporal and Vertex Androgenetic Alopecia in Men. Skin Pharmacol Physiol. 2015;28(5):236-44.

21. Goluch-Koniuszy ZS, ‘Nutrition of women with hair loss problem during the period of menopause’, Prz Menopauzalny, 2016 Mar;15(1):56-61.

22. Rushton DH. Nutritional factors and hair loss..Clin Exp Dermatol. 2002 Jul;27(5):396-404.

23. Mubki T. Use of Vitamins and Minerals in the Treatment of Hair Loss: A Cross-Sectional Survey among Dermatologists in Saudi Arabia. J Cutan Med Surg. 2014 Nov;18(6):405-12.

24. Cheung EJ, Sink JR, English Iii JC. Vitamin and Mineral Deficiencies in Patients With Telogen Effluvium: A Retrospective Cross-Sectional Study. J Drugs Dermatol. 2016 Oct 1;15(10):1235-1237.

25. Goluch-Koniuszy ZS. Prz Menopauzalny. Nutrition of women with hair loss problem during the period of menopause. 2016 Mar;15(1):56-61.

26. Genovese L, Corbo A, Sibilla S. An Insight into the Changes in Skin Texture and Properties following Dietary Intervention with a Nutricosmeceutical Containing a Blend of Collagen Bioactive Peptides and Antioxidants. Skin Pharmacol Physiol. 2017;30(3):146-158.

27. Thompson JM, Li T, Park MK, Qureshi AA, Cho E. Estimated serum vitamin D status, vitamin D intake, and risk of incident alopecia areata among US women. Arch Dermatol Res. 2016 Nov;308(9):671-676. Epub 2016 Sep 2 28. Emily L. Guo & Rajani Katta, ‘Diet and hair loss: effects of nutrient deficiency and supplement use’, Dermatol Pract Concept, 2017 Jan; 7(1) pp.1-10.

29. Lourith N, Kanlayavattanukul M, ‘Hair loss and herbs, for treatment’, J.Cosmet Sci 2013:12;210-222.

30. Harada et al, ‘Administration of capsaicin and isoflavone promotes hair growth by increasing insulin-like growth factor-I production in mice and in humans with alopecia’, Growth Hormone IGF Res, 2007:17;408-415.

31. Takahiro Tsuruki & Masaaki Yoshikawa’, ‘Design of soymetide-4 derivatives to potentiate the antialpecia effect’, Biosci Biotechnol Biochem, 2004, pp.1139-1141.

32. Park S, et al. ‘Fructus panax ginseng extract promotes hair regeneration in C57BL76 mice’, J Ethnopharmacology, 2011:138;340-344.

33. Debasis Bagchi, Harry G. Preuss, Anand Swaroop, Nutraceuticals and Functional Foods in Human Health and Disease Prevention, pp.478 34. Wickett et al., ‘Effect of oral intake of choline-stabilized orthosilicic acid on hair tensile strength and morphology in women with fine hair’, Arch Dermatol Res, 2007; 299; 499-505 35. Barbara Szyszkowska,corresponding author Celina Łepecka-Klusek, Katarzyna Kozłowicz, Iwona Jazienicka, and Dorota Krasowska, The influence of selected ingredients of dietary supplements on skin condition, Postepy Dermatol Alergol. 2014 Jun; 31(3): 174–181.

36. Debasis Bagchi Harry G. Preuss Anand Swaroop, Nutraceuticals and Functional Foods in Human Health and Disease PreventionCRC Press, October 15, 2015 37. Rushton DH, Norris MJ et al., ‘Causes of hair loss and the developments in hair rejuvenation’, <https://www.ncbi.nlm.nih.gov/pubmed/18498491> 38. 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.

39. Hornfeldt CS, Holland M, Bucay VW, Roberts WE, Waldorf HA, Dayan SH. The Safety and Efficacy of a Sustainable Marine Extract for the Treatment of Thinning Hair: A Summary of New Clinical Research and Results from a Panel Discussion on the Problem of Thinning Hair and Current Treatments. J Drugs Dermatol. 2015 Sep;14(9):s15-22. Review.

40. Carl S. Hornfeldt & Mark Holland, ‘The Safety and Efficacy of a Sustainable Marine Extract for the Treatment of Thinning Hair: A Summary of New Clinical Research and Results from a Panel Discussion on the Problem of Thinning Hair and Current Treatments’, Journal of Drugs in Dermatology, 14 9(2015).

41. Thom, ‘Efficacy and tolerability of Hairgain in individuals with hair loss: a placebo-controlled, doubleblind study’, J Int Med Res, 2001 Jan-Feb;29(1):2-6.

42. Martin Godfrey, Sarah Brewer, Anil Budh-Raja and Licia Genovese, An Overview of the Beneficial Effects of Hydrolysed Collagen as a Nutraceutical on Skin Properties: Scientific Background and Clinical Studies Sara Sibilla, The Open Nutraceuticals Journal, 2015, 8, 29-42 29 1876-3960/15 2015.

43. Nikki Zanna, Evidence base and benefits associated with a collagen-based nutraceutical drink, Journal of Aesthetic Nursing, V6, 2017. <http://www.magonlinelibrary.com/doi/abs/10.12968/ joan.2017.6.3.136> 44. Cranwell W, Sinclair R, Male Androgenetic Alopecia, 2016, < https://www.ncbi.nlm.nih.gov/books/ NBK278957/> 45. Finner AM. Nutrition and hair: deficiencies and supplements. Dermatol Clin. 2013 Jan;31(1):167-72.

46. EU Comission, EU Register of nutrition and health claims made on foods, <http://ec.europa.eu/food/ safety/labelling_nutrition/claims/register/public/?event=register.home)>

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Case Study: Treating the Tear Trough Dr Munir Somji presents a case study of a patient treated with dermal filler for a tear trough concern The tear trough is a common ageing concern for many aesthetic patients, as it tends to be the first thing people notice when making eye contact with one another. Infraorbital hollowing can give patients a fatigued appearance, perhaps despite them having sufficient rest. In my experience, treatment for this area has extremely high satisfaction ratings and gives an instant ‘freshness’ that many patients crave. It is, however, a difficult area to treat, as detailed knowledge of the anatomy coupled with an inherent knowledge of dermal filler rheology is required. The ‘tear trough deformity’ was first coined by Flowers in 1993.1 In general, it can be described as a periorbital hollow that extends obliquely from the medical canthus to the midpupillary line. Any depression lateral to this is termed the ‘palpebromalar groove’, ‘lid-cheek junction’ or ‘nasojugal groove’. For the purpose of this article, we will be discussing techniques for rejuvenation of the tear trough area.2 Since 1993, there have been numerous classifications of the deformity of the tear trough area and its aetiology.3 The classification that aids my clinical practice is the Tear Trough Rating Scale (TTRS),4 which gives practitioners a way to quantitatively assign the tear trough deformity, measuring the volume of prolapsed fat, skin rhytidosis, hyperpigmentation and depth of tear trough. Explaining this scale to patients tends to give them a better understanding of the results they can expect to obtain from a tear trough augmentation treatment. I also find that it provides practitioners with the perfect tool to manage expectations. For example, if a patient has a higher degree of pigmentation than depth of tear trough, they may be better suited to different treatments to achieve maximal results. Treatments for pigmentation such as skin peels and daily application of topical tyrosinase inhibitors would be appropriate.

Before

Figure 1: Pre-treatment photograph showing a clearly demarcated tear trough deformity that is accentuated when the patient is fixed during upward gaze. Note existing hyperpigmentation of the skin.

Case study A 29-year-old patient of Middle Eastern origin presented to my clinic complaining of ‘dark circles’. The patient had travelled from

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Dubai and was only able to stay in the country for two weeks.

The consultation was performed three months prior to her arrival during her previous trip to London. She was fit and well with no previous medical or surgical history, and no known allergies. The only medication she was on was the oral contraceptive pill Yasmin, and she did not claim to take any herbal supplements. She had previously tried over-the-counter eye creams to no avail. Upon examination, she had a clearly defined mild to moderate tear trough deformity with the presence of a palpebromalar groove, which pronounced her ‘dark circles’. There was also a degree of hyperpigmentation of the skin underneath the eye (Figure 1). It was Immediately after

Figure 2: Immediately posttreatment showing the injection points on the skin. The first injection point is 0.5cm lateral to the lateral canthus and then three further boluses along the palpebromalar groove. The raised insertion point of the 25 gauge cannula can also be appreciated.

explained to her that tear trough correction would not help the latter.

I recommended that the patient undergo treatment with dermal filler to address both the tear trough deformity and correction of the palpebromalar groove, recommending further treatments for periocular hyperpigmentation. Topical anaesthetic was applied using a 4% lidocaine cream occluded for 10 minutes. I got the patient to sit upright in the chair, with her eyes open during the procedure to enable accurate demarcation of the tear trough.

My product choice was Teosyal Redensity II; this is because it has a low hygroscopic behaviour due to the mixture of cross-linked and non-cross-linked hyaluronic acid at 15mg/g concentration.5 I have found that due to this, it is less likely to swell within the periocular area in comparison to other fillers. I started with treating the palpebromalar groove with small bolus injections, starting from 0.5cm lateral to the lateral canthus, working my way down the groove (Figure 2). The filler was placed deep to the internal aspect of the orbital septum to create an increase in volume with a 30 gauge needle. For this area, I prefer to use a needle as it allows me to be precise in what is an unforgiving area. Approximately 0.1ml was used for each eye. It was noted that at this point, further correction of the palpebromalar groove was required above the orbicularis oculi muscle. However, because of the risk of bruising, I did not proceed with a sharp needle. I revisited the superficial palpebromalar groove with a cannula towards the end of the procedure to complete augmentation. Once the lateral aspect of the eye was treated, I proceeded to correct the tear trough deformity. A 25 gauge cannula was used to place filler deep to the suborbicularis oculi fat (SOOF). Most practitioners would agree that filler should be placed supraperiosteally,6 however, given the low hygroscopic behaviour of Teosyal Redensity II, I believe it is safe to place filler as you would do micro fat in the deeper layers of SOOF.7 To date, after more than 1,000 injections with this technique, I have had no incidences of persistent swelling or puffiness.

Filler was gently placed in an intermittent retrograde microbolus fashion along the length of the tear trough at the level of the orbital rim. The entry point was 1cm away from the end of the tear trough.

The product was then gently massaged. At this point, all the deep injections were performed. Given that the patient had good skin elasticity and thickness, the decision was made to inject filler in

Reproduced from Aesthetics | Volume 4/Issue 12 - November 2017

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Figure 3: Patient 10 days after the procedure.

the subcutaneous layer above the orbicularis oculi muscle, over the tear trough deformity and the palpebromalar groove. If a patient has good skin thickness I find there is less chance of lumps forming post injection when placed in the subcutaneous layer. Micro-fanning thread injections were made with the cannula and continually massaged over the area. In total, 0.8ml was used for both eyes with 0.4ml for each eye. After the treatment, no ice packs or cooling were applied. Only if there is post-operative bruising do I use them.

The patient was advised to not wear makeup for 24 hours post injection, to avoid exposing herself to extreme temperatures, and to avoid exercise for the following 48 hours. She was booked in for a review in 10 days, as she could not make the normal 14-day review.

At 10 days, she was happy with the result (Figure 3). There was still persistent mild swelling, in particular at the needle and cannula insertion site. I see this quite often and it normally takes a maximum of three weeks for this to settle. The patient had no bruising or tenderness at the treatment site. I saw her 14 months later for retreatment.

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Treatments in this area should only be undertaken by advanced practitioners, due to the danger areas which, if injected, could lead to necrosis and even blindness.8 Under correction is the key to avoiding complications as well a detailed knowledge of injection anatomy. I recommend those wanting to perform these treatments to familiarise themselves with injection anatomy and attend courses which involve product specific injection techniques. I believe the use of a cannula is imperative in this region to gain satisfactory results.

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Dr Munir Somji is the chief medical officer of DrMedispa, specialising in facial aesthetics and hair restoration surgery.

Dr Somji has performed numerous tear trough deformity corrections utilising a variety of different techniques that have been perfected through experience and further study.

He runs clinics in Central London and Essex.

REFERENCES 1. Flowers RS. Tear trough implants for correction of tear trough deformity, ClinPlast Surg.

1993;20:403–15.

2. Haddock NT, Saadeh PB, Boutros S, Thorne CH. The tear trough and lid/cheek junction: Anatomy and implications for surgical correction. Plast Reconstr Surg. 2009;123:1332–40.

3. Tear Trough Deformity: Review of Anatomy and Treatment Options Ross L. Stutman, MD Mark A. Codner, MD Aesthetic Surgery Journal, Volume 32, Issue 4, 1 May 2012, Pages 426–440.

4. Sadick NS, Bosniak SL, Cantisano-Zilkha M, Glavas IP, Roy D, Definition of the tear trough and the tear trough rating scale. J Cosmet Dermatol. 2007;6:218–22.

5. Teoxane press release, Teosyal® Puresense Renensity [II]: A Different Gel Designed for Eye Circles, (2014) <https://teoxane.com/sites/default/files/redensity2_press_release.pdf> 6. Kane MA. Treatment of tear trough deformity and lower lid bowing with injectable hyaluronic acid. Aesthetic Plast Surg. 2005;29:363–7.

7. Chang YC, Rovaris DA. Lipoenxertia autóloga perior-bitária no rejuvenescimento facial: Análise retrospectiva da eficácia e segurança em 31 casos (Portuguese) [Auto-logous periorbital fat grafting in facial rejuvenation: A retrospective analysis of efficacy and safety in 31 cases]. Rev Bras Cir Plást 2012; 27(3): 405–410. doi: 10.1590/S 8. Beth L Swinger, Blind to the Risk: 4 Ways to Avoid Blindness from Dermal Fillers, Harley Academy, <https://www.harleyacademy.com/avoid-risk-blindness-dermal-fillers/>

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Contouring the Male Jawline Dr David Jack provides a detailed analysis of the anatomy of the jawline and how to effectively contour this area in male patients using injectables For many years, the majority of patients visiting my clinic seeking contouring treatments have been female. In the last few years, however, there has been definite upturn in the number of male patients I see â&#x20AC;&#x201C; around a 10-15% increase in the last year alone in those primarily seeking filler treatments. Whether this is driven by a greater awareness of such treatments in the press and social media is not entirely certain, however, awareness of the diverse uses of dermal fillers in general does seem to be increasing. For the male patients I see, the most commonly sought treatments are: lip fillers, followed by jawline and chin contouring, followed by mid-face filler. Given the increased uptake in such treatments, it seems sensible to explore these treatments in a bit more depth. In this article, I will provide an anatomical background for treatments used to contour the male jawline, some background of the differences between the male and female jawlines to consider, and an outline of current treatments that are applicable to this area.

Anatomical considerations As with any aesthetic treatment, a thorough understanding of the underlying anatomy and anatomy of ageing is paramount to providing the optimum aesthetic result for your patient.

A systematic approach to this area, always keeping in mind the underlying normal anatomy, is important to address every issue in a safe and controlled way for the patient seeking treatment.

Establishing the foundation of the jawline, the mandible forms from two halves which are fused in the midline at the mandibular symphysis. Anatomically, it consists of a curved tooth-bearing body, extending from the midline symphysis with the mental protuberance inferiorly (which itself has a central depression and two lateral mental tubercles, forming the chin), to the ramus laterally. The ramus projects superiorly with two processes: the coronoid process, to which the temporal muscle attaches, and the neck and condyle process, which is topped by the articular surface, forming the mandibular part of the temporomandibular joint. Between these two processes of the ramus is the mandibular notch. The large masseter muscle attaches to almost the entire surface of the ramus of the mandible, and is the major component of the fleshy part of the lateral jawline, which can be palpated on examination. This tends to decrease in bulk with age. The body of the mandible also provides origin or attachment for several muscles: the mentalis and part of the orbicularis oris originate from the

incisive fossa, just inferior to the incisor teeth; the depressor anguli oris and depressor labii inferioris attach to the oblique line superiorly and the platysma muscle attaches inferior to the line.1 There are two important foraminae, one each side, transmitting the inferior alveolar branches of the mandibular branch of the trigeminal nerve. The nerve enters the mandible via the mandibular foramen in the ramus of the mandible, behind the deep surface of the lateral pterygoid muscle to the deep surface of the masseter.

Within the body of the mandible, the nerve runs in the mandibular canal and gives off branches supplying sensation to the teeth, then exits the bone as the mental nerve with the mental blood vessels via the mental foramen to supply sensation to the chin and lower lip.2 The mental foramen is located lateral to the mental tubercles and changes direction from childhood as anterior facing to posterosuperior in adulthood. The location and direction of these nerves are important to consider when selecting which injection technique to use (cannula or needle), to minimise risk of damage.2 The superficial fat pads and salivary glands of the face are another important consideration in this area when it comes to injectables. Superficial to the ramus of the mandible and masseter, the parotid gland varies in size between individuals and can extend posteriorly to the deep surface of the ramus. It contains the parotid duct, which pierces the buccinator muscle to open into the vestibule of the mouth at the level of the second maxillary molar. The gland also contains the trunk and main branches of the facial nerve. Superficial to the gland is superficial lamina of the deep cervical fascia, and posteriorly, the greater auricular nerve is in close proximity. The lateral temporal cheek fat pad lies superficial to the parotid gland, with the middle cheek fat pad compartment anteriorly, and the superior and inferior jowl (or mandibular) fat pads lying further anteriorly over the anterolateral surface of the body of the mandible.3 These fat pads are separated by a number of important septae or ligaments that give rise to some of the characteristic signs of ageing seen in the lower face. These include the mandibular septum, which separates the jowl fat pads from the neck fat and is adherent to the anterior surface of the body of the mandible,4 and the mandibular cutaneous ligament, which tethers the skin anterior to the jowl fat pads to the bone anteriorly, creating the groove seen anterior to the jowl with descent of the fat pads in age.5,7 Running

Reproduced from Aesthetics | Volume 4/Issue 12 - November 2017

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over the superficial surface of the mandible in the plane deep to the platysma, risorius and zygomaticus major, the facial artery branch of the external carotid lies relatively superficially, being crossed superficially by branches of the facial nerve, deep also to the superficial fat pads of the face to run superomedially in a tortuous route over the face. The point at which it crosses the border of the mandible can be easily palpated and should always be noted and marked with any injectable treatment to avoid damage or intra-arterial injection. The marginal mandibular branch of the facial nerve is another important structure to be aware of when injecting in this area. Running deep to the platysma and the depressor anguli oris, it crosses the border of the mandible from the neck about 3cm anterior to the angle of the mandible, always superficial to the facial artery and anterior facial vein,3 and provides motor supply to the depressor labii inferioris, depressor anguli oris and mentalis, and communicates with the inferior alveolar nerve.3,7 Male vs. female jawlines Developmentally, all faces start phenotypically as female, then under the influence of significantly elevated testosterone levels during puberty in the male, secondary male characteristics develop.6 In the jawline, these features include a much larger, stronger and heavier-set jawline, more definition of the angle and ramus of the mandible, and higher muscle bulk generally. The male chin tends to be wider and more square, rather than V-shaped in the female. It is exceptionally important to consider the individual patient when assessing for contouring treatments, and to have a different approach in male patients than you would for females, to avoid feminisation of these features.6 A number of changes appear with ageing in the lower face in both men and women, including: loss of volume and descent of the jowl fat pads (in addition to reduction in mid-face volume and descent of the mid-face structures), dehiscence of the mandibular septum and descent of mandibular fat pads into the neck, mandibular bone resorption (particularly with loss of dentition in later life) and increased skin laxity. Gravity and the downward pull of the strong platysma muscle accelerates this volume loss-related descent. Treatments in this area can be targeted for two distinct purposes – firstly, to address any anatomical deficit that may be present, which can be augmented in a way to provide a more harmonious masculine jawline in relation to the other facial structures – i.e. adding

Aesthetics Journal

volume that was never there in the first place.

Secondly, to address signs of general ageing in the jawline, by replacing volume that has been lost over time. Jawline enhancement and contouring is a treatment that can make quite a significant difference to the entire face, for both men and women. In women, contouring techniques using injectables tend to be used primarily to create more of an almond-shaped face.6,8 In men, most often these techniques are used to create a more defined, masculine appearance, improving the definition of the angle of the mandible and creating more of a rectangular, strong chin.

The ideal male jawline As mentioned above, any technique in the lower face should be considered to both replace what has been lost with age, and to augment and add volume to where volume has never been in the first place. The use of any injectable in this area is therefore based on the injector’s own perception of the volumetric three-dimensional starting point of the individual patient. There are numerous lines of projection that can be used as a guide for chin projection – such as an ideal chin being one that reaches a continuous imaginary line in the sagittal plane, drawn from the menton, to the most anteriorly projecting part of the lip.9 Likewise, a photogrammetric study conducted in 2016 found that the ideal male jawline had the following characteristics:10 • 130° angle in profile view • Intergonial width that is similar to facial width • Vertical position in frontal view at the oral commissure or at least not below the lower lip • Jawline slope in the face frontal view nearly parallel to (with a maximum 15° downward deviation from) a line extending from the lateral canthus of the eye to the nasal alae • Ascending ramus slope 65°-75° to the Frankfort horizontal line and curvature in the oblique view, visible from earlobe to chin and not pointy Patient selection As with any aesthetic procedure, appropriate patient selection and management of expectations are probably the key factors in determining success. It is likely, from my experience, that men seeking jawline contouring treatments are generally those for whom body image is particularly important.

A thorough history, including screening questions for any symptoms of body dysmorphia is essential, and a thorough explanation of the limits of the particular

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treatments being undertaken is of course mandatory. For dermal filler treatments in the jawline, it should always be mentioned to patients that there will be a possibility of need for correction with further filler at a later stage to refine the result. It should also be explained that a gradual approach is necessary, that there are limitations to the ability to correct any perceived underlying asymmetry and that no desired aesthetic outcome can be necessarily guaranteed. Likewise, with any radiofrequency or HIFU treatment being used to improve jawline contour, it must be emphasised that the results from such procedures are subtle and again, no particular outcome can be guaranteed.

Non-surgical techniques With the ideal proportions and angles in mind, and the ideals of the male face set out, it can be quite a challenge to decide exactly which techniques and products are going to be best for our individual patients. As with all areas of the face, I find a combination treatment approach is always best; combining injectables with skin surface treatments. I find it useful to keep in mind whether I am primarily replacing or primarily augmenting volume, which always helps with the estimation of how much product might be required. Usually, I find that less is needed for primarily augmenting volume in younger patients.

For male jawlines, I normally select a filler with a relatively high G-prime (i.e. high elasticity and viscosity), as the filler is likely to be subject to a number of deforming forces during its lifetime, particularly if injected in the masseteric area. My filler of choice for deep contouring would be Juvéderm Voluma, given its reversibility and high G-prime.

Others, such as Restylane Lyft and Teosyal RHA 4 are also good choices. I personally rarely use collagen-stimulating fillers due to their lack of reversibility in the event of a vascular compromise. Injection techniques are very much dependent on personal preference, but a combination of needles and cannula techniques are often required for this area, particularly around the facial artery, where a cannula is often preferred by some injectors. Likewise, a gradual augmentation is often desirable, so spacing treatments over a number of sessions is a good idea to avoid overfilling.

Although every patient is different and it is impossible to give a general rule about male jawline contouring, my technique usually involves deep intramuscular boluses of filler onto the periosteum in the region of the angle of the mandible using a needle. Usually, if

Reproduced from Aesthetics | Volume 4/Issue 12 - November 2017

In Practice News using two syringes of 1ml, this would be around 0.3-0.5ml on each side in two to three points. I generally then use a bolus of around 0.1-0.2ml bilaterally, just anterior to the mandibular retaining ligament, to correct any slight defect there, should there be any. Again, this is a deep injection. Then, I would place a deep bolus onto the surface of the mental process on each side – 0.1-0.2ml – to square the chin if need be. It is sometimes advantageous to use a little bit of filler slightly more superficially in the subcutaneous plane using a cannula along the area of the body of the mandible, however, the need for this varies from patient to patient. It is a high-risk zone, due to the presence of the marginal mandibular branch of the facial nerve and the facial vessels, so should only be attempted by experienced injectors and where there is definite need. Neurotoxins can be used in this area too, particularly if there is some drooping of the jowl fat pads. I approach this by asking the patient to grimace, then when the platysma is fully activated and contracted, I mark the bands – the strongest of which tend to be those posterior to the mandibular retaining ligament. I then inject along the bands, making sure the most superior injection point is at least 1cm below the jawline to avoid any inadvertent spread and relaxation of the depressors of the mouth. I tend to find around 20-25U of botulinum toxin sufficient in this area – this is of course an off-label use of toxin products. Likewise, a small dose of toxin injected into the mentalis can also improve the chin area. Skin and SMAS laxity in older male patients is also an important consideration, so energy-based treatments such as HIFU and radiofrequency (both ablative and non-ablative) can often be useful adjunctive treatments to injectables in this area, usually also treating the mid-face.

Conclusion The jawline is an area that is of concern to many male patients seeking aesthetic procedures. A comprehensive knowledge of the anatomy is important when considering treatments in this area, so in this article I have outlined the most important structures to consider when it comes to injecting here. As with other areas of the face, it is important not to treat in isolation and ideally use a number of different treatment modalities for an optimum result.

Dr David Jack is an aesthetic practitioner based between his clinics in Harley Street in London and Scotland. He graduated from the University of Glasgow and later became a member of the Royal College of Surgeons of Edinburgh. Dr Jack trained in the NHS until 2014, mostly in plastic surgery, before leaving to establish his non-surgical aesthetic practice, having worked in this sector part-time for almost seven years.

REFERENCES 1. Hur MS, Hu KS, Cho JY, Kwak HH, Song WC, Koh KS, Lorente M, Kim HJ. Topography and location of the depressor anguli oris muscle with a reference to the mental foramen. Surg Radiol Anat.

2008;30(5):403–7 2. Moore, Keith L, and Arthur F. Dalley. Clinically Oriented Anatomy. Philadelphia: Lippincott Williams & Wilkins, 1999. Print.

3. Mohammed Alghoul, MD, Mark A. Codner, MD; Retaining Ligaments of the Face: Review of Anatomy and Clinical Applications, Aesthetic Surgery Journal, Volume 33, Issue 6, 1 August 2013, Pages 769–782 4. Reece EM, Pessa JE, Rohrich RJ, The mandibular septum: anatomical observations of the jowls in aging-implications for facial rejuvenation Plast Reconstr Surg. (2008) Apr;121(4):1414-20 5. Batra APS, Mahajan A, Gupta K. Marginal mandibular branch of the facial nerve: An anatomical study.

Indian Journal of Plastic Surgery: Official Publication of the Association of Plastic Surgeons of India.

2010;43(1):60-64.

6. Mauricio de Maio, Berthold Rzany The Male Patient in Aesthetic Medicine Springer 2009 7. Braz, André; Humphrey, Shannon et al, Lower Face: Clinical Anatomy and Regional Approaches with Injectable Fillers, Plast Reconstr Sur: 2015 136 (5Suppl) - p 235S–257S 8. de Maio M, Ethnic and Gender Considerations in the Use of Facial Injectables: Male Patients Plast Reconstr Surg. (2015) Nov;136(5 Suppl):40S-43S 9. Robert T Sataloff, Anthony P Sclafani Sataloff’s Comprehensive Textbook of Otolaryngology: Head & Neck Surgery JP Medical Ltd, (2015) 10. Mommaerts MY The ideal male jaw angle, An Internet survey, J Craniomaxillofac Surg. 2016 Apr;44(4):381-91

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Treating the Male Mid-face Dr Tahera Bhojani-Lynch discusses male aesthetics and presents a case study showcasing her method of treating the mid-face In facial aesthetics, we as aesthetic practitioners are more used to looking at female faces, as these patients make up the bulk of most of our patients. You may often observe male patients whose treatments have resulted in feminine high-arched eyebrows or female-like cheeks. In my experience, men who ask for specific feminisation of the face are typically homosexual or transgender, but requests for this type of treatment can, occasionally, come from heterosexual men. However, in many cases, feminisation of the male face is the result of an error of judgement from an inexperienced practitioner. As females are currently the more common patient for aesthetic procedures, practitioners often use their experience of female face volumisation to also treat a male face. Therefore, when treating the male mid-face, the common mistake is the assumption that all genders need the same treatment to look good.

The truth is that the shape and proportion of an aesthetically-pleasing male face is quite different to that of a female, and maintaining, enhancing or adding to these masculine features on a man’s face is the secret to a successful male treatment.

To judge what is best suited on a male compared to that of a female when treating the mid-face, it is important to identify what the differences are and then understand how to reproduce them on an existing canvas.

The attractive masculine face Many men are considered better looking as they get older rather than in their youth, which is not something that is commonly said about women. One only has to look at the young David Beckham, who was not necessarily thought of as memorable or eye-catching in his 20s, but was voted sexiest man alive at the age of 40, by People magazine,1 and has been in Glamour magazine’s list of sexiest men consistently since 2009.2

Aesthetics Journal

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Certainly, when humans were hunters and gatherers, men were more likely to choose younger mates as they produced healthier offspring, so it is believed men are generally programmed to find youth attractive. Women, however, tended to choose older men as mates, who had proven themselves to be survivors and providers.

The children of good providers were more likely themselves to thrive and survive. Thus, women are biologically programmed to find physical fitness and maturity fundamentally attractive, so age in itself is not considered off-putting. Anything that emphasises the differences between the male and female face, adds to the attraction between sexes.3,4 Post puberty, the effects of growth hormones and testosterone accentuate the definition of cutaneous ligaments on the face, particularly if a man is physically fit with good muscle tone (a necessity for a good hunter). The resulting shape of the face is recognisably universally attractive. The angular shape of the jawline from a strong platysma, the taught line of the masseteric cutaneous ligament and the zygomatic cutaneous ligament, form distinctively masculine lines in the mid and lower face.5-7 Figure 1 shows that masculine features are recognisable by the width and angle of the chin and jaw, the flat planes of the cheeks, and the more horizontal eyebrows.

The space between the width of the cheeks and the jaw is smaller for men which makes the face squarer, while women have wider cheeks and a lower face that is narrower in comparison, making them look more feminine.6,8

Male

Androgynous

Female

Figure 1: Different types of faces showing masculinity and femininity.6,8 Image courtesy of Dr Arash Afraz and Massachusetts Institute of Technology. The stimuli are generated in FaceGen Modeller.

In Figure 1, it is clear to see that from left to right, the cheeks curve, the chin becomes more pointed and the brows more arched, making the face appear more feminine. Bearing these defining features in mind when treating men will ensure that the masculine aesthetic is maintained or enhanced.

There is an area in the male mid-face that gives a typically virile appearance. This is the space created by the masseteric cutaneous ligament anteriorly and the zygomatic cutaneous ligament superiorly. I like to call this area the ‘hot hollow’, although this is not a well-known phrase. Filling the hollow may make the face look younger and smoother, but takes away its masculine edge and softens the angles.7,9,10 Anatomy of the ageing face We have come to realise that loss of volume in the mid-face significantly contributes to the ageing changes in the face, whilst the superficial medial fat compartment and the infraorbital (or suborbicularis) fat pad (the SOOF) are spared.11 This selective fat loss leads to an exaggeration of the nasolabial fold, sagging of the skin inferiorly, and the appearance of a distinct groove in the mid-face.

This type of volume loss occurs in both men and women.

In the female face, we have become accustomed to replacing the loss of volume with a convex curve, using anterior and lateral

Reproduced from Aesthetics | Volume 4/Issue 12 - November 2017

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projection. We also commonly create width to the upper face, giving the illusion of a more pointed chin. Doing the same to a male face would serve to make the face more feminine and should be avoided, if the patient wishes to achieve a masculine appearance.

The depletion of volume in the deep medial fat, in the face of a male patient, results in loss of support of the infraorbital fat compartment, so that the eyes look ‘baggy’. The nasolabial fold is exaggerated and the groove in the mid-face gives a sad and downward-dragged look to their whole appearance.11 Effective treatment of male face volume loss should concentrate on filling the loss in the mid-face without creating a curve. The treated

Infraorbital fat

Superficial medial cheek fat

Medial SOOF Lateral SOOF Fixation point Buccal fat Deep medial cheek fat

Nasolabial fat

Figure 2: The superficial facial fat pads and deep facial fat pads.11

planes should be flat, aiming to keep the profile angular. Injection technique should respect the defined lines of the temporal crest, orbital margin, zygomatic arch and masseteric cutaneous ligament.

While treating the mid-face, it’s important that the jawline is assessed and treated if need be to produce a straight flat edge.

I usually use hyaluronic acid (HA) dermal fillers for treatment of the mid-face. Ideally, the product should be cohesive and give good projection and it should be suitable for injection deep into the soft tissues straight on to the periosteum. However it must also be able to integrate well with the soft tissues so it is safe to place subdermally with a cannula, which is my preference over needle.

Treatment can be done either with a needle that is placed down to the bone creating support like a ‘tent pole’ at the point of maximum loss of volume, or with a cannula, along the zygomatic arch, to the deep medial fat compartment. I prefer the latter on a younger face as it will accentuate the cheekbone more, as long as the product is placed flat and angled and not too curved. In an older patient, a midface bolus to bone, with a Before After needle, can give a point of support at the junction of the cutaneous ligament of the orbicularis oculi and the malar groove, in one injection point.

Before

After

Figure 3: A 54-year-old male patient who presented with mid-facial ageing, resulting in eye bags and a tired look. Patient before and five days after treatment of the mid-face.

Case study: treatment of the ageing male mid-face A 54-year-old male patient presented to my clinic with the complaint of ‘eye bags’ (Figure 3). The patient said that he did a lot of presentations at work and didn’t want to always look tired when he stood up in front of an audience.

In his consultation, I

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observed that fat loss of mid-facial volume was the cause of his under-eye bags. Due to the loss of support to the under eyes, I determined that contouring using a HA dermal filler should begin with support to the mid-face, the idea being to produce a straight line along the zygoma and bridge the gap caused by the loss of the deep medial fat compartment. It is important to not overfill under the cheek or create a curve, because I believe a man’s face looks more attractive with a flat plane or concavity lateral to the masseteric cutaneous ligament and below the zygoma.4,5 Once the mid-face was supported, strengthening the shape of the zygoma and jawline was important to define that masculine aesthetic. The final step in treatment was to place some product on the underside of the zygoma at the top of the masseteric cutaneous ligament to give a defined demarcation to the ‘hot hollow’ when viewed from the front, and, if necessary, to support the nasolabial fold. These are both best done with a cannula due to the potential proximity of the angular artery. In total, the patient was treated with 3ml of a cohesive, HA filler with good tissue integration properties.

Five days after the treatment, the patient observed some bruising around his right eye but had no other side effects. The five-day result achieved (Figure 3) also included some botulinum toxin to the glabellar area and frontalis, to reduce horizontal brow lines and enhance the flat brow, to appear more masculine. He was extremely happy with the overall result and said he feels younger without an artificial look.

Conclusion Over the years we have learned that there is an art to treating a face that is not just about lines and wrinkles. Treating male faces is a growth market that requires a different learning curve. Treatments that maintain the gender and enhance differences give men and women effective treatments that they appreciate and will enhance your reputation as a practitioner.

Dr Tahera Bhojani-Lynch is a doctor and surgeon specialising in ophthalmology and has more than 20 years’ experience in medical aesthetics. As a Member of the Royal College of Ophthalmologists, she was the first female British graduate to perform LASIK eye surgery in the UK and is a certified laser refractive surgeon.

REFERENCES 1. The Telegraph, David Beckham is crowned ‘Sexiest Man Alive 2015’, 2015. <http://www.telegraph. co.uk/men/style/david-beckham-is-crowned-sexiest-man-alive-2015/> 2. Aidan Turner, Glamour 100 Sexiest Men 2016, Glamour, 2016, <http://www.glamourmagazine.co.uk/ gallery/sexiest-hottest-men-of-2015-2016> 3. Johnston VS, Hagel R et al 2001, Evidence for Hormone Mediated Adaptive Design. Evolution and Human Behaviour 22: 251-267 4. AN, Feinberg DR et al, Sex Dimorphic Face Shape Preference in Heterosexual and Homosexual Men and Women, Archives of Sexual Behaviour, December 2010, Volume 39,: 1289-1296 5. Perret DI et al, Effects of Sexual Dimorphism of Facial Attractiveness. Nature. 394: 884-887.

6. Nussey S & Whitehead S, Endocrinology: An Integrated Approach, BIOS Scientific Publishers: 2001.

7. Daily Mail, Why faces appear male or female...it depends on which part of our brain is analysing them’, 2010. <http://www.dailymail.co.uk/sciencetech/article-1332688/How-faces-appear-male-femaledepending-lookin-them.html> 8. Anne Trafton, When gender isn’t written all over one’s face, 2010. <http://news.mit.edu/2010/facegender-1126> 9. Fink B, Neave N.,The biology of facial beauty. Int J Cosmet Sci. 2005 Dec;27(6):317-25.14672494.2005.00286.x.

10. Penton-Voak IS & Perrett DI, Female Preference for Male Faces Changes Cyclically: Further Evidence, Evolution of Human Behaviour 21: 38-48.

11. Wan D, Amirlak B et al, The Clinical Importance of Fat Compartments in Midfacial Aging, Plast Reconstr Surg Glob Open 2013; 1:e92

Reproduced from Aesthetics | Volume 4/Issue 12 - November 2017

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depth, may be treated more safely with a less viscous hyaluronic acid with lower G-prime properties hence reducing the risk of the Tyndall effect or the filler being visible or lumpy after injection.3,4 Exploring causative factors such as wrinkle depth, cause and location alongside product choice is key in deciding the optimum treatment course for patients.

Clinical scales

Wrinkle Severity Scales Dr Rupert Critchley discusses how to effectively use wrinkle severity scales in patient treatment plans As aesthetic practitioners, assessment of wrinkles during aesthetic consultation is one of the key techniques we can use to determine and convey the best treatment approach for our patients. When determining how to address wrinkles there are a number of valid and reliable wrinkle severity scales available, such as the Wrinkle Severity Rating Scale (WSRS) and the Glogau classification, among others, that can be used to assist aesthetic practitioners. These clinical tools provide a means of quantitative assessment of facial skin folds, which can be easily conveyed to our patients. These scales can provide an ‘objective eye’, which may prove very useful during consultation.

Sometimes, and perhaps more importantly, clinical scales can also be a useful means of expectation management and overall patient satisfaction. For example, patients can be shown how many notches they have moved up the scale post treatment.

Examination of expression There are many subjective methods of wrinkle assessment available to aesthetic practitioners. First and foremost, we can use a simple method of differentiation to ascertain whether wrinkles are static or dynamic by examination of expression. These lines, that appear when moving the muscles of the face, can be treated with botulinum toxin, whereas deeper lines, that are not affected by movement, may be better corrected with dermal filler and deeper volumisation.2 We can then further subdivide wrinkles to decide on product type. For example, wrinkles that rest at a very superficial

Types of wrinkles

More objective methods of assessing wrinkle severity include a number of safe and reproducible clinical scales, which can be used in conjunction with your more subjective eye.

The Wrinkle Severity Rating Scale The WSRS was validated in 2004 by Day et al. as a new clinical outcome instrument for quantitative assessment of facial skin folds, in particular the nasolabial folds (NLF).5 During this time, nasolabial fold injections were more common than mid-face volumisation, hence the need for a quantitate scale. This FDAapproved 5-grade scale also allows an assessment to be made of patient satisfaction with treatment and the important, although highly subjective, outcome.6 Having been used in a large number of validated studies, mostly in application to the nasolabial fold depth, the WSRS scores the nasolabial fold depth from 1 through to 5 with the latter being the most severe (Figure 1).7-9 Using the WSRS could be invaluably useful as a quantitate measure of improvement as well as an easy and reproducible method of documenting results. As a general rule, the further down the scale post treatment, the greater the expected patient satisfaction.5 The WSRS can be used throughout aesthetic consultation when assessing patients, treatment planning and in follow up post procedure, providing both practitioners and patients with a reliable method of expectation and result management. The WSRS is applicable to nasolabial fold depth in this area only and for use Grade

Severity

Grade 1

No visible NLF. Continuous skin line.

Grade 2

Shallow but visible NLF with a slight indentation.

Grade 3

Moderate deep NLF. Visible at normal appearance.

Grade 4

Very long and deep NLF. Prominent facial feature. Less than 2mm visible fold if stretched.

Grade 5

Extreme, deep and long NLF. Between 2-4mm V-shaped fold if stretched.

Figure 1: Wrinkle Severity Rating Scale5

Wrinkles can be classified as either static or dynamic. Dynamic wrinkles are caused by repetitive muscle movements. Years of continued squinting, worrying, frowning and smiling can trigger these. Forehead wrinkles and lateral canthal lines are good examples. Static wrinkles, on the other hand, result from a loss of skin elasticity due to the skin’s collagen breaking down and the tissue becoming lax. Static wrinkles can be further agitated by genetics, poor diet and smoking. Examples include lines at the corner of the mouth and wrinkles on the neck.1

alongside dermal fillers. For example, a softer and less severe line, scoring grade of 2 or 3, may be corrected with a smaller volume of dermal filler. This can be conveyed to your patient prior to treatment and, in follow up, the scale can be used once again to gauge improvement and, subsequently, patient satisfaction. Although it does have its uses, I would personally recommend that the WSRS is still used in conjunction with examination of the patient while they are expressing, as well as the use of suitable before and after imagery to complement documentation. Including WSRS or equivalent (the

Reproduced from Aesthetics | Volume 4/Issue 12 - November 2017

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Group

Classification

Typical Age

Description

Skin Characteristics

I

Mild

28-35

No wrinkles

Early photoageing: mild pigment changes, no keratosis, minimal wrinkles, minimal or no makeup required

II

Moderate

35-50

Wrinkles in motion

Early to moderate photoageing: early brown spots visible, keratosis palpable but not visible, parallel smile lines begin to appear, wears some foundation

III

Advanced

50-65

Wrinkles at rest

Advanced photoageing: discolouration, visible capillaries, visible keratosis, wears heavier foundation

IV

Severe

60 and above

Only wrinkles

Severe photoageing: yellow/grey skin colour, prior skin malignancies, wrinkles throughout, no normal skin, cannot wear makeup because it cracks and cakes

Figure 2: The Glogau Classification10,14

Glogau scale or a modified Fitzpatrick scale) into consent form paperwork, alongside patient discussion notes, may also be of benefit to the practitioner.

Limitations of WSRS A statistical review has pointed out an important drawback in which, subjectivity, especially during the use of WSRS in clinical studies, can vary quite dramatically.5 Interestingly, it uncovers that in a certain study, only 70% of the 30 photographed cases would be given the same wrinkle score when evaluating them on two separate occasions.5 It must be duly noted that the WSRS does not help us pick the most appropriate treatment for our patients (like botulinum toxin vs dermal filler) and is not useful in assessment of wrinkles/lines affecting other areas of the face other than the nasolabial folds.

Alternate validated clinical scales such as the Glogau classification or modified Fitzpatrick wrinkle scales (which comprises three classes of nasolabial wrinkling) are more useful in these situations.11,12 With the rapidly progressive development of aesthetic techniques and a holistic, full face approach to treatment becoming more popular, the WSRS may now appear a little restricted in its clinical use. However, the nasolabial folds remain a common area of concern to our patients, therefore the WSRS is potentially still a useful clinical tool.

The Glogau classification The Glogau classification, developed by dermatology professor Dr Richard Glogau in 1996, categorises wrinkle severity.10 Referenced by dermatologists, plastic surgeons and aesthetic practitioners worldwide, it is a reproducible and easy-to-use clinical scale that provides another useful measure of treatment effectivity.10 Those that fall under the category of wrinkles in motion, or dynamic lines, may have better outcomes with toxin injection, whereas deeper lines visible at rest or static wrinkles may be best treated with dermal filler.

Skin characteristics here are also useful from a dermatology point of view when classifying and treating signs of photoageing. For further information, see Figure 2.

Limitations of Glogau Alongside both patient and clinician subjectivity, the Glogau classification scale has limitations to other wrinkle rating scales. The main limitation is that it does not help select the specific procedures for each group or predict the response or anticipated skin reactions to topical treatments.13

Summary In conclusion, the WSRS provides a clinical tool for the objective assessment of nasolabial fold depth. Limitations include clinician subjectively and its use confined to that of dermal filler treatments addressing the nasolabial fold only. The Glogau classification helps to assess the face while in motion and is useful to classify and treat signs of photoageing. Although both are useful for facial assessment, using different validated tools together such as WSRS and the Glogau scale, along with before and after imagery in an aesthetics consultation, will provide both practitioner and patient with a reliable method of expectation and results management.

Dr Rupert Critchley is the lead clinician and director of Viva Skin Clinics and its sister training faculty the VIVA Academy. After qualifying as a doctor in 2009, he has completed an array of courses in advanced nonsurgical aesthetics; attained MRCS part A and is also a fully qualified GP. REFERENCES 1. Shahrokh C. Bagheri, Chris Jo, Clinical Review of Oral and Maxillofacial Surgery, Elsevier Health Sciences, 2 Dec 2013. P414 2. Dr Amanda Oakley, Facial lines and wrinkles, Waikato Hospital, Hamilton, New Zealand, 2004. <https://www.dermnetnz.org/topics/facial-lines-and-wrinkles/> 3. Muhn C, Rosen N, Solish N, Bertucci V, Lupin M, Dansereau A, Weksberg F, Remington BK, Swift A, The evolving role of hyaluronic acid fillers for facial volume restoration and contouring: a Canadian overview. Clin Cosmet Investig Dermatol. 2012;5:147-58. doi: 10.2147/CCID.S30794. Epub 2012 Oct 5.

4. Clin Interv Aging. 2008 Dec; 3(4): 629–634.Published online 2008 Dec.PMCID: PMC2682392 Hyaluronic acid gel (Juvéderm) preparations in the treatment of facial wrinkles and folds 5. Day DJ1, Littler CM, Swift RW, Gottlieb S. The wrinkle severity rating scale: a validation study. Am J Clin Dermatol. 2004;5(1): 49-52.

6. Fagien S, Carruthers JD. A comprehensive review of patient- reported satisfaction with botulinum toxin type A for aesthetic procedures. Plast Reconstr Surg. 2008; 122:1915–25.

7. Carruthers, A., Carey, W., de Lorenzi, C., Remington, K., Schachter, D. and Sapra, S. Randomized, Double-Blind Comparison of the Efficacy of Two Hyaluronic Acid Derivatives, Restylane Perlane and Hylaform, in the Treatment of Nasolabial Folds. Dermatologic Surgery, 2005, 31: 1591–1598.

8. Nast, A., Reytan, N., Hartmann, V., Pathirana, D., Bachmann, F., Erdmann, R. And Rzany, B. Efficacy and Durability of Two Hyaluronic Acid–Based Fillers in the Correction of Nasolabial Folds: Results of a Prospective, Randomized, Double-Blind, Actively Controlled Clinical Pilot Study. Dermatologic Surgery, 2011. 37: 768–775. doi:10.1111/j.15249. Narins, R. S., Brandt, F. S., Dayan, S. H. And Hornfeldt, C. S. Persistence Of Nasolabial Fold Correction With A Hyaluronic Acid Dermal Filler With Retreatment: Results Of An 18-Month Extension Study.

Dermatologic Surgery, 2011. 37: 644–650.

10. Glogau, R. G. Aesthetic and anatomic analysis of the aging skin. Semin. Cutan. Med. Surg. 15: 134, 1996.

11. Inja Bogdan Allemann and Leslie Baumann, Hyaluronic acid gel ( Juvéderm™) preparations in the treatment of facial wrinkles and folds’, Clin Interv Aging. 2008 Dec; 3(4): 629–634.<https://www.ncbi. nlm.nih.gov/pmc/articles/PMC2682392/> 12. David Shoshani, Md, Elana Markovitz, Rn, Stan J. Monstrey, Md, Phd,Y And David J. Narins, Md, Facsz, The Modified Fitzpatrick Wrinkle Scale: A Clinical Validated Measurement Tool for Nasolabial Wrinkle Severity Assessment, the American Society for Dermatologic Surgery, Inc, 2008.

13. Zein E. Obagi, The Art of Skin Health Restoration and Rejuvenation, Second Edition, CRC Press, 18 Dec 2014, p81 14. Richard G Glogau, Glogau Wrinkle Scale, http://sfderm.com/glogau-wrinkle-scale/>

Reproduced from Aesthetics | Volume 4/Issue 12 - November 2017

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Case Study: Concealing Scars Permanent makeup artist and paramedical tattooist Hina Solanki provides an overview on medical tattooing and details two instances of successful scar concealment When many people hear the word ‘tattooing’, they probably think of the tattoos people have on their body and not necessarily that of the medical kind. Medical tattooing can often be referred to as cosmetic tattooing, micropigmentation, semi-permanent makeup, scar camouflage and paramedical micropigmentation. The procedure can be used to conceal various conditions including alopecia, vitiligo, surgical scars and burns, to name a few.

Medical tattooing can transform the way people feel about themselves and boost their self-esteem and confidence. A person’s skin condition may have affected their work and relationships, often due to a lack of self-confidence. It’s important for aesthetic practitioners to be aware of medical tattooing as they may be able to refer patients. For example, practitioners or dermatologists who are not able to help with vitiligo should be advising their patients about the possibility of medical tattooing. Additionally, surgeons can reassure patients who may be concerned about the scars following surgery that there can be a solution.

How does it work?

Medical tattooing is a tattooing technique that inserts pigment into the skin with a single-use fine needle, into the chosen procedure site.1 In this technique, the pigment is only implanted into the upper dermal layer. From my experience, if pigment is implanted into the skin as deep as normal body art tattoos are, the colours will not be true enough to mimic traditional makeup, which is important to consider when covering up scars. Pigment is then blended to the skin tone. Several Before different colours may be blended to build up the skin, to create natural looking skin tones and give the appearance of a natural finish. Freckles may also be implanted to match the patient’s normal skin area.

After It is very important to remember that this procedure will camouflage the patient’s scar, not make it disappear. The idea is to make the scar less noticeable and not have the Figure 1: Patient before and after areola reconstruction using medical tattooing eye drawn to it

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immediately. The result will also depend on the severity of the scar and may take more than one session. Below are two examples of medical tattooing on patients that I have treated. The first case study is of an areola reconstruction over a scar after a simple mastectomy and the second is a scar camouflage treatment for postsurgery scars to the forearm.

Case study one: areola recreation

For this patient, I recreated an areola over a scar across a newly-inserted implant. The areola and nipple, along with breast tissue, were all removed during the patient’s mastectomy surgery and an implant was inserted by the surgeon to rebuild the breast. If patients have been referred to me from a surgeon, I ensure I liaise with the surgeon and work to the time frames they suggest so that the area heals well.

I recreated the areola and nipple by using three different shades.

By using a circular movement, with a five-round needle, I was able to create a ripple effect, resulting in a more texturised appearance, which produced a very natural-looking areola. For the nipple, I then used some lighter shades to create a ring with a three-microneedle device, giving the illusion of an outward-projecting nipple. A fourflat needle was then used on the outer edge of the areola. This provided a softened edge, to ensure the areola did not look ‘too perfectly’ circular. All of these needles mentioned vary in thickness and are commonly used for shading work and to create a circle formation on the skin.2 This type of procedure can take two sessions or more. If the scar tissue is dense and tight, then care is needed when inserting the needle, so that the placement of the pigment goes into skin, to achieve the desired results. If too much pressure is used, the pigment could merge out and the resulting colour may appear too grey. If not enough pressure is used, then during the healing process, the pigment may be rejected and leave the skin. In my experience, a scar which is silvery white and flat, with not much tight scar tissue, would retain the most pigment and the bestlooking result, however it is important to note that no scar is consistent all the way through.

After the first session, the patient was very pleased, but during healing there was some unevenness in pigment, which is completely normal. In the second session, I went over the area again and evened out the pigment. The first procedure would have broken down some of the scar tissue present in the areola and, from personal experience, it’s almost always easier to get pigment to sit correctly the second time around. The procedure usually takes around two hours. There can be some soreness or swelling to the area, which sometimes lasts up to five days. A light dressing should be applied following the procedure. I normally advise my patients to wear loose, comfortable clothing and most definitely a loose-fitting bra; they normally have their post-surgical bra. The way pigment breaks down in each patient is different but generally, most patients will not need the area retouched for about five years.

Overall the patient was happy. In my experience of treating breast cancer patients, this is their chance to fully say goodbye to cancer and frequently provides patients with a sense of closure.

Case study two: self-harm scar camouflage This patient came to me for a consultation looking for somewhere she could get help covering her scars, but also somewhere where she wouldn’t feel like she was being judged. It’s often very hard

Reproduced from Aesthetics | Volume 4/Issue 12 - November 2017

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After

Figure 2: Before and after scar camouflage treatment following a skin graft on the arm

for self-harm patients to talk about their problem with anyone and many manage to keep their scars hidden from friends and family for decades. This patient underwent a very successful skin graft procedure by a surgeon to cover self-harm scars to the forearms.

Surgery was performed two years prior to having cosmetic tattooing.

In my experience, medical tattooing can generally be done one year after having a skin graft however, depending on the case, it may take up to two years. Very tight scar tissue meant that the medical tattooing procedure had to be done very slowly using a fine needle, to implant pigment into the skin with a pointillism method, where you hold the needle directly above the skin to create microdots through the whole scar. This technique also helps to break down and loosen the tight scar tissue due to the penetration. Four different shades of pigment were used on this patient, two for the freckled appearance, to create more depth, and the other two shades were used over the whole area that was being treated, to match the patient’s skin colour.

The freckles were done unevenly, in both small and large sizes, to mimic the appearance of true freckles. Pointillism for the freckles could have created too dense a colour tone, so I used a shading needle in small, circular movements to create different sized freckles and used it to push out the pigment in some areas, so not to create a freckle that was too rounded. This allowed the freckles to blend in better with the rest of the skin. The patient was delighted with the result which took almost four hours to achieve. There was no follow up on this particular procedure as the patient was due to work abroad soon after, otherwise the patient would have come in for a follow up procedure to check the result, which can last up to five years.3 Complications are highly unlikely, however, the patient may have poor pigment retention which would mean that they may need to have more sessions. If the healing is delayed or the area required medical attention, I would advise the patient to visit her general practitioner.

Aftercare Aftercare for any medical or cosmetic tattooing procedure is very important.4 After the procedure, I provide full aftercare instructions on short-term and long-term care. The aftercare is the same for all procedures. Instructions on dressing the area may vary.

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• Keep the treatment area moist with a healing balm containing natural ingredients such as chamomile, lavender and vitamin E, or aftercare ointment, and apply three times per day minimum.

Be mindful about not double dipping into the balm pot to prevent cross contamination. To avoid this, advise patients to use the back of their hand as a palette and a cotton bud to place a small amount of aftercare balm on the treatment area.

• Do not get the procedure site soaking wet for five to seven days and be careful when showering or washing hair. Instead, cleanse the procedure site with damp cotton wool with saline water or tap water. Do not overuse water but use enough to be able to clean the area. Pat dry with a tissue and then reapply the balm.

• Do not pick, peel or scratch the treatment area. This could result in pigment loss or infection, or worse, scarring. If patients really do get an uncontrollable urge to itch, a light pat to the treatment area with clean hands may help or I advise to apply more balm to lessen the tightening feeling of healing skin.

Long-term care After the initial seven days of healing, patients will need to use a strong SPF to protect the treatment area from fading too quickly.

Once a month, I advise to check the healing of the procedure site and apply more balm if need be. In my experience, tattooed skin tends to be drier, so applying some balm will ensure maximum longevity for the treated area.

If patients regularly swim, I advise to apply petroleum jelly over the treatment area to protect it from the chlorinated water. Chlorine can also fade the enhancement faster.5 Patients should inform you if they are having a chemical peel or laser procedure as these can also fade enhancements more quickly. A full four weeks in-between having a cosmetic tattoo and a peel/laser treatment should be left so the skin is given time to heal.

Conclusion The patients that were included in both these case studies reported a confidence boost and a sense of liberation after receiving these life-changing treatments. It is important for aesthetic practitioners to consider the possibilities of medical tattooing for their patients and, in circumstances where practitioners may not be able to treat the patient but where medical tattooing may be an option, there should be the opportunity to refer them to professionals.

Hina Solanki is a permanent makeup artist, scar medical tattooing specialist and author of the Permanent Make Up Guide. Following a health scare of her own, Solanki developed expertise in medical scar camouflage as she was passionate about helping others rediscover their selfconfidence after suffering from illness or injury. Patients of all ethnicities from across the world seek her expertise to camouflage scar tissue.

REFERENCES 1. Breastcancer.org, Nipple Reconstruction (2017) <http://www.breastcancer.org/treatment/surgery/ reconstruction/types/nipple> 2. Ebay, 5 Tips on Choosing the Correct Size Tattoo Needle (2016) <http://www.ebay.co.uk/gds/5Tips-on-Choosing-the-Correct-Size-Tattoo-Needle-/10000000177748054/g.html> 3. Laboratories Biotic Phocea, Medical Tattooing < http://biotic-phocea.com/medical-tattooing/> 4. East Kent Univerity Hospital, Micropigmentation (medical tattooing): your aftercare (2015) <www. ekhuft.nhs.uk/EasySiteWeb/GatewayLink.aspx?alId=7493> 5. Authority Tattoo, How long after getting a new tattoo can you swim? (2016) <https://authoritytattoo. com/new-tattoo-and-swimming/>

Short-term care I advise patients to do the following for the first five to seven days after the procedure:

Reproduced from Aesthetics | Volume 4/Issue 12 - November 2017

Advertorial HARPAR GRACE

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iS Clinical Fire & Ice Resurfacing Treatment: The UK’s most dynamic fusion treatment With zero downtime, recognition globally as a coveted celebrity A-List treatment and proven versatility as an aesthetic device partner – can you afford not to offer iS Clinical Fire & Ice within your treatment portfolio? iS Clinical Fire & Ice is one of the most famous facials in Hollywood, with celebrities and dermatologists alike, and it continues to be one of the UK’s most results driven treatment facials. It is clinically formulated with the purest pharmaceutical grade ingredients and designed to rapidly and safely resurface the skin, reduce fine lines, address problematic skin and encourage cellular renewal. This is one of very few pharma grade BOTANICAL resurfacing treatments that offers maximum results, with zero downtime, due to the combination of product formulations used within the treatment to replenish and offset the resurfacing process.

This treatment treats a range of skin conditions and has gained global acclaim for being the ultimate low risk ‘go to’ special occasion preparation treatment.

The perfect aesthetic partner for your portfolio Complements and enriches the following offerings within clinic:

• Peel Partner: complements other peel treatments in the market, including the medical grade TCA peels, due to its botanical base and ability to act as an introduction and post peel treatment for a number of others in the market that cannot be used as often or long term.

• Device compatible: can be combined with other devices, lasers, microdermabrasion, radiofrequency, light therapy, cryotherapy and treatments to create new concepts and signature treatments.

Key indications and conditions iS Clinical Fire & Ice can treat include:

7 reasons why offering iS Clinical Fire & Ice is strategically beneficial for your practice: 1. Low investment (£8) with high return (up to £450 per treatment)

2. ZERO downtime for patients 3. No specialist equipment required to perform treatment 4. Can be combined with devices, lasers, light therapy and other treatments to create new concepts

5. Unrivalled upselling potential from treatment 6. Pregnancy safe 7. PR, marketing materials and support Leading practitioners and clinics offering iS Clinical Fire & Ice include: Miss Sherina Balaratnam (S-Thetics), Dr Rita Rakus, Dr Preema Vig, Waterhouse Young Clinic, Mrs Sabrina Shah-Desai, Marea Brennan Thorns (Qutis), Emma Chan, Mr Nigel Mercer (Bristol Plastic Surgery), Dr Stefanie Williams (Eudelo), Dr Tijion Esho, The Bulgari Spa London.

rating • &Anti-Inflammatroy • Collagen Synthesisng • Brightening • Acne problematic skin • • • • • 56

Hyperpigmentation Ageing skin Dehydrated skin Introductory resurfacing Instant radiance market; bridal & red carpet events

For more information about iS Clinical Fire & Ice and how it can integrate within your clinic portfolio to increase your PR, client satisifaction and profitability please call +44 (0) 845 1166242 or email enquiries@harpargrace.com.

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A summary of the latest clinical studies Title: Vertical Lifting: A New Optimal Thread Lifting Technique for Asians Authors: Kang SH, Byun EJ, Kim HS Published: Dermatologic Surgery, October 2017 Keywords: Asian skin, facial rejuvenation, PDO threads, threadlift Abstract: With the evolution of facial rejuvenation methods, thread lifts have gained popularity among patients who seek cosmetic improvement. Absorbable wedge-shaped polydioxanone (PDO) sutures are currently available, and they are extremely popular in the aesthetic clinics in Korea. In case of midface and mandibular jowl lift, threads are most often inserted in an oblique manner with vectors of rejuvenation directed toward the temple.

However, specific characteristics of skeletal anatomy should be considered when deciding which technique to use in Asians. Herein, the authors introduce a vertical lifting technique most suitable for Asians, in which short (6cm in length), wedge-shaped PDO sutures are inserted vertically downward in the anterior malar and submalar areas. A retrospective chart review was performed on cases of facial laxity treated with vertical thread lifting. A total of 39 Korean patients were included. All participants underwent a single treatment session. The results were assessed objectively using serial photography and subjectively based on the patients’ satisfaction scores. Complications were also recorded. Most patients (89.7%) considered the results satisfactory. Consensus ratings by 2 independent dermatologists showed that the objective outcomes at the 6-month follow-up were largely categorized as very much improved (10.3%), much improved (43.6%), and improved (33.3%).

The incidence of complications was low, and the complications were minor. Thread lifting with short, wedge-shaped PDO sutures is safe and effective for facial rejuvenation.

Title: Effects of Fractional Picosecond 1,064 nm Laser for the Treatment of Dermal and Mixed Type Melasma Authors: Chalermchai T, Rimmaneethorn, P Published: Journal of Cosmetic and Laser Therapy, October 2017 Keywords: Hydroquinone, laser, picosecond, melasma Abstract: Picosecond laser is a novel modality for pigmented skin disorders with extremely short pulse duration. This study aimed to investigate the efficacy of fractional picosecond 1,064 nm laser in melasma treatment. Female subjects with melasma were enrolled and received fractional picosecond 1,064 nm laser plus 4% hydroquinone cream on one randomly-assigned side of the face; results were compared to use of hydroquinone cream only on the contralateral side. The modified melasma area severity index (mMASI) score, melanin index by Mexameter MX18®, participant satisfaction score by quartile rating scale, and quality of life by Dermatology life quality index (DLQI) were evaluated over 12 weeks.

Thirty female subjects completed the protocol. The mean (± standard deviation, SD) mMASI score at the 12-week visit was significantly reduced in the picosecond laser-treated areas compared to controls (3.52 ± 1.4 and 4.18 ± 2.03 respectively; p = 0.035).

Observed adverse effects included transient mild erythema and mild skin desquamation. The addition of fractional picosecond

1,064 nm laser to 4% hydroquinone was effective and significantly better than 4% hydroquinone alone for the treatment of melasma.

Title: Facial Assessment and Injection Guide for Botulinum Toxin and Injectable Hyaluronic Acid Fillers: Focus on the Midface Authors: DeBoulle K, Braz A, et al.

Published: Plastic and Reconstructive Surgery, October 2017 Keywords: Botulinum toxin, hyaluronic acid, injectables, midface Abstract: This second article of a three-part series addresses techniques and recommendations for aesthetic treatment of the midface. Injectable fillers are important for rejuvenation of the midface by replacing lost volume and providing structural support; neuromodulators play a smaller role in this facial region. Fillers are used for volumization and contouring of the midface regions, including the upper cheek and lid-cheek junction and the submalar and preauricular areas. Also, treatment of the frontonasal angle, the dorsum, the nasolabial angle, and the columella may be used to shape and contour the nose. Neuromodulators may be used to treat bunny lines and for elevation of the nasal tip. The midface is considered an advanced area for treatment, and injectors are advised to obtain specific training, particularly when injecting fillers near the nose, because of the risk of serious complications, including blindness and necrosis. Injections made in the midcheek must be performed with caution to avoid the infraorbital artery.

Title: Concealing a Shiny Facial Skin Appearance by an Aerogelbased Formula Authors: Cassin G, Diridollou S, et al.

Published: International Journal of Cosmetic Science, October 2017 Keywords: Aerogel, cosmeceutical, skin Abstract: To explore, in vitro and in vivo, the potential interest of an Aerogel-based formula, in concealing a naturally shiny facial skin.

In vitro, various formulae and ingredients were applied as a thin film onto contrast plates and studied through measuring the shine induced following pump spraying of a mixture of oleic acid and mineral water as a sebum/sweat mix model. In vivo, two different formulae with various concentrations of Aerogel were randomly tested on half side of the face vs. bare side of Chinese women, under some provocative environmental conditions, known to enhance facial shine. Both studies included comparative evaluations using a half-face procedure (treated/untreated or vehicle.) In the first case, evaluations were quantitatively carried out whereas the second one was based on a quantitative self-evaluations from standardized full-face photographs. In vitro, the tested Aerogel, incorporated at 1% or 2% concentration in a common O/W cosmetic emulsion, shows an immediate light scattering effect, thereby masking shine.

Such effect appears of much higher amplitude than that of two other tested particulate ingredients (Talc and Perlite). A noticeable remanence of anti-shine effect was confirmed in vivo in extreme conditions. The latter was self-perceived by all participants in the second study. As a cosmetic ingredient, this new Aerogel appears as a highly promising ingredient for concealing the facial skin shine, a source of complaint from many consumers living in hot and humid regions.

Reproduced from Aesthetics | Volume 4/Issue 12 - November 2017

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Avoiding Email Marketing Mistakes Marketing consultant Adam Hampson discusses 10 common email marketing mistakes that can damage your campaigns and provides tips on how to avoid them Once you’ve enticed people to sign up to your mailing list with an appealing offer like an online skin assessment or skincare tutorial, your next challenge is to ensure that they open your emails. Successful email marketing evolves through a process of research, testing, and analysis of the data provided by your email marketing software. MailChimp, InfusionSoft, Mad Mimi, Constant Contact, Aweber, Campaign Monitor and others all provide excellent data about how your audience is interacting with the emails you send out. If you make mistakes, they may lead to a decrease in interaction between you and your patients, including people opting out of receiving future mailings from you. To make sure this doesn’t happen, here’s my list of the top ten mistakes to avoid:

1. Sending address Just because it’s common practice to send email marketing campaigns from a ‘noreply’ address doesn’t mean it’s best practice. Using a ‘noreply’ address can send the message that you’re not interested in having a conversation with people on your mailing list beyond what you want to promote to them.1 Takeaway If you currently send your emails from an address such as ‘noreply@yourdomain.com’, try changing it to your name or something like ‘hello@yourdomain.com’ and invite people to give you feedback. It’s a subtle way of showing that you value what your recipients have to say.

2. Targeting Sending an email campaign to everyone on a mailing list rather than to a targeted segment is another common mistake. You may have people on your mailing list who aren’t patients yet and others who have been patients for years. Some of your subscribers may only be interested in facial treatments, while others may want to know

more about body sculpting. Different groups will be motivated by different content.

4. Too many emails or not enough How many marketing emails should you send? The ideal number will depend on your content and your target audience, as well as what you can commit to within your budget. Ask yourself before you send out a new communication, “What value will my subscribers gain from receiving this email?”

Takeaway Keep an eye on those all-important metrics; one indicator that you’re sending out too many emails is a sharp decrease in open rates or a spike in unsubscribe rates.

5. Minimal value Takeaway To boost your email campaigns, segment your list into different target groups; your email marketing software will have a segmentation feature. Alternatively, you could create different sign-up incentives to attract specific patient-types to different mailing lists, e.g. a series of guides about skincare in your 30s, 40s and 50s etc., aimed at getting people to sign up to age-segmented lists.

Another common email marketing mistake is to focus solely on selling rather than providing value. People sign up to mailing lists when they feel there is something to gain from doing so. I recommend that at least 80% of your emails focus on building a patient relationship rather than securing a sale – you might do this by sharing blog articles, advice, links to resources, case studies or treatment photos.

3. Personalisation

Takeaway Offer your mailing list content that reflects why they’re interested in aesthetic treatments, even if they never go on to buy from you. They might not become a patient but they could become a brand ambassador by telling others about your clinic.

Various statistics show the benefits of personalising marketing emails.2 Data from global information services company Experian found that brands that use personalised subject lines experience 27% higher unique click rates (i.e. the number of individuals who click on a link in an email, one or more times, across all of their devices) and 11% higher click-to-open rates (i.e. the number of unique clicks on links in an email divided by the number of unique opens), compared with non-personalised mailings.3 Personalised emails are open to mistakes, especially when they are auto-generated through email marketing software. The most common faux pas is an email addressed to ‘Hello *¦FULLNAME¦*’. When people receive this, it drives home that personalisation is just an illusion.

Takeaway If you do use personalisation elements in your email campaigns, send yourself a test email to check that everything is working properly. Often the above problem occurs when a person hasn’t given their name when signing up to a mailing list. Most email marketing tools have a ‘merge tag’ feature where you can tell them to use the first name where available but begin an email with a generic greeting if a name is missing.4

6. No personality You can be professional in your marketing emails without being aloof or unfriendly.

When people receive an email, they want to feel that it comes to them as an individual from an individual and that they share common ground with the sender.

Takeaway Don’t be afraid of showing your team at work, showcasing the equipment you use or talking about your passion for new techniques – people will love seeing the human faces of your business and the enthusiasm you have for the specialty.

7. The wrong subject line If you get the subject line right, the number of people who open your email should soar – 33% of people open an email based on the subject line alone5 – but get it wrong and your audience may never get as far as reading your content; 69% of recipients will report an email as spam based on the subject line.5

Reproduced from Aesthetics | Volume 4/Issue 12 - November 2017

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To you, the call to action might be obvious, but your readers will only know what steps to take next if you tell them The most common subject line mistakes include: • Clickbait: Clickbait-style headlines have just one purpose, to get the reader to open or follow a link to a specific web page. The problem is that a title like ‘These 7 weird tricks will change your life forever’ usually opens to content that’s far from life changing. In my experience, clickbait titles may result in higher open rates for initial campaign emails but, if the content consistently fails to live up to the promise of the subject line or if it’s considered misleading, recipients can begin to lose trust in a brand and opt out from future emails, meaning you no longer have permission to contact them.

• Being boring: Using a dull subject line will offer no incentive to open an email.

Remember, recipients probably have an inbox full of weekly newsletters – why should they open yours? A recent study into the best subject lines, by marketing automation company MailChimp, found that people prefer short and descriptive subject lines, 50 characters or fewer.6 • Typos: A typo in your subject line can convey negative messages about your attention to detail and professionalism; proofread your subject line (and the email itself) before you hit send.

• Capitalisation: It can be tempting to capitalise your entire subject line so that it stands out from other emails in your recipients’ inboxes. However, online, capital letters are synonymous with shouting and no-one wants to be shouted at. Capitalising one word in an email subject can be impactful, e.g. ‘We want to hear from YOU’, but there’s evidence to suggest that capitalised words can increase the chance of an email triggering spam filters.7

type of titles most appeal to your recipients.

You can then use the winning subject line to contact larger segments of your list.

Takeaway Carefully monitor your campaign open rates and experiment with subject titles. You should use A/B split testing,8 which involves sending out the same campaign with slight variations of the subject line wording to segments of your mailing list, to find out what

Takeaway Always give your email campaigns a clear call to action by including a button or link, for example, saying ‘Read the full story here’, ‘Make me a VIP’ or ‘Book your next appointment’ that takes them through to your website.10

8. Ignoring the pre-header The pre-header is the short line of text that sits at the very top of a marketing email. It often says something generic like: ‘Having trouble viewing this email? Click here’. What many businesses forget is that, if people have the ‘message preview’ feature in their inbox switched on or they’re viewing their emails on a smartphone, the pre-header is displayed below the subject line before they even open the email. This is a perfect piece of on-screen real estate to put a marketing message or call to action to entice people to open the email so it’s important to take advantage of.

Takeaway Changing the pre-header message to a marketing message will increase the chances of achieving higher open rates – research website Marketing Experiments found that doing this resulted in a 104% increase in open rate.9 Pre-headers work best when they tie in with the subject line, for example, teaming ‘How to get glowing skin’ with a pre-header such as ‘Don’t miss this time limited offer – 20% off your next facial if you book by Friday’.

9. Call to action A call to action tells recipients what action you would like them to take after reading your email. Do you want them to click through to your website? Sign up to a new service?

Send in their comments and reviews or perhaps book an appointment? To you, the call to action might be obvious, but your readers will only know what steps to take next if you tell them. Having no call to action, or one that is not clear, is a common mistake that marketers make.

10. Final checks Before you send out an email to your list, send yourself a test copy. Do all the links in the email work and lead to the right places?

Are there any spelling or grammatical mistakes? Does the email have a clear message throughout and have you included a subject title? Make sure you double-check everything before you hit ‘Send’.

Takeaway Small details make a big impression. For example, it’s important to include links to your website or a landing page to generate web traffic and enquiries.

Conclusion Email marketing mistakes are bound to happen. The important thing to do is to monitor your open and click-through rates and play around with different options, to determine what works best for your business and database. The key is to show your patients that they matter and you care about the content you send out.

Adam Hampson is founder and director of Cosmetic Digital, a web design and digital marketing agency specialising in aesthetics and medical cosmetics. Hampson delivers a number of keynotes, lectures and seminars on digital marketing and web design.

REFERENCES 1. Aweber, “Do not reply” address? No, thank you!, <https://blog. aweber.com/articles-tips/do-not-reply-address-dont-bother.htm>, viewed September 2017 2. Campaign Monitor, 70 Email Marketing Stats Every Marketer Should Know, <https://blog.hubspot.com/blog/tabid/6307/ bid/33971/9-undeniable-advantages-of-using-personalizedcontent-in-your-marketing.aspx>, 6th January 2016 3. Experian, New insight from Experian Marketing Services helps brands prepare for the holiday season, <https://www. experianplc.com/media/news/2016/q2-2016-email-benchmarkreport/>, August 2016 4. Mailchimp, FNAME merge tag trick, <https://blog.mailchimp.com/ fname-merge-tag-trick/>, December 2008 5. Hubspot, 19 eye-opening subject line stats that will supercharge your email open rates, <https://blog.hubspot.com/sales/ powerful-subject-line-stats-that-will-supercharge-your-openrates>, updated 26th September 2017 6. Mailchimp, Best Practices for Email Subject Lines, <https:// kb.mailchimp.com/campaigns/previews-and-tests/bestpractices-for-email-subject-lines>, 23rd August 2017 7. Spam support by Calco UK, Why do my emails go missing?, <http://www.calcouk.com/help/all_caps_spam.html>, viewed October 2017 8. Optimizely, What is Split Testing?, <https://www.optimizely.com/ split-testing/>, September 2017 9. Marketing Experiments, Email Pre-headers Tested: The Surprising Sensitivity of a Single Line of Text, < https:// marketingexperiments.com/email-marketing/preheaderstested>, 8th January 2015 10. Campaign Monitor, 75 Calls to Action to Use in Your Email Marketing Campaigns, <https://www.campaignmonitor.com/ blog/email-marketing/2016/03/75-call-to-actions-to-use-in-emailmarketing-campaigns/>, August 2016

Reproduced from Aesthetics | Volume 4/Issue 12 - November 2017

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• The 10 Wonders Box: a high value bumper box containing 10 musthave products to transform the skin. This could include cleansing, exfoliating and moisturising products, for example.

Christmas Marketing PR consultant Charlotte Moreso provides her top tips for boosting sales over the Christmas period Christmas is not just an opportunity for retailers to increase their sales. The run-up to Christmas and New Year offers clinics a solid opportunity to boost profitability by leveraging treatment and product sales. Opportunities fall into two areas: retail sales of products and gift vouchers as presents, and party preparation treatments. Patients are very busy at this time of year, and whilst looking good for the festivities may be on their mind, you can help by making it simple and easy to get the treatments and skincare they want, pushing it to the forefront of their minds. Of course, the only way potential and current patients will know about this is by promoting product and treatment sales through an integrated marketing and PR plan. Whilst being mindful not to devalue your clinic or ‘cheapen’ your brand, this is an ideal time to develop a plan and run special offers.

Gifts to go If you do not currently sell ready-to-go product gift sets, then create your own bespoke Christmas gift boxes. This can be easily done by purchasing simple, yet classy, boxes in Christmas-themed colours such as white, silver or gold. Insert shredded tissue in a complementing colour and add a variation of products themed for differing gift recipients. For example: • The Groomed Gents’ Box: an array of skincare for men that could include a cleansing wash, scrub, serum and moisturiser.

• The Trouble-Spotting Box for Teens: an ideal purchase for mothers to give to their children. You could fill this box with the essential skincare products to leave their teen’s skin clean and clear. Suggestions include a cleanser or facewash containing salicylic or glycolic acid, clay mask, blemish treatment for active blemishes and an oil-free moisturiser.

• The 10 Years Younger Box: core products to help ageing skin (retinol, vitamin C, growth factor serum, hyaluronic acid etc.).

Each box can be defined and displayed using different coloured ribbon. Postcard-size information cards on the contents of each box can be inserted. These can be easily created by your local printers at a very low cost. You simply have to provide the copy, your logo, contact details and product images – you can obtain these from the distributor or brand – I advise to ask for 300dpi JPEGs. Gift sets should be priced at a saving versus cost of purchasing individual products, and it’s a great idea to include a voucher that offers a complimentary skin consultation. This entices the gift recipient into the clinic, with the view to achieving add-on sales via treatment bookings. It also gives the patient added value when buying a gift set.

Do not forget to promote gift vouchers too. It’s best to make this simple by creating a short menu of treatments to select from. Depending on what treatments you offer, try and include at least four for the face (one aimed at creating glowing skin, one for skin perfecting, and ideally two antiageing) and two or three body treatments to select from (aimed at skin tightening and cellulite reduction). You can print this voucher menu and display it on reception. You will find that these are often lastminute purchases for those stuck for ideas or forgotten presents.

Special offers Value package offers are a strategic way of attracting bookings but it’s essential that you adhere to Keogh’s recommendations when marketing these offers. The Keogh Review of the Regulation of Cosmetic Interventions states, ‘Advertising and marketing practices should not trivialise the seriousness of procedures or encourage people to undergo them hastily’.1 Avoid offering, ‘buy one get one free’, ‘refer a friend’ or doing competitions for cosmetic treatments, and steer away from time-limited deals and financial inducements.

Instead, think about offering a complimentary treatment when booking courses, either of the same or a different treatment, as an add-on.

These add-ons can work to incentivise the patient into trying the new treatment and/or boost the results of the booked treatment.

Party perfect treatments The run up to party season isn’t just about shopping and getting nails polished. Patients are under pressure to look their best at work, events and family festivities despite feeling frazzled and run off their feet. Now is the time to offer solutions that will leave patients ‘little black dress ready’ or with an instant glow that exudes health and confidence, while wiping the stress away.

Develop a creative and catchy ‘Festive Party Prep’ menu that includes the face and the body:

If you do not currently sell ready-to-go product gift sets, then create your own bespoke Christmas gift boxes

Reproduced from Aesthetics | Volume 4/Issue 12 - November 2017

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Party prep face treatments Festive Fillers: an instant fix to rejuvenate and plump the face.

Festive Facial: gentle lasers, microdermabrasion and radiofrequency treatments will provide skin with an instant lift and glow, ready to look youthful and fresh at the forthcoming parties.

Party Peel: a selection of light peels to leave skin glowing.

Little black dress treatments Party Legs: skin toning, cellulite and/or circumferential reduction using cavitation, radiofrequency, body wraps or any other device you may have for leg treatments.

Bingo Wing Blitzer: decrease circumference and tone up bingo wings to have patients dance-floor ready. Radiofrequency and ultrasound treatments work well on this area.

Knee Raiser: uplift sagging knees using radiofrequency treatments.

Sore Shopper Feet: can you delegate an aesthetician or other suitably-trained employee to offer complimentary foot massages with every treatment during the month of December?

Other treatments Sweat Shop: botulinum toxin or other treatments aimed at treating hyperhidrosis are ideal to promote this time of year. Patients will notice excess perspiration as they are out and layered up for the outdoors, which may lead them to build a sweat.

Winter Redness: winter is not a friend of the skin and many people will experience broken capillaries as they are subjecting their skin to extreme changes in temperature – hot to cold – as they leave parties, shops and work. This is an ideal time to offer remedies such as laser treatments for broken capillaries and products to improve dull skin.

Festive taster treatment open day Open up your clinic to patients by inviting them to drop in and experience a demonstration of your menu of treatments. This will help entice them to make a booking. Offer festive nibbles and drinks, decorate the clinic and scent the air with a festive fragrance to create atmosphere. Try and book talks and/or demonstrations from company representatives to add extra credibility; this should be fairly easy to organise as it would be of benefit to the company to attend, who will likely see increased sales on the evening. Also, have your lead practitioners provide short and snappy talks to guests about key treatments. A nice touch is for the clinic owner to greet each guest personally where possible. Whilst you have guests there, encourage immediate bookings by offering special rates if they book a treatment or course on the day. Popular deals include receiving one treatment free when booking a course of six, or 20% off a course of six, should

Top tip – the science You may understand and appreciate the intricacies of the product’s science technology, but the average patient is unlikely to in the same way. They will more simply want to know if the treatment works, how long it will be until they will see results, if it will hurt and how much it will cost. So, when promoting, don’t blind patients with science and keep your conversation on this subject short and snappy.

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your margins allow this. Time your open day mid-November so that they have plenty of time for courses of treatment. Ensure each guest leaves with a goody bag of samples – you can ask your distributors to contribute to this which, again, is likely to be of benefit to them as it promotes their products. Also, be sure to have a good display of any gifts you are retailing.

12 days of Christmas There are many ways of using social media to your advantage during this period, as well as the aforementioned suggestions.

One idea is to create your clinic’s 12 days of Christmas. Use each day to promote different gifts and treatments. Time this for early November for treatments and post the gifts at the latter end of the 12 days.

Promotion Now that you have a plan, you will need to professionally design the invitation and treatment menu. Bring the design to life with use of classic imagery that will appeal to your clinic’s demographic such as a black and white shot of a Christmas drinks’ party with women wearing cocktail dresses. You can purchase images from photo agencies at a very low cost. Search Google for ‘photo agencies’ and you will have a selection to shop from. The invite is best to be postcard-sized as A4 sheets of paper, from my experience, tend to get thrown away due to their size and don’t look as professional. Place the invite details on the front and the treatment menu on the reverse, with brief one-line descriptions of the treatment. If you prefer, you can create a separate post-card sized treatment menus that allow you to include a more detailed treatment description. House the invite and treatment menu in an envelope to depict quality rather than simply affixing a stamp to the invite.

Delivering the message Once you have designed these elements, you can market using a mix of mechanics: • Email and post to your patient database: the benefits of sending emails are that they are delivered instantly and make it easier for patients to respond straight back via email. However, it’s a good idea to both email and post invites. There’s nothing quite like receiving a quality invite in the post.

• Post Office drops: to spread your outreach and target new patients not on your database, the Post Office offers a service whereby you can select surrounding postcodes and they can drop your invite to the homes in these areas. You can find information and costs of this service online, but once you have selected the areas, you simply provide the invites in envelopes and they do the delivery for you.

• Social media: use all of your social media channels to talk about the Festive Taster Treatment Open Day, your menu of treatments, as well as the gifts and vouchers. It’s a good idea to include a countdown to the event. Try and include a little bit of new information with each post such as the value of the goody bag, expert attendees that will be demonstrating treatments and special offers. You can start this two weeks prior to the event.

Press Your starting point is to write a press release. This is a simple overview of the gifting and treatments you have to offer. By including your

Reproduced from Aesthetics | Volume 4/Issue 12 - November 2017

In Practice News creative treatment menu, you will stand out from your competitors.

Include a personal invite for journalists to come and try a treatment for free in return for an editorial review. Send this only to your local editorial consumer press as it’s not something trade press would usually review. Note this is not paid-for advertising; so, what this means is that you cannot guarantee that they will include a review, and also, you cannot control the messaging, content of the copy or its tone. Editorial copy can reflect their honest opinion and so you have to be confident in your treatment outcome, the practitioner conducting the procedure and, of course, ensure the treatment is right for the journalist.

You must be prepared that they may write something negative as they have no obligation to write a purely positive review. To ensure the best possible write-up, look after your journalist from the second they walk in the door, make them comfortable and relaxed and don’t rush them, though also be conscious they are often always short of time due to deadlines. Spend time explaining the treatment in detail so that they fully understand what is involved, including any discomfort and downtime, and when results may be visible. This manages their expectations and helps to guard against negative reviews. Follow up is critical. Call and email the day after and a week after, and be available to answer questions they may have, or to book them in for a further treatment should it be required. You should take before and after pictures, not only for the journalist to use in their publication, but it often helps illustrate treatment efficacy if questioned. In terms of when to target press, time is of the essence as media professionals work far ahead, so, prepare your release as early as possible and mail to your local magazines and newspapers as soon as you can. Ensure you have the correct journalist to send this to by browsing through the titles and noting the names of those who write about beauty or wellbeing. Ensure your press release has the contact details of how to book an appointment or find out more information. Be prepared that they may ask for imagery to go alongside a story. The product/device companies may have shots you can use, so it’s worth asking if you don’t have your own pictures. You may need to follow up the mailing with a telephone call to the journalist. Once the article is out, scan or take a picture of the coverage and post on social media.

Summary Making the most of marketing around the festive season requires planning and careful execution to deliver a creative, yet quality, offering, to appeal to your target market. This can not only boost your profits but secure new patients and make you stand out from the Christmas crowds.

Charlotte Moreso is the managing director of True Grace PR. Moreso has worked as a PR and marketing consultant in the health and beauty industry for more than 20 years, running highly successful campaigns for global commercial brands and smaller UK beauty brands. Her work has won several industry awards.

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REFERENCES 1. Gov.uk, Review of the Regulation of Cosmetic Interventions, (2013) <https://www.gov.uk/ government/uploads/system/uploads/attachment_data/file/192028/Review_of_the_Regulation_ of_Cosmetic_Interventions.pdf>

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represent something other than a person. If you are currently doing so and don’t convert your Facebook Profile to a Business Page, you are at risk of Facebook permanently removing your account.4

Utilising Facebook Adverts SEO consultant and social media lead Callum Daly explains the benefits of using Facebook advertising in your clinic’s marketing strategy There is a plethora of social media platforms available to businesses worldwide: Twitter, LinkedIn, Snapchat, Google+ and YouTube to name just a few.

Yet nothing will compete with the social media giant that is Facebook. With more than one billion registered accounts and more than two billion active users each month,1 it is a channel that, in my professional opinion, needs to be adopted and treated as a priority in every marketing strategy.

Effective Facebook advertising can work wonders for any business, but it is important to get it right first time. No-one wants to waste a penny of their marketing budget by not knowing how to use the tools that are available to them. You need to ensure that you understand what your primary objective

is, how to reach your target audience and finally, how to measure the success of your efforts. This article will explain how to effectively use Facebook to advertise your clinic and services.

Step one: create a Facebook Page for your business Every successful project needs a solid foundation; that foundation is a responsive, well-thought-out and easy to digest Facebook Business Page. Facebook Business Pages offer completely different functions to the ordinary Facebook profiles, one of the functions being that it doesn’t use ‘Facebook friends’ to measure social media influence. It is against Facebook’s Terms and Conditions to use a personal account to

A brief history of Facebook Originally called ‘The Facebook’ the now-global social networking site was launched

by Mark Zuckerberg in 2004. At first, membership was restricted to Harvard College students, but after enlisting some of his fellow students to help grow the site, Zuckerberg and his team were able to expand the site to additional universities and colleges. That same year Sean Parker, the founder of Napster, an online music store, became the company president and changed the site’s name to just Facebook.2 Since then, the site has gone from strength to strength. In September 2006, Facebook announced that anyone aged 13 and over with a valid email address could join the networking site. In 2012, Facebook bought the photo-sharing app Instagram for $1 billion to eliminate competition from fellow photo-sharing networking sites. This was also the same year that Facebook hit more than one billion registered users.3

There are many benefits of using a Facebook Business Page for your clinic, which include: • Features that help you connect with customers and reach your goals, as these pages are designed for businesses and organisations • Access to ‘page insights’, where you can see metrics with posts that people engage with, as well as visitor demographics such as age and location • Providing other employees access to edit your Business Page • Creating ads and boosting posts A Facebook Business Page will allow you to promote your clinic services to a wider audience as well as being able to engage with your current patients. You should add your contact details, reviews from previous patients, post regular content that is relevant to your audience and add a portfolio of before and after photographs – however, do not use these on the ads themselves, just on a Facebook post, this will be discussed later in the article.

A Facebook Business Page becomes a fantastic platform to discuss, inform and advertise your services as well as increase brand awareness, engagement, SEO opportunities and offer a greater understanding of your audience and potential customers.5 The first thing you will be prompted to do is choose a category for your business based on six choices. The first choice, ‘Local Businesses or Places’ is the most appropriate for aesthetic clinics. Once you’ve selected the appropriate category, you will be prompted to upload a company profile and image header, useful search terms that promote your business and services that you provide and a link to the company website (not mandatory). In order to keep in line with your clinic’s brand, I would recommend that your profile image should be your clinic’s logo and strapline, whereas the image header should be either a high-resolution image of the facilities, the staff, the location, an image that depicts the service provided, or a combination of all four.

Step two: choose an advertising option There are two different options for creating

Reproduced from Aesthetics | Volume 4/Issue 12 - November 2017

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What are boosted posts?

A boosted post is a post from your Business Page that, for a fee, can take priority and appear high up on your audience’s News Feeds. The fee depends on how many people you want the post to reach. They are different from sponsored posts which function similarly to ads, where you can choose a target demographic and invest funds into making them aware of your business.

Organic reach has unpredictable value, and no matter how advanced a Facebook strategy may be, there is still a chance that your posts get lost in a potential customer’s News Feed. Boosting your posts guarantees a degree of visibility for posts that you believe are important.6 I would recommend starting to boost your posts at some point, preferably after you’ve done at least one campaign.

a Facebook ad – the Facebook Adverts Manager and the Power Editor. Power Editor is a Facebook advertising tool designed for larger advertisers who want to create, edit and publish multiple ads at once and have precise control of their campaigns. As we’re starting from the basics, I would recommend using the Adverts (Ads) Manager to create a campaign. A campaign is what you want to accomplish with the advert, in other words, your objective.

Step three: choose your campaign objective Not all advertisements are the same, some are great for getting people to like your page or increase the engagement of your posts, while others increase the conversions to your website.

Using Ads Manager, the objective that you choose should remain consistent throughout each individual campaign that you create.

This means that if you decide you want to create a campaign that drives clicks to your website, all of your ads within this campaign must also target the same goal.

There are many objectives that you can choose from, some of them being: • Page post engagement: promote your page posts • Page likes: get page likes to grow your audience and build your brand • Clicks to websites: get people to visit your website • Website conversions: get people to perform certain actions on your site (such as booking a consultation) • App installs: get people to install your mobile or desktop app (if applicable) • Event responses: increase attendance to your event (for instance a treatment launch) • Offer claims: create offers for people to redeem in your online store

Step four: define your audience and budget This is, by far, one of the most important parts of creating a successful Facebook Ads campaign. Depending on your objective, your audience and budget can be as big or small as you would like. The most important thing is to concentrate your advertising efforts into an objective that has potential to get more leads and sales; I would suggest being a little more selective with your audience.

The audience of your ad can be customised based on the following demographics: Location Age Gender Languages Interests Behaviours (pages your potential audience engage with) • Connections (friends and those following) • • • • • •

For example, if you are a clinic based in Kent and your objective is to generate more leads from young adult males, I would recommend selecting the following audience: • • • • • • •

Kent 18-35 Males English Health, beauty, fitness Beauty page, fitness pages Beauty blogger, celebrities

In some cases, a target audience changes on a regular basis, however, I would recommend making a note of the audience as Facebook doesn’t have an option of saving it.

Budget Once you’ve selected your audience, you can look at distributing your advertising spend for each campaign. How much you

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spend is important. But, for as little as £1 a day, you can make a real impact.

According to MoZ, a well-known SEO service company, by spending $1 a day on Facebook Ads, you have a chance to get in front of about 4,000 people who wouldn’t have seen your ad otherwise. If you pair that with the idea that you may be doing something your competitors aren’t, you’re creating some real awareness.9 Most businesses, no matter if they’re just getting started or past the startup phase, can afford to spend the equivalent of $30 a month — in fact, according to Moz, you probably shouldn’t be in business if you don’t have that sort of cash to dedicate to marketing. Plus, since Facebook ads have the lowest average cost per 1,000 impressions of any advertising platform (averaging around $0.25 per 1,000 impressions), you can easily afford to throw a couple of dollars a day into the advertising mix.7 Using the details stated above, this should give you an understanding of what you could get for your money. For your first campaign, I would suggest using a small amount of the budget and run it for approximately one month. This will give you an adequate amount of data to analyse once the campaign has finished running.

This doesn’t mean that you should only monitor after the month is finished, if you spot anything through the campaign that you think needs changing, then do so.

Step five: choose a placement for your ad Now that you’ve decided which users you want to target, what you want them to do, and how much you are going to spend on them, the next thing you are going to do is choose how your ad will look. There are four formats to choose from, they are: Carousel Creating an advert with two or more scrollable images or videos. These ads would work best if your clinic would like to generally promote its services.

Single image Creating up to six adverts with one image each at no extra cost. These ads would work best if you want to promote something more specific, such as a product launch or a recruitment message.

Single video Creating an advert with one video. This ad provides a perfect opportunity to promote a certain treatment, showing a patient receiving that treatment in clinic.

Reproduced from Aesthetics | Volume 4/Issue 12 - November 2017

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Since Facebook bought out Instagram in 2012, you can now post your Facebook ads onto Instagram, without having to have an Instagram account Slideshow Creating a looping video advert consisting of up to ten images. Again, this ad can be used to promote a range of services you offer in your clinic.

Unfortunately, you cannot choose more than one format without having to create duplicate campaigns, which would increase the cost. Once you’ve selected your format and included the content you will be able to preview the advert, which will show how it will appear on Facebook.

It is important to mention that since Facebook bought out Instagram in 2012, you can now post your Facebook ads onto Instagram, without having to have an Instagram account.8

with different metrics giving you a complete overview of how your campaigns are performing such as:

Step six: go live!

Impression The higher the number, the more people who have seen your ads.

Once you have followed all of the above steps you can start your campaign.

Providing you have met Facebook’s Terms and Conditions, the ad should run instantaneously, or at the date that you want to start the campaign. A full list of Facebook Advertising Policies can be found on the Facebook Advertiser Help Centre.9 Whilst the campaign is running, you should be able to see some results depending on what your objective was. This could be more page likes, better engagement or more visits to the website. If you’re not seeing any changes to your business, you can edit the ad, such as changing the text or images, whilst it is running.10

Step seven: campaign reporting and monitoring Once the campaign has finished, it is necessary for you to evaluate its performance. The easiest way to review your campaign is by using Facebook Ads Manager: here you can filter your campaigns by date, objective, and investigate campaigns further to measure the performance of every single ad set or ad.

As you look at the ‘Campaigns’ tab in the Ads Manager, you’ll see a reporting table

Cost-per-click This gives you a monetary value of how much each click (engagement) costs; naturally, the smaller the number, the cheaper the click.

Cost-per-conversion Similar to the cost-per-click. A monetary value of the cost of each ad converts into the number of the visitors visiting your website, by clicking on the ad. The smaller the number, the cheaper the click, the cheaper the cost of getting users to visit your website.

Unique link clicks This shows the number of clicks from unique visitors; it will only count that person once and disregard those who click on your ad more than once in a 24-hour period.

You can change the metrics you see in your ad reports to help you find the most relevant data to your specific campaign and business.

This can be quite useful in the instance of creating ads with numerous demographics or different placements.

In addition to these campaign metrics, you can break these reports down even further.

Using the breakdown menu, you can gather further information from your campaign reports such as: • Delivery: age, gender, location, browsing platform, platform, device, time of day, etc.

• Action: conversion device, destination, video view type, video sound, carousel card, etc.

• Time: day, week, two weeks, month

bespoke to you. This data will be vital if you choose to run another ad campaign. For example, you will have information on: • Hotspot areas that responded well with your campaigns; would you like to target them again?

• Age groups who did not respond well; are they your target audience? Do you think you should consider changing your ad to relate to that target audience?

• People visiting your ads at a certain time; should you push more ads at that specific time or throughout the day?

Conclusion Whether you’re a small independent clinic, a medium size chain of businesses, or a large-scale enterprise, I’m sure that you have at least thought of including Facebook advertising in your marketing strategy.

If you were too anxious to commit to an unfamiliar channel, do not know how to use it or what it’s benefits are, I hope this article has assisted in your Facebook advertising journey. All in all, it’s a useful tool to increase engagement, attract new and returning customers and boost sales. It can be a vital part of your marketing plan.

Callum Daly is a SEO consultant and social media lead at Receptional Ltd. Daly has more than three years of marketing and social media experience.

He is skilled in social media analytics and works to increase clients’ social media presence, organic impressions and average engagement rates.

REFERENCES 1. Statista, Most famous social network sites worldwide as of April 2017, ranked by number of active users (in millions), <https:// www.statista.com/statistics/272014/global-social-networksranked-by-number-of-users/> 2. Sarah Phillips, A brief history of Facebook, The Guardian, (2007) <https://www.theguardian.com/technology/2007/jul/25/media. newmedia> 3. James Peckham, History of Facebook: All The Major Updates & Changes From 2004-2016 (Know Your Mobile, 2016) <http:// www.knowyourmobile.com/apps/facebook/21807/historyfacebook-all-major-updates-changes-2004-2016> 4. Facebook, Converting Your Progiel Into a Facebook Page (Facebook, 07 September 2017) < https://www.facebook.com/ help/175644189234902/> 5. Cosmetic Courses, How to set up Facebook for your Aesthetic Clinic (Cosmetic Courses, 30 June 2016) <https://www. cosmeticcourses.co.uk/blog/facebook-aesthetic-clinic/> 6. Olsy Sorokina, What Are Facebook Boost Posts And How They Can Help Your Business (Hootsuite, 24 October 2014) 7. Nikita Patel, How Much Should Small Businesses Spend on Facebook Ads? (Hint: there’s a way to find out (AdEspresso, 30 April 2014) 8. Facebook Business, Instagram Advertising Basics, (2017) <https://www.facebook.com/business/help/976240832426180> 9. Facebook, Lead adverts (2017) <https://www.facebook.com/ policies/ads> 10. Facebook: Advertiser Help Center, Edit an ad (2017) <https:// www.facebook.com/business/help/165119026899353>

This can be incredibly useful, as it gives you an in-depth set of metrics which are totally

Reproduced from Aesthetics | Volume 4/Issue 12 - November 2017

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“If you’ve had complications and dealt with them, that’s a good thing” Dr Andrew Weber reflects on his career and explains how he combines his general practice experience with medical aesthetics “I lived in West London, trained in North London, I’m a GP in Chiswick and I have a clinic here in Richmond, which is considered as Greater London – I think I’ll always be based in or around London,” says Dr Andrew Weber. “I really enjoy having my clinic in Richmond. When aesthetics started, Harley Street was where most of the demand was, but now a lot of reputable clinics and well-respected practitioners are established in the suburbs of London.”

Dr Weber started his higher education at Nottingham University, studying mechanical engineering, before transferring to a medical course, which became of far greater interest to him. He says, “I’ve always been very scientific but wanted to pair this with a more humanistic approach, in what I consider a hugely purposeful and caring profession. I went to the Royal Free Hospital School of Medicine in London and then went on to study the General Practice Vocational Training Scheme. He continues, “General practice is great, as well as being challenging, it provides a broad base of knowledge.

I worked in areas of special interest such as surgery, family planning, diabetes and I even ran an erectile dysfunction clinic for about five years as an associate specialist.”

Dr Weber joined a GP Partnership in Chiswick, which became Chiswick Family Practice, after completing his vocational three year rotation training. In 1999, Dr Weber set up Bodyvie with his wife, Barbara Weber, after identifying a gap in the market. In terms of managing general practice with his medical aesthetics clinic, Dr Weber says, “I’ve decreased my commitment to general practice over the last couple of years, aesthetics is now at the forefront. It’s a great balance being able to combine the two, keeping my work varied and interesting. I love the interaction and helping people in different but meaningful ways.” When asked what his biggest accomplishment is so far, Dr Weber says, quite simply, “Having Bodyvie. We’ve always adopted a general practice ethos of continuity; you’re [the practitioner] there for the long term. In our clinic, it’s important for patients to have a doctor for life and a long-term relationship, which is what we have always tried to retain.” Explaining how he believes his clinic achieves this, Dr Weber adds, “We remain an independent business. We aren’t a chain and haven’t franchised so we control our identity and ethos which our patients value.”

As well as working in general practice and medical aesthetics, Dr Weber has experience in the field of medico-legal work. He recalls, “The Medical Protection Society (MPS) approached me 15 years ago, to provide expert reports regarding cases of litigation. The field of medical aesthetics was in its infancy at the time with few specialising in the area. I provided reports primarily for the defence, for MPS. Reports mostly related to dermal fillers and injectable treatments.”

Reflecting on how this has helped his career, Dr Weber explains, “It was beneficial as I had to do a lot of research. You have to back everything up with facts and find supporting papers, studies and

statistics, so I learnt a lot.”

Speaking of his favourite treatment to administer, Dr Weber says, “Botulinum toxin is one of my favourites as it provides instant gratification and patients can notice the difference in just a couple of days. It’s nice and simple but it’s also not as easy as everyone thinks as, although the anatomy is very similar, everyone is different. For example, the strength of people’s muscles and formation varies a lot, which is important to be aware of as a practitioner.” He adds, “You have to adapt your treatment methods, as the amount of product and distribution patients will need can fluctuate.”

Being the medical director of his clinic, Dr Weber interviews new staff regularly. When asked what he looks for in a practitioner, there’s one question he always has. “We ask interviewees one simple question – ‘Have you ever had any complications?’ A lot of them will actually say no. The only reason you will never have had complications is if you haven’t done enough treatments or you’re lying. It’s very simple, if people are honest, I’m more likely to hire them.” Stressing the importance of this, he continues, “Practitioners shouldn’t be hesitant about discussing complications. If you’ve had complications and dealt with them, that’s a good thing, and it is information you should be passing on to others in the specialty.”

What is your industry pet hate?

Professionals who work outside their area of expertise and/or beyond their qualifications. You’ve got to know your limitations.

Refer to someone who is more experienced if you’re unsure or unfamiliar with a problem, treatment or complication.

What do you enjoy the most in aesthetics?

Everything. I think it’s having access to a comprehensive range of treatments that complement each other, which is what I like about our clinic; we have a nice armoury of devices and injectables.

Which area of aesthetics do you think will grow the most in the next few years?

Stem cells is where medical aesthetics is going very quickly.

Platelet rich plasma (PRP) will also grow but I think stem cell technology will take over.

What is your favourite area to treat?

I like treating just the face. Although people use botulinum toxin, for example, for sweating, migraines and tension headaches, using it for the face for aesthetic reasons gives me the most satisfaction when treating a patient.

Reproduced from Aesthetics | Volume 4/Issue 12 - November 2017

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complex and intricate procedures such as injectable aesthetic procedures.4 Simulation training Simulation models are commonly used throughout medicine for both surgical and non-surgical procedures. For example, simulation arms are regularly used for venipuncture and cannulation practice, which are used in almost every medical school. Simulation models are also widely used in aesthetic training courses as they can be easier to acquire than real-life patients. The latest Health Education England training requirement recommendations state that trainees must observe, practice and be assessed in simulated clinical environments.5 However, it does not explicitly specify whether this should be on real-life patient volunteers or simulation models. There are numerous simulation models available for aesthetics training. These vary in sophistication and, therefore, in price and availability. High fidelity head and neck models, with muscles and additional structures, are generally used for injectable training. Nylon thread, human hair and goat skin can Ms Priyanka Chadha, Miss Lara Watson be added for hair transplant training.6 Silicon pads or cattle skin and Mr Nihull Jakharia-Shah debate the are often used for suturing, excision, flap surgery and skin graft use of simulation training in aesthetics training; and fruits or vegetables with thick peels can be used for dermabrasion training.13 Models resembling any part of the Simulation ‘is the imitation or representation of one act or body can be ordered, however, in our experience, the above are the system by another’ and, according to the Society for Simulation most commonly used on aesthetic training courses. in Healthcare, a global organisation that seeks to improve performance in patient care through simulation, in a training Advantages and educational environment, it ‘is a bridge between classroom Studies demonstrate the benefit of simulation training on skill learning and real-life clinical experience’.1 acquisition in addition to the psychomotor performance of trainees, As technology becomes more advanced and affordable, the for instance, the manipulation of tools, dexterity, grace and speed of potential for its use has transitioned into training for minor movement when conducting the procedure.7-11 A major advantage is procedures, including those within the aesthetic sector. However, that it creates a low-pressure, risk-free environment in which to learn. many aesthetic practitioners still have mixed views on the value of As students are practicing on simulation models, there is no risk to simulation-based training over the traditional approach of graded patients and simulation can allow practitioners to be better prepared practice on real-life patients. Thus, the debate around the value of when dealing with real-life patients by having prior experience of simulation models must be re-evaluated to determine its true value performing the procedures, thus increasing patient safety.12 Although within the aesthetic specialty. it can be argued that simulation training does not completely emulate real-life scenarios, in our experience, there is a difference between Traditional training a clinician treating a patient who only has theory knowledge without The traditional teaching method for clinical skills, which is based on prior practical experience in performing the task, versus one who has real-life patient experience, has been documented in literature as practiced the procedure numerous times on a simulation model. The covering the following five steps:2 latter clinician is likely to be arguably better prepared and perform the 1. Students learn basic knowledge relating to the condition requiring procedure safely.7 the treatment, the relevant anatomy and instrumentation required.

Simulation also provides an easily accessible learning opportunity. With 2. Students observe the procedure being completed, providing them the traditional training model, students rely on the availability of specific with an overview and enabling self-evaluation. clinical scenarios, such as patients with certain conditions, to ensure 3. The students observe the procedure again with step-by-step they receive adequate practice and exposure. With simulation training, explanation by a supervisor. This provides an opportunity to break once the simulation model has been purchased, scheduled training the procedure into key steps and allows students to ask questions. sessions can be undertaken at any time for as long as one desires, 4. The students talk through the procedure whilst the supervisor enabling more convenient teaching as you do not have to manage conducts it. This ensures a student’s understanding of the skill and the real-life models or wait for access to one with a particular condition. the steps of the procedure prior to attempting it themselves.

Additionally, the fact that simulation allows trainees to practice various 5. Students can perform the procedure under close supervision.3 procedures on specific parts of the body without relying on different patients to request these procedures is especially valuable for more Throughout the aforementioned steps, constant feedback and rare or complex procedures, for which clinical practice would be coaching should be given. difficult to come by and the stakes would be higher, for example, This traditional model is becoming increasingly challenged by treating complications.1 educational providers due to concerns surrounding patient safety and Trainees can also create more personalised learning as they can focus its efficacy as the best method for acquiring clinical skills, especially for on elements of the task they find most difficult, practicing it as many

The Last Word

Reproduced from Aesthetics | Volume 4/Issue 12 - November 2017

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times as they need to, without having to repeat the entire process each time. Although practicing the entire process on a real model helps to emulate the true clinical scenario more effectively, it is a benefit to focus on specific aspects of the task once a general familiarity/competence has been gained. Hand positioning, needle angulation and use of the microcannula, for example, can be rehearsed in a controlled setting without incurring risk or discomfort to a patient.

Disadvantages The biggest disadvantage of simulation training is the fact that it is a simulation. Although clinical scenarios can be artificially manufactured, they will never truly reflect real-life experiences. A successful encounter or treatment requires building a good rapport with the patient, having good communication and clinical judgement.

This is especially important for aesthetic practitioners as patient satisfaction is arguably the most important outcome, unlike with the public sector, where clinical outcome and financial expenditure factor more heavily into the overall success of a treatment.13 The occurrence of patient distress or discomfort, haematoma formation and hypersensitivity reaction for example, cannot be replicated in currently accessible simulation training models which, therefore, carries some limitation to the scope of simulation in aesthetics.

However, all scenarios can be mimicked to some extent and exposure to this before being in a real-life situation will, more often than not, result in increased confidence from the clinician and better outcomes for the patient.14 Tying into the argument surrounding the artificial nature of simulationbased training is the need to develop the ‘aesthetic eye’. Simulation models do not provide sufficient exposure to the variety of aesthetic outcomes that can occur from administering products. Each patient will respond differently and varying quantities and sites of injection will yield different results, which will not be reflected when a student consistently trains on a simulation model.

Simulation training is also expensive compared to clinical learning.

The equipment alone can cost thousands of pounds for a simulation head and neck. Following this, there is a cost of maintaining the equipment and hiring specific areas.

Simulation is also only as useful as the participant’s engagement.

Although simulation allows students to practice certain elements of procedures, this can lead to neglect of other aspects such as patient communication. The learning process for students is also dependent on the quality of the feedback given by supervisors, therefore, the efficacy of simulation training is reliant on having high quality, engaged supervisors.15 Finally, its use as an assessment tool can only be a surrogate for real-life clinical assessment. This problem presents due to two main factors; that simulation can never truly emulate real-life scenarios and students will be aware that the scenarios are simulations. The latter disrupts a true evaluation as the simulation fails to capture the emotional elements of a clinical scenario such as stress, anxiety and natural doctor-patient rapport.

However, the initial problem can be minimised through two methods; firstly, as simulation models become more sophisticated, over time they will more closely emulate real-life scenarios, for example models that can bleed to emulate complications. Secondly, the introduction of a validated national simulation training programme with a specific and thorough outline of what needs to be examined and how to examine it using a simulation, would enforce the validity of simulation-based training in aesthetic medicine. No validated programme exists yet, and further discussions with healthcare regulatory bodies is needed to produce this for the future.

Aesthetics

Conclusion There are disadvantages to simulation training, namely the cost and the artificial nature of the experience, however, as a means of supplementing the learning of simple aesthetic procedural skills, simulation training can provide an effective learning experience that preserves patient safety. We believe simulation-based training has a significant place in the future of training in medical aesthetics, however, as there are limitations to this type of training, it is our opinion that the optimum training programme would include a combination of both simulation training and supervised training on real-life models.

Disclosure: Miss Priyanka Chadha and Miss Lara Watson are directors of the training academy Acquisition Aesthetics, which offers simulation-based training combined with supervised training on live models. Mr Nihull Jakharia-Shah is the educational and academic lead for Acquisition Aesthetics.

Ms Priyanka Chadha is a director at Acquisition Aesthetics training academy, which is a Finalist for The Enhance Insurance Award for Best Independent Training Provider at the Aesthetics Awards 2017. Ms Chadha currently works as a Plastic Surgery Registrar in London and her academic CV comprises national and international prizes and presentations, as well as higher degrees in surgical education and training.

Miss Lara Watson is a director at Acquisition Aesthetics and is hoping to pursue a career in maxillofacial surgery. Currently in the final year of the Dentistry Entry Programme for Medical Graduates (DPMG) at King’s College, London, Miss Watson has been awarded an academic distinction for the course to date.

Mr Nihull Jakharia-Shah is a final year medical student at King’s College London. He has completed a BSc degree in Regenerative Medicine and Innovation Technology, passing with First Class Honours. During this he studied biomaterials including aesthetic skin grafting products and has developed a passion for research and clinical practice of the skin.

REFERENCES 1. Society for Simulation in Healthcare. About simulation. <http://www.ssih.org/About-SSH/AboutSimulation> 2. George JH, Doto FX. A simple five-step method for teaching technical skills. For the Office-based Teacher of Family Medicine. 2001;33(8):577-8 3. Society for Simulation in Healthcare. What is simulation? 2009. <http://www.ssih.org/About-SSH/ About-Simulation> 4. Grantcharov, Teodor P, and Richard K Reznick. ‘Teaching Procedural Skills.’ BMJ : British Medical Journal, 336.7653 (2008): 1129–1131 5. HEE, ‘PART ONE: Qualification requirements for delivery of cosmetic procedures: Non-surgical cosmetic interventions and hair restoration surgery’, Health Education England, 2015. <https://www. hee.nhs.uk/sites/default/files/documents/HEE%20Cosmetic%20publication%20part%20one%20 update%20v1%20final%20version_0.pdf> 6. Khunger, Niti, and Sushruta Kathuria. ‘Mastering Surgical Skills Through Simulation-Based Learning: Practice Makes One Perfect.’ Journal of Cutaneous and Aesthetic Surgery. 9.1 (2016): 27–31.

7. Grantcharov TP, Kristiansen VB, et al., ‘Randomised clinical trial of virtual reality simulation for laparoscopic skills training’. Br J Surgery, 2004;91:146-50 8. Aggarwal R, Grantcharov TP, et al., An evidence-based virtual reality training program for novice laparoscopic surgeons. Ann Surg, 2006;244:310-4 9. C.-A.E. Moulton, A. Dubrowski, et al., Surgical skills: what kind of practice makes perfect?: a randomized, controlled trial. Ann Surg, 244 (3) (2006 Sep), pp. 400-409.

10. E.D. Grober, S.J. Hamstra, K.R. Wanzel, et al. Laboratory based training in urological microsurgery with bench model simulators: a randomized controlled trial evaluating the durability of technical skill. J Urol, 172 (1) (2004 Jul), pp. 378-381 11. L.P. Sturm, J.A. Windsor, et al., A systematic review of skills transfer after surgical simulation training.

Ann Surg, 248 (2008), pp. 166-179 12. E.D. Grober, S.J. Hamstra, K.R. Wanzel, et al. The educational impact of bench model fidelity on the acquisition of technical skill: the use of clinically relevant outcome measures. Ann Surg, 240 (2) (2004), 374-381 13. Kosowski TR et al. ‘A systematic review of patient-reported outcome measures after facial cosmetic surgery and/or nonsurgical facial rejuvenation. Plast Reconstr Surg. 2009 Jun;123(6):1819-27 14. Moorthy, K., Vincent, C., & Darzi, A. (2005). Simulation Based Training. British Medical Journal, 330, 493-494 15. Brooks, N., Moriarty, A., & Welyczko, N. (2010). Implementing simulated practice learning for nursing students. Nursing Standard, 24(20), 41

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