Aesthetics October 2014 by Aesthetics & CCR

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VOLUME 1/ISSUE 11 - OCTOBER 2014

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LightSheer DESIRE

The Gold Standard of Laser Hair Removal. Safe. Fast. Effective. See pages 36 and 37 for more details

Laser Complications CPD Article 6659_Anzeige_13.indd 1

Dr Firas Al-Niaimi on complications that can occur during laser procedures

Tattoo Removal

Post-procedure Protocol

18.09.14 09:12 Working with the Media

We examine the evolving technologies used to remove unwanted tattoos

Leading practitioners share their advice on caring for patients post treatment

Tingy Simoes on the best ways to present information to the press

Vbeam Vbeam

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* This ad is not intended for use in the U.S. market. ©2012. All rights reserved. Syneron, the Syneron logo are trademarks of Syneron Medical. Candela and Vbeam are trademarks of the Candela Corporation. PB78001EN * This ad is not intended for use in the U.S. market. ©2012. All rights reserved. Syneron, the Syneron logo are trademarks of Syneron Medical. Candela and Vbeam are trademarks of the Candela Corporation. PB78001EN * This ad is not intended for use in the U.S. market. ©2012. All rights reserved. Syneron, the Syneron logo are trademarks of Syneron Medical. Candela and Vbeam are trademarks of the Candela Corporation. PB78001EN

Contents • October 2014 INSIDER 06 News The latest product and industry news 14 News Special The power of video

CLINICAL PRACTICE Tattoo Removal Page 19

17 F.A.C.E 2 f@ce Aesthetics reports from the anti-ageing congress in Cannes

CLINICAL PRACTICE 19 Special Feature: Tattoo removal We explore the evolving technologies of tattoo removal and ask practitioners to share their advice 24 CPD Clinical Article Dr Firas Al-Niaimi looks at the possible complications associated with laser treatment 29 Advertorial A look at the new Healthxchange Academy 30 Clinical Focus Dr Barry Cohen examines the role of pH in cosmeceuticals 33 Treatment Focus Dr David Eccleston on methods for treating hyperhidrotic patients 36 Advertorial An introduction to the new LightSheer® DESIRE™ for the reduction of unwanted hair 38 Techniques Debbie Thomas details the process of facial rejuvenation with laser 40 Clinical Focus Allie Anderson explores the importance of post-procedure care in an aesthetic treatment 44 Spotlight On Mr Christopher Inglefield outlines RF treatment for the periorbital region 47 Treatment Focus Mr Taimur Shoaib on advanced uses of PRP for aesthetic indications 51 Advertorial Dr Simon Ravichandran discusses the Dermalux® Tri-Wave device for the treatment of photo-ageing 52 Abstracts A round-up and summary of useful clinical papers 54 Aesthetics Awards Special Focus Find all the information on the judging process and how to book

IN PRACTICE Publicity Page 56

Clinical contributors Dr Firas Al-Niaimi is a consultant dermatologist and laser surgeon, currently working for sk:n clinics. He trained in Manchester, and completed an advanced surgical and laser fellowship at St. John’s Institute of dermatology in London. Dr Barry J.Cohen is a fully trained plastic and reconstructive surgeon and a diplomat of the American Board of Plastic Surgery. His private practice is located in the Washington D.C area. Dr David Eccleston is a cosmetic doctor and GP, with a special interest in dermatology, based in Birmingham. David is the clinical director of MediZen, a clinic in Sutton Coldfield. Debbie Thomas has been a skin care specialist for over 11 years. In 2010 she opened the Debbie Thomas Collective and has become renowned for her successful use of lasers. Mr Christopher Inglefield is the founder of London Bridge Plastic Surgery. With over 25 years’ experience, he has been at the forefront of the plastic surgery evolution. Mr Taimur Shoaib is a specialist consultant plastic surgeon with over 20 years’ experience. He runs a cosmetic practice in Glasgow, and is a faculty member of the Allergan Medical Institute. Wendy Lewis has authored 11 books on anti-ageing and cosmetic surgery and lectures internationally. She is the president of Wendy Lewis & Co Ltd and founder/editor in chief of Beautyinthebag.com

IN PRACTICE 56 Publicity Healthcare PR Tingy Simoes shares her advice on how to nurture your relationship with the press 59 Marketing Dan Travis presents the benefits and limitations of marketing via Google AdWords 62 Presentation Pam Underdown analyses the best methods to fully engage your audience 66 In Profile Wendy Lewis speaks to New York plastic surgeon Dr Sam Rizk about his journey into aesthetics 68 The Last Word Dr Marie Louise von Sperling on cosmetic regulatory requirements in Denmark NEXT MONTH

Voting closes soon for The Aesthetics Awards 2014. m Visit www.aestheticsawards.co today to vote!

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

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Editor’s letter The conference season approaches, so we have more opportunities for education in medical aesthetics; essential for our progression and growth. Some of our team attended the F.A.C.E 2 f@ce meeting in Cannes last month (not a difficult location to attract Amanda Cameron Editor delegates to), and in our report this issue we highlight the interesting topic discussions, such as new filler techniques and treating skin of colour. More aesthetic conferences in the UK and abroad are taking place in October and November, including the British College of Aesthetic Medicine and British Association of Cosmetic Nurses association meetings, which we will be reporting on fully in next month’s issue, for those unable to attend. The Aesthetics Conference and Exhibition 2015, to be held in March, will soon be upon us. Building on the success of last year’s conference, we are all set for a unique and exciting event next year, focusing on education and the patient journey in a new dynamic format. Next month’s issue will contain a preview of the confirmed programme, speakers and content along with details of the Expert Clinics and Masterclasses. Here at Aesthetics we always strive to ensure that we have topical educational articles of interest to all our

readers. To that end we have regular meetings with our Editorial Advisory Board, one of which took place during September. We were delighted to welcome our newer members Dr Raj Acquilla, Dr Tapan Patel and Dr Christopher Rowland-Payne, along with our existing board, to a discussion centred around key topics in the profession and suggestions for engaging article topics and concepts for future issues of the journal. The meeting provided fascinating insights from the worlds of plastic surgery, dermatology and medical aesthetics, which will allow us to continue to put together a wide range of articles over the coming months, that will contain something for everyone in the sector. Our board all have different areas of expertise, and their support gives us the synergy and creativity needed to compose articles of substance. This month our focus is Lasers and we feature clinical articles on tattoo removal and facial rejuvenation along with a comprehensive CPD-accredited article from Dr Firas Al-Niaimi detailing the complications that can occur when using lasers. We recognise the importance of covering complications and risks alongside the latest treatments and techniques, a philosophy that will also play an important part at ACE 2015. Finally − a reminder to have your say in The Aesthetics Awards 2015. Voting closes on 31st October so visit www.aestheticsawards.com to cast your vote and book your tickets.

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

Dr Raj Acquilla is a cosmetic dermatologist with over 11 years

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

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

Mr Dalvi Humzah is a consultant plastic, reconstructive and

Dr Tapan Patel is the founder and medical director of VIVA

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

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

Sharon Bennett is chair of the British Association of

Mr Adrian Richards is a plastic and cosmetic surgeon with

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

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

Dr Christopher Rowland Payne is a consultant

Dr Sarah Tonks is an aesthetic doctor and previous

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

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

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ADVERTISING Hollie Dunwell • Business Development Manager T: 0203 096 1228 | M: 07557 359 257 hollie@aestheticsjournal.com Andrew Grant • Administration and Production T: 0203 096 1228 | support@aestheticsjournal.com MARKETING Jenna Earl • Marketing Manager T. 0203 096 1228 jenna@aestheticsjournal.com Helen Batten • Events Manager T: 0203 096 1228 | helen@synaptiqgroup.com DESIGN Peter Johnson • Senior Designer T: 0203 096 1228 | peter@aestheticsjournal.com Chiara Mariani • Designer T: 0203 096 1228 | chiara@aestheticsjournal.com

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

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

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Conference

Talk Aesthetics

ACE 2015 set to remain the UK’s leading medical aesthetic conference

What you’ve been tweeting about this month #trends 111 Harley St / @111HarleySt #cosmeticsurgery procedures like ‘doubleeyelid’ surgery & permanent make-up are becoming more popular in North Korea #subtlety Good Surgeon Guide / @goodsurgeon Cosmetic surgery should whisper not shout! #clinichours Jill Woods / @JillBWoods Ok hands up – who runs late night clinics to meet the need of commuters?

The Steering Committee of the Aesthetics Conference and Exhibition (ACE) 2015 have announced more details of the new educational programme, along with naming the chairmen for the Fat and Dermatology sessions. Specialist consultant plastic surgeon Mr Taimur Shoaib will chair the Saturday morning session on 7 March, whilst internationally recognised expert in cosmetic dermatology Dr Christopher Rowland Payne will oversee the afternoon session on Sunday 8 March. The main conference agenda is to comprise four sessions: Body and Fat, Injectables Masterclasses Parts I and II, and Skin Health. Each session will take the form of a virtual clinic, featuring live technique demonstrations, surgical and nonsurgical expert presentations, treatment outcomes, consultation and complication exploration, plus use of the latest technology to provide an engaging and interactive delegate experience. ACE will be distinct in its novel, interactive style; utilising exciting new technology to allow delegates to engage with the expert panels via educational videos and apps. This new dynamic agenda style, unique to ACE, will allow practitioners to choose which session best suits their professional needs, or to attend all four to experience the complete educational programme. On Saturday morning, Mr Shoaib will host an educational session on skin tightening after fat removal, options for fat volumisation of the face, and fat removal from the body. Case studies and outcomes will be discussed by leaders in this area of medical aesthetics, including Dr Mike Comins, who will discuss devices and methods in non-promotional presentations.

#hands Harley Street Skin / @harleystskin TOP TIP: Always nourish and protect your hands, they are often sadly neglected and show the signs of ageing first. #stats Rhitrition / @Rhitrition DID YOU KNOW?! > 69% of American adults over 20 are classified as Overweight or Obese #diet #health To share your thoughts follow us on Twitter @aestheticsgroup, or email us at editorial@aestheticsjournal.com

Botulinum toxin

Merz UK launch Bocouture for crow’s feet lines Merz Pharma UK has launched its new indication for Bocouture in the temporary improvement of crow’s feet lines. This makes the UK the first market in the world to commercialise this new indication and, according to Merz, assists aesthetic practitioners in meeting the growing needs of their patients. According to a recent survey of 3,000 European women, conducted by the pharmaceutical company, the area around the eye is the first place where they notice signs of ageing – with more women considering treatment around their eyes than any other facial area. Stuart Rose, managing director of Merz UK, said, “This new approval for Bocouture allows aesthetic practitioners the reassurance of treating their patients on-label with two licensed indications.” The MHRA approval for Bocouture as a treatment for crow’s feet lines is based on the results of a phase III placebo-controlled trial in 111 patients. 6

Sunday afternoon will feature a panel of distinguished skin experts, including Dr Stefanie Williams and headed by Dr Rowland Payne, comparing patient consultation skin analysis, and exploring treatment options for numerous dermatologic conditions such as rosacea and acne. This panel will also discuss the latest aesthetic skin treatments and cosmeceutical ingredients, investigating how they work and when they should be used and prescribed. The injectables masterclasses will be hosted by ACE steering committee members Mr Dalvi Humzah, Dr Tapan Patel and Dr Raj Acquilla. In the afternoon of Saturday 7 March, they will present a live masterclass on the beautification of the upper face. This will continue in Part II on the Sunday morning, where they will share valuable advice on treating the lower face and neck with injectables. Using multiple screens featuring live treatment footage and corresponding anatomy dissection exploration, the team of experts will cover all the essential elements involved in facial beautification using injectables. Registration for ACE 2015 will open in October. Visit www.aestheticsconference.com to keep up to date with the latest developments.

Aesthetics | October 2014

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Technology

MYA launch indoor Google tour MYA Fitzroy cosmetic surgery hospital is the first facility of its kind to offer an indoor virtual tour from Google. The internal Google ‘business-view’ is a 360-degree video-like tour that allows potential patients the chance to navigate their way through the hospital. According to MYA, their aim is to let viewers experience a typical patient journey, prior to having surgery, whilst demonstrating that they are a transparent, patient-focussed business. John Ryan, MYA chairman, said, “Not only are we confident about sharing our new hospital and the procedures that take place, we are also the only major cosmetic surgery provider to publish full clinical data and have an online forum.” The virtual tour allows viewers to take a look around two operating theatres, the recovery room, anaesthetic room and 16bed ward. Ryan added, “For a patient to make an informed choice, transparency is crucial. We challenge other cosmetic surgery companies to be more open.” Training

HEE finalise phase 1 of nonsurgical recommendations Health Education England (HEE) has finalised phase 1 of their report: Review of qualifications required for delivery of non-surgical cosmetic interventions. The key outcomes of the first phase of the programme, that took place between October 2013 and May 2014, are outlined and include draft education and training frameworks for five cosmetic treatment modalities. These include botulinum toxin and dermal filler injections, chemical peels and skin rejuvenation treatments, laser, Intense Pulsed Light (IPL) and Light Emitting Diode (LED) treatments, and hair restoration surgery. HEE have worked with regulators and royal colleges to draw up a draft training framework that recognises a range of entry points for each of the modalities. They have recommended five levels of qualification and outline what is expected at each level for the different treatments. For example, in relation to the injection of botulinum toxin it suggests that a practitioner at level 4 will have completed the first year of a foundation degree, be able to perform a basic skin analysis, and understand safe treatment options and the side effects. Only a practitioner at level 6, with a BA/BSc degree, would be able to deliver botulinum toxin to the upper face, and they must have a Masters degree to reach level 7 – giving them authorisation to inject the lower face and neck. Three common themes for inclusion in training modules have been identified and include; knowledge, skills and values, and behaviours and attitudes. The first will look at, amongst others, patient support and consent, emerging treatments, pain management, health and safety, and aftercare. The second will focus on risk assessments, consultations, and communication and mentoring skills. The third theme will assess patient care, complaint handling, competence limitations, public health promotion, ethical practice and professionalism. The report claimed that not one individual cosmetic procedure has decreased in popularity since 2012, and non-surgical procedures account for more than 75% of the market value. Chief executive of HEE, Ian Cumming, wrote, “The expertise, insights, and willingness to collaborate from all of our stakeholders have provided us with the means to identify and endorse the many areas of common ground upon which we hope to build as we advance into the second phase of our work.” The HEE report says that it will give all practitioners, even those currently practising without a recognised clinical qualification, the opportunity to attain the necessary skills and expertise to deliver treatments safely and proficiently. Phase 2 of the report, which began in May 2014, will consider and make recommendations on accreditation of qualifications and course delivery. Aesthetics | October 2014

Insider News

Guy Goudsmit, managing director of ABC Lasers Why has ALMA developed a gynaecological laser? Stress urinary incontinence affects one in three women with very few non-surgical solutions. Surgical solutions are expensive, painful and have a variable success rate. ALMA used its expertise with fractional lasers to create an effective ablative approach to collagen stimulation and tightening, with the precision and comfort that no other laser or treatment can provide. What benefits does this bring to practitioners and patients? The patient benefits of FemiLift® are that it is pain free, requires no hospital stay or recovery time and is relatively inexpensive. The FemiLift®’s unique single-use probe ensures that there is no risk of infection and complies with UK sterilisation regulations. For the practitioner, the new optical delivery provides an easy to use and ergonomically designed vaginal probe – exclusive to FemiLift®. The procedure takes 30 minutes and the outpatient nature of the treatment is available to gynecologists, urologists and specialist plastic surgeons. This treatment is highly sought after by aesthetic clinics that are able to offer FemiLift® via those specialists. What makes beam splitting technology different from other treatments for vaginal laxity/stress urinary Incontinence? Alma Lasers has developed unique robotic scanning technology. FemiLift® uses this beam splitting method to deliver a 9 X 9 pixelated 2 pattern per 1 cm area. This allows ablation withEasy Choice Unlimited Options. One 1 Platform. 70 FDA Approved Treatments. deep dermal heating, which causes collagen remodelling, contraction, and neogenesis and allows for a shorter treatment time and more precise control. The collagen remodelling allows tissue re-generation, causing structural support,Featuring ClearLiftTM reducing stress urinary incontinence and urge celebrity’s choice: “Hollywood Facelift” urinary incontinence. HarmonyTM Laser360° The most complete What does the future hold for ABC Lasers? anti-ageing innovation We have an exciting surgical line, launching under IMPACT Deep Ultrasound the AlmaLIFE® family of products. clinically proven to improve skin texture including lines, A big favourite of mine is the new LipoLIFE® which wrinkles and scars provides benefits over liposuction. We can offer a faster procedure with simultaneous power delivery and aspiration, offering smoother and quicker results with dramatic safety improvements. A study regarding the vitality of fat harvested during the LipoLIFE® procedure showed unprecedented levels of tissue viability (97%+) to be re-implanted successfully (in the 0845 170 7788 breast, buttocks or face) www.abclasers.co.uk info@abclasers.co.uk to the same patient. INNOVATION. RESULTS. SUCCESS TM

www.abclasers.co.uk | 0845 170 7788

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Rejuvenation

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Skin cancer

Vibrance needle shaping device launched in UK

Study suggests skin cancer risk increases by 90% with weekly sunbed use

Fusion GT has launched a needle-shaping device to the UK aesthetic market that claims to aid volume reconstruction of the face and body. Vibrance is a microsurgical product that claims to allow practitioners to perform micro transplants of the subcutaneous layer, while simultaneously performing bio-stimulation. It does not inject any kind of filler or drug. According to the distributor, Vibrance can use a mix of electric currents blended together to perform various kinds of treatments with different protocols, selectable by the practitioner. Treatment indications include lip enhancements, cheekbone reconstructions, water retention reduction and skin toning. Fusion GT also claims that Vibrance can be used to treat scars and expression lines, lymphatic electro-drainage and the mobilisation of adipose tissue. The portable device is batteryoperated, and all parts that are in contact with the skin are made of bio-compatible material. Vibrance has so far been successful in Italy and Greece.

Weekly use of sunbeds over 15 years increases the risk of skin cancer by 90%, a study suggests. This latest warning relates to squamous cell carcinoma (SCC), which is twice as common as melanoma, but can be overlooked, as it is not linked to isolated incidents of burning. The research was presented at the World Congress on Cancers of the Skin in Edinburgh this year. The researchers from the University of Dundee and Leiden University Medical Centre in the Netherlands explain that SCC is caused by longer-term, cumulative exposure to UV through repeated tanning. A spokesperson for the British Association of Dermatologists (BAD) said, “One defence of the sunbed industry is that sunbeds do not increase your risk of skin cancer if you do not burn, however this study weakens this argument”. UV intensity levels were measured along with the average length of sunbed sessions people have each year. Also taken into account was a person’s cumulative UV exposure from the sun. Results showed that by 55-years-old, people who used sunbeds were 90% more likely to develop SCC than those who did not. Sunbed use was defined as having a 12-minute session every eight days, over a 15-year period from age 20-35 years. Laser

Syneron announces CE mark for PicoWay Laser Syneron has announced that its new PicoWay device has received CE accreditation for the treatment of pigmented lesions and tattoo removal on any skin type. PicoWay is a dual wavelength device, utilising 532nm and 1064nm wavelengths to deliver energy to the skin in trillionths-of-a-second pulses, known as picoseconds. Having received CE approval, Syneron is hoping that PicoWay will also receive FDA clearance in the US by the end of 2014. “Our investment in PicoWay’s research and development demonstrates Syneron’s commitment to develop technology that enables physicians to provide best-in-practice treatments for their patients,” said Amit Meridor, CEO of Syneron. “Since PicoWay has the shortest picosecond pulse duration and the highest peak power of any device on the market, we believe that fewer treatments will be needed and that the percentage clearance will be higher.” The device will be launched in the UK on October 10.

Not all HA dermal ﬁllers are created equal. Intelligent manufacturing technology creates a variable density gel1 resulting in... Optimal tissue integration2 Greater dermal compatibility3

Superior cosmetic results4 High patient satisfaction5

Injectable Product of the Year 2013

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

Tel: +44 (0) 333 200 4140 Email: customerservices@merz.com

www.belotero.uk.com

BEL093/0314/FS Date of preparation: April 2014

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Vital Statistics

Business

Murad acquires UK partner Murad, Inc. has completed the acquisition of its long-term distribution partner in the UK, which, according to the skincare company, will aid their expansion into Europe. They hope that the news will give Murad the opportunity to directly manage its business in professional UK channels. Global general manager, Richard Murad, said, “While we have a presence in more than 40 markets worldwide, with the acquisition of a UK distributor as our European hub, we are making a major strategic investment that will dramatically expand our ability to reach consumers who are eager to transform their skin with Murad skincare.” The company say that they will invest in a London-based education centre, providing staff with advanced training in all aspects of their roles. Elliot Walker, managing director of Murad UK, will assist with the acquisition transition while the company recruits for the newly created position of general manager for the UK and Europe. Murad also aims to improve their presence in Asia with the planned acquisition of a Hong Kong distributor.

Skin cancer referrals have risen by 41% since 2009 Public Health England

2014 marks the 25th year

since the FDA approved Botox for medical use The Harley Medical Group

On average, men start losing their hair aged 38

Laser

ABC Lasers launch 308 Excimer System Distribution company ABC Lasers have added the 308 Excimer System to its product portfolio. With a wavelength of 308nm, ABC says that the system is ideally suited to treat psoriasis, vitiligo and alopecia areata, amongst other aesthetic indications. The distributors say that the 308 Excimer System allows practitioners to treat patients as quickly and effectively as with an ordinary excimer laser, but the smaller size and lower weight make it considerably easier. Dr Dirk Grone of Berlin, Germany, said, “The 308 Excimer System revolutionised the therapy of itchy and inflammatory skin diseases. All indications of the excimer laser can be effectively treated with fast, long-lasting results. At the same time it is a small, handy and very user-friendly device.” The variable power density of the device – 50 to 6,000 mJ/cm2 – can be adjusted to individual treatments. As well as this ABC say that a higher UVB dose can be applied, thanks to a 16cm2 spot with adaptable shape and size, which allows specific target areas to be treated. The laser distributors claim that this will reduce the number of treatment sessions required and improve patient and clinical results significantly. The 308 Excimer System has seen success abroad, particularly in India, where a recent study published in the Indian Journal of Paediatric Dermatology supported its use. Dr Sanjeev Aurangabadkar from Hyderabad, India, said: “The 308 Excimer System is highly portable, space saving and efficient; it needs no consumables and I have found it maintenance-free so far. The device is an invaluable tool in the therapeutic armamentarium of my clinic, which includes six laser systems.” The 308 Exicmer System is available in the UK now.

L’Oreal Professionnel

In the US, 45,224 tattoo removals were performed in 2013 – an increase of 4,423 since 2011 ASAPS

In a survey of 1,000 women, 39% identified the stomach as the area they would most like to improve British Military Fitness

Over a year, American Society for Dermatologic Surgery members reported a 46% rise in laser hair removal patients ASDS 2013

72% of people are more likely to make a purchase from a small or medium business after following them on Twitter

Market Probe International

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Events diary 3rd-4th October 2014 British Association of Cosmetic Nurses BACN Meeting 2014, London www.cosmeticnurses.org 6th December 2014 The Aesthetics Awards 2014, London www.aestheticsawards.com 29th January - 1st February 2015 International Master Course on Ageing Skin IMCAS Annual Meeting 2015, Paris www.imcas.com/en/imcas2015/congress 7th - 8th March 2015 The Aesthetics Conference and Exhibition 2015, London www.aestheticsconference.com

Accreditation

Save Face launches consumer campaign Save Face is launching a nationwide consumer campaign to raise awareness of its accreditation register, which launched on September 26. Since its launch earlier this year, the organisation has recognised practitioners across the UK for their high standard of aesthetic practice. Now Save Face hope to make the general public aware of the resource, which aims to help consumers find safe and fully qualified non-surgical aesthetic practitioners in their region. Director of Save Face, Brett Collins, said, “The register will soon be live for everyone to access and it will completely transform the industry. It will change the way consumers search for practitioners and it will provide a benchmark for all practitioners to adhere to or work towards.” A £140,000 advertising campaign will adorn the London Underground – covering 25 platforms, 100 escalator sites and 1,000 tube carriages. The organisation is also investing heavily in an SEO campaign and adverts will appear on high traffic consumer websites such as Cosmopolitan, Grazia and Glamour. “We are committed to delivering a register that consumers can trust, working with practitioners to raise standards as a whole, and in restoring confidence in the non-surgical cosmetic treatment industry,” said Collins. “It’s exciting to see the Save Face message spreading because we know what a difference it will make.” 10

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Industry

Caroline Van Hove announced as MD for Allergan Pharmaceutical company Allergan has announced the promotion of Caroline Van Hove to vice president and managing director. Previously senior marketing director of facial aesthetics and then medical aesthetics in Europe, the Middle East and Africa (EAME), Allergan says Van Hove was the driving force behind several of their key initiatives. She led the ‘Quality is Key’ campaign in the wake of the PIP breast implant crisis – aiming to restore consumer confidence in medical aesthetic treatments. In addition to this, Van Hove played an important role in the expansion of consumer education programmes across Europe. The newly appointed managing director began working for Allergan in Europe 12 years ago and was involved in the original launch of Vistabel in Europe and Botox in the US. She will now be responsible for the business performance of Allergan’s facial aesthetics portfolio and breast implant business across Europe, Africa and the Middle East. Peels

Mesoestetic launches new peels Mesoestetic Pharma Group has launched two new medical peels, extending its mesopeel line. Mesopeel products are intended to treat hyperpigmentation, ageing, acne, cuperosis and rosacea, amongst other aesthetic concerns. The mesopeel bionic age recovery aims to treat moderate to severe stage III to IV skin ageing, moderate to advanced photo ageing, medium and deep wrinkles, loss of firmness and skin density and dull and lacklustre skin. Made up of 36% pyruvic acid, 24% glycolic acid, 4.8% lactobionic acid, and 4.8% shikimic acid, Mesoestetic claim that the bionic age recovery is the first combined peel that presents itself in a single use wipe. The second new peel launched to the UK aesthetic market is the mesopeel phenTCA. It is a medium to deep self-neutralising peel used to treat moderate to severe ageing and acne scars, and is made up of 20% trichloroacetic acid and 10% phenol. Mesoestetic claim that it stimulates synthesis of collagen fibres, boosting elasticity and skin regeneration. According to the pharmaceutical company, both peels can be administered as multi-layers in either a single session or consecutive sessions. They advise that treatment should begin with lower concentrations and be increased according to skin tolerance and the level of effect. Business

Cynosure acquires Ellman Cynosure announced that it has acquired the assets of Ellman International, a radiofrequency medical device manufacturer based in New York, for approximately $13.2 million in cash. The global laser manufacturer hopes that the transaction will expand their market opportunities and enhance their revenue. Michael Davin, Cynosure chairman and CEO, said, “Ellman combines a 55-year history of innovation with an outstanding reputation for developing high-quality products that serve the needs of a global customer base.” Ellman product lines include the RF-based skin-tightening device, Pelleve Wrinkle Reduction System, and PelleFirm RF Body Treatment System used for the temporary reduction in the appearance of cellulite. Davin said, “Ellman’s RF product line broadens our technology platform, while its aesthetic lasers allow us to offer a value solution at a different price point than our current offerings.” Aesthetics | October 2014

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Research

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Rejuvenation

Pursing lips cause greatest facial tissue strain in people over 40 Soft-tissue strain is more noticeable in the mid and lower face of people over 40, according to a study. Published in September, in the Journal of the American Society of Plastic Surgeons, results of a pilot study found that the face can be objectively and quantitatively evaluated using dynamic major strain analysis. Eight women and five men between the ages of 18 to 70 were imaged at rest and demonstrating various facial expressions, using a dual-camera system and 3-dimensional optical analysis. Facial expressions included; smiling, laughing, surprised, angry, grimacing and pursing their lips. Their facial strains defining stretch and compression were computed and compared. Results showed that the areas of greatest strain were localised to the mid and lower face for all expressions. Subjects over the age of 40 had a statistically significant increase in stretch in the perioral region when pursing their lips compared to their younger counterparts (58.4% vs 33.8%, P = 0.015). There was also a significant degree of stretch (61.6% VS 32.9%, P = 0.007) and asymmetry (18.4% VS 5.4%, P = 0.03) in the nasolabial fold region in the older age group. The researchers concluded that 3-dimensional optical imaging technology could be used to advance understanding of facial soft-tissue dynamics and the effects of animation on facial strain over time. Collagen

Researchers claim to have developed a pain-free collagen delivery system Researchers at the National University of Singapore (NUS) have created a microneedle patch, in the hope of achieving faster and more effective delivery of painkillers and collagen. Led by Dr Kang Lifeng, the team believe that they have successfully developed a technique to encapsulate lidocaine and collagen in tiny needles attached to an adhesive patch. They claim that the microneedles deliver the drug or collagen rapidly into the skin without discomfort to the user. Using a photolithography-based process, the researchers fabricated a transdermal patch with polymeric microneedles. They claim that because the needle shafts are only about 600 micro-metres in length, they do not cause any perceivable pain on the skin. The research team have filed a patent for their technique and plan to conduct further clinical trials to examine the efficacy of delivering collagen for cosmetic and skincare purposes.

Sculptra recommendations published in the JDD Expert European recommendations for the use of Poly-L-Lactic acid (PLLA, Sculptra) for facial rejuvenation have been published in the Journal of Drugs and Dermatology (JDD). The European Expert Group has outlined how optimal results are achieved through a detailed knowledge of facial anatomy, correct treatment procedure – specifically the right dilution, the correct injection technique, and appropriate aftercare. Dr Linda Eve, senior trainer and chairman of the UK Sculptra advisory board and member of the European Expert Group, said, “We now have excellent European guidelines for the usage and safety of Sculptra, which together with the US consensus, provides a solid and comprehensive global understanding of the benefits and application of this unique and extremely effective collagen stimulating product.” Sculptra is a facial injectable which aims to replace volume loss by considering the entire face and its structural foundation. Dermatology

Galderma releases latest corporate book The 2014 edition of the Galderma Corporate Book is called Engaging the Dermatology Community. Reflecting the company’s avowed commitment to dermatology, the book is divided into three sections: Providing innovative medical solutions, Partnering with healthcare professionals, and Patients around the world. “It is thanks to our valuable exchanges with external stakeholders from the dermatology community that we are able to accomplish our mission to shape the future of dermatology,” said Galderma president and CEO, Humberto C. Antunes.

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Pershing Square, Valeant and Allergan reach agreement on shareholder meeting In a hearing before the Delaware Court of Chancery, Allergan Inc. settled pending litigation with Valeant Pharmaceuticals Inc. and Pershing Square Capital Management by agreeing to call a special shareholder meeting on December 18 2014. Shareholders of record at the close of business on 30 October 2014 will be entitled to receive notice of, and vote, at the meeting. Shareholders who submitted special meeting requests will not be required to provide updated information to the company in advance of the meeting, as usually dictated by Allergan’s bylaws. At the meeting, shareholders will have the opportunity to voice their opinions on a number of matters; including the removal of six incumbent members of the Allergan board, the appointment of an independent slate of directors, amendments to Allergan’s bylaws and a request that Allergan engage in negotiations with Valeant and Pershing Square. Allergan said it continues to believe that Valeant’s unsolicited exchange offer is “grossly inadequate” and urged shareholders to reject the offer. Meanwhile, the Securities and Exchange Commission is investigating claims made by Allergan that Pershing Square committed insider trading by buying nearly 10% of the Botox maker’s stock in the days before Valeant offered to buy the company. “At the time of the merger proposal to Allergan on April 22, neither Valeant nor Pershing Square had taken any steps whatsoever regarding a tender offer,” a Pershing Square representative said in an emailed statement. “There is nothing illegal, unethical or improper in taking a toehold position before a merger is proposed, even if it is not wanted by the target’s management. We welcome the SEC’s review of the facts.” Valeant said, “We have no concerns about the legality of our actions and do not believe this has any impact on [the] timing of any deal.” It is common for the SEC to review complex financial transactions without taking action. SEC spokeswoman Florence Harmon declined to comment on the investigation. Allergan also declined to comment. Journal

CPD correction In the July issue of the Aesthetics journal, the table in Figure 3 featured in the ‘Emerging aspects in botulinum toxin use’ CPD article showed the toxin product Azzalure® as 500 sU content. This was an error and the correct figure is 125 sU. The initial and correct information was supplied to the journal by the article’s co-author, Dr Andy Pickett, and Aesthetics apologises for the misprint. The amended table is reproduced here for clarification. MAIN BoNT-A PRODUCTS Production Strain

Process

Dysport®

Hall

Fermentation Dialysis Chromatography

Azzalure®

Hall

Botox®

U/vial [Product specific]

Excipients (in vial)

500 sU

HSA 125 ug

Lactose 2.5mg

Fermentation Dialysis Chromatography

125 sU

HSA 125 ug

Lactose 2.5mg

Allergan “hyper”

Fermentation Precipitation “Crystallisation”

100 B

HSA 500 ug

NaCI 0.9mg

Vistabel® & Vistabex®

Allergan “hyper”

Fermentation Precipitation “Crystallisation”

50 V

HSA 500 ug

NaCI 0.9mg

Xeomin®

Hall

[Unpublished]

100 X

HSA 1mg

Sucrose 5mg

Bocouture®

Hall

[Unpublished]

50 B

HSA 1mg

Sucrose 5mg

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News in Brief

Industry

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Aesthetics | October 2014

Tickets selling fast for The Aesthetics Awards 2014 With the announcement of the finalists, and voting and judging well underway, tickets for the prestigious Aesthetics Awards 2014 are selling quickly. To be held at The Park Plaza, Westminster Bridge in Central London, on Saturday 6th December, the ceremony will be accompanied by fantastic music, food and entertainment. Tickets can be booked by visiting www.aestheticsawards.com FDA to conduct studies for the approval of Evosyal The FDA has accepted the Investigational New Drug (IND) application to conduct studies for Evosyal. Healthcare company Alphaeon, who acquired the advanced botulinum toxin Type A last October, said they are very pleased with the news. The toxin was injected for cosmetic purposes more than six million times in 2013, according to ASPS. $10,000 book published to help cosmetic surgeons win patients A book that claims to turn practitioners into celebrity doctors and increase referrals can only be purchased from Barnes and Noble and costs $10,000. Cosmetic Surgeon Marketing Motto’s author, Philip Guye, claims it will help you influence patients to tell others about your practice. “It’s like mind control and our book shows you step-bystep how to do it,” he said. Optical skin cancer probe developed A three-in-one skin probe has been developed, promising to offer dermatologists a more rapid and effective method of detecting skin cancer. The probe, still in trial stages, is about the size of a pen and the equipment that supports it fits onto a cart that can be wheeled between rooms. Syneron Medical introduces new spot size for Gentle Pro laser series Syneron Medical has introduced a new FDA-cleared 55mm spot size to its Gentle Pro laser series, allowing for treatment of onychomycosis (nail fungus). The new spot size expands the functionality of the GentleYAG Pro and the GentleMax Pro Nd:YAG, currently used for hair removal and treatment of vascular and pigmented lesions.

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The power of video

With a recent video depicting the effects of sun damage receiving millions of views, the power of video to educate patients is evident. We explore the method behind the moving image Since its release in August, a three-minute film portraying skin damage caused by the sun has received more than 13 million views. ‘How the sun sees you,’ created by New York-based artist Thomas Leveritt, is a video that shows participants’ reactions as they see their face – and subsequently the effect of sunscreen – for the first time in UV light. The ultraviolet spectrum on Leveritt’s camera enables people of all ages, races and skin types to see pigment irregularity that is not visible to the naked eye; a result that shocked viewers around the world. Participants’ reactions are captured in the three-minute video, and the camera also shows these participants going on to apply sunscreen – which because of its protective nature, appears as a dense black cream under the UV light. Social media users have responded in their thousands; one viewer who was particularly impressed with Leveritt’s work was Jennifer McWhirter, a PhD candidate at the School of Public Health and Health Systems at the University of Waterloo, Canada. She took to Twitter to write, “Thomas Leveritt has unknowingly summarised my entire body of research into one very beautiful, motivating film.” McWhirter has been researching how images and mass media influence people’s view on skin cancer and tanning behaviours for the past five years. She says, “The film demonstrates the havoc UV exposure can wreak on human skin and how sunscreen protects us. The result is a message that will likely motivate a lot of people to use sunscreen. It offers straightforward, convincing visual evidence, which many people have not seen before in a creative way.” UK-based consultant dermatologist, Dr Sandeep Cliff, agrees that the shock-factor is an effective way of educating patients about the dangers of tanning. He says, “Showing horror photos of the effect the sun has on skin ageing, along with images of aggressive surgery, shocks patients into taking action.” Although experts agree that ‘How the sun sees you’ is an excellent health education tool, Leveritt admits that this wasn’t his intention whilst making the film; “I had no burning desire to educate but that’s the reaction it’s had,” he says. “I’m certainly pleased that it’s received so many views; if you can stop people getting any kind of skin cancer then it’s surely a good thing.” McWhirter says, “Communication science has demonstrated, 14

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over and over again, how persuasive pictures can be. Our brains process images faster than text and we are more likely to be persuaded by images. “A pamphlet at a practitioner’s office simply cannot garner the kind of attention that a film can. By creating short, effective, entertaining films with carefully selected visuals, and sharing them widely on social media, there is a huge opportunity to extend the reach of health messages.” McWhirter adds, “The written word will always be an important and influential form of communication; however, visual-based media, such as short films, can cut through language barriers and illiteracy, and leave a longer-lasting impression on people, compared to textbased communication.” Clearly there are many benefits to creating educational films in aesthetics, but a study published in the Journal of the American Academy of Dermatology in February 2014, found that people responded better to different topics. Researchers divided 50 high school students into two groups. One watched a short film on how sun damage can cause skin cancer, while the other emphasised the sun’s influence on wrinkles and premature skin ageing. Results showed that whilst all of the teens remembered the same amount of information about UV light and sun-protection measures, only those who had watched the film about UV’s effect on appearance showed a dramatic increase in sunscreen use. Dr Cliff says he has recognised a lack of awareness about sun damage in the media. “There is information but it is often sporadic and intermittent, which is soon forgotten by the public,” he explains. Linking the results of the study with his observations, Dr Cliff says, “Patients are aware of the effect sun has in relation to skin cancer, but their knowledge regarding the ageing process is limited.” Arguably, it could be said that more students started using sunscreen as they had learnt something they hadn’t already been aware of, and something that seemed more imminent– that the sun causes skin ageing, as well as cancer. The powerful communication of this message via video resulted in a direct increase in the use of sunscreen. McWhirter suggests educational films become popular because they play on viewers’ emotions. In relation to ‘How the sun sees you’, she says there are psychological reasons as to why people have responded so strongly to it. She says that the surprise encountered by the participants – first seeing their skin in UV light for the first time, and then seeing the thick, black depiction of sunscreen on camera, draws the viewer in. “Their reactions to their hidden skin damage are very candid, helping to captivate the viewers’ attention,” she says. “We can easily imagine ourselves feeling the same way when seeing our own skin in such a condition for the first time – people watch it, like it, and share it, because it creates an emotional response in them.” Dr Cliff says that as a practitioner he would now be encouraged to relate health information to his current and potential patients via video. For this, Leveritt’s advice is simple: make them engaging. He believes that low attention span is a myth, and the answer lies in the content of what you’re putting forward. “The brain is the wrong tool to target – people know smoking is harmful, yet they still do it – people’s emotions are what should be targeted.” McWhirter concludes, “Film isn’t just the future of health communication, it’s the present – and we need to catch up. It’s where visual health communication and education have to be if they’re going to be effective.”

Aesthetics | October 2014

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

dry eye. General disorders and administration site conditions; Common: injection site haemotoma. Post-Marketing Experience; Flu-like symptoms and hypersensitivity reactions like swelling, oedema (also apart from injection site), erythema, pruritus, rash (local and generalised) and breathlessness have been reported. Overdose May result in pronounced neuromuscular paralysis distant from the injection site. Symptoms are not immediately apparent post-injection. Bocouture® may only be used by physicians with suitable qualiﬁcations and proven experience in the application of Botulinum toxin. Legal Category: POM. List Price 50 U/vial £72.00 Product Licence Number: PL 29978/0002 Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer Landstraße 100, 60318 Frankfurt/Main, Germany. Date of revision of text: August 2014. Further information available from: Merz Pharma UK Ltd., 260 Centennial Park, Elstree Hill South, Elstree, Hertfordshire WD6 3SR.Tel: +44 (0) 333 200 4143 Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard Adverse events should also be reported to Merz Pharma UK Ltd at the address above or by email to medical.information@merz.com or on +44 (0) 333 200 4143. 1. Bocouture 50U Summary of Product Characteristics. Bocouture SPC 2014 August available from: URL: http://www.medicines. org.uk/emc/medicine/23251. 2. Prager, W et al. Onset, longevity, and patient satisfaction with incobotulinumtoxinA for the treatment of glabellar frown lines: a single-arm prospective clinical study. Clin. Interventions in Aging 2013; 8: 449-456. 3. Sattler, G et al. Noninferiority of IncobotulinumtoxinA, free from complexing proteins, compared with another botulinum toxin type A in the treatment of glabelllar frown lines. Dermatol Surg 2010; 36: 2146-2154. 4. Prager W, et al. Botulinum toxin type A treatment to the upper face: retrospective analysis of daily practice. Clin. Cosmetic Invest Dermatol 2012; 4: 53-58. 5. Data on File: BOC-DOF-11-001_01 Bocouture® is a registered trademark of Merz Pharma GmbH & Co, KGaA. 1165/BOC/AUG/2014/LD Date of preparation: August 2014

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We report on the scientific agenda at F.A.C.E 2 f@ce 2014

F.A.C.E 2 f@ce congress This year’s F.A.C.E 2 f@ce congress was held for the third time in Cannes, France. Focusing on anti-ageing medicine and facial plastic surgery, the two-day congress has migrated from its first location in Marrakesh to become a firm aesthetic landmark in Cannes, where the conference is now host to an international audience. Since it was founded in 2010, the congress has developed a solid scientific programme that strives to instigate unbiased discussion around the evolving science of aesthetics. Its co-founders, Dr Frédéric Braccini, Dr Jérôme Paris and Dr Patrick Trevidic, outline their approach to the event as ‘getting back to basics’: “In Europe there were big conferences that became big fayres,” says Jérôme Paris. “We wanted to go back to the real basics of a medical conference, which should be scientific programme first. This is what we’ve tried to do; the DNA of our conference is the scientific programme.” Wendy Lewis, president of global aesthetics consultancy Wendy Lewis & Co, spoke at this year’s F.A.C.E 2 f@ce. She says, “No one needs an excuse to visit the Cote D’Azur, but the F.A.C.E. 2 f@ce congress is a very good one. Scientific directors Dr Patrick Trevidic, Dr Frédéric Braccini and Dr Jérôme Paris assembled a stellar line-up of thought leaders in cosmetic surgery, dermatology and aesthetic medicine from Europe, the Middle East, Asia and the USA. I was honoured to be invited to speak on aesthetics clinic marketing to such an international audience. What stands out to me about this meeting, among many others I attend, is the unique camaraderie and

mutual respect of the scientific directors and scientific coordinators. Trevedic, Paris and Braccini hand pick their faculty and make everyone feel very welcome. Their enthusiasm for promoting science and clinical excellence in this forum is infectious.” The F.A.C.E 2 f@ce conference agenda is formed around three main topics: aesthetic medicine, aesthetic surgery and reconstructive surgery. This year’s sessions included a discussion on the management of complications in aesthetic treatments, treating skin of colour, techniques for treating the neck, and the differences in approach to male and female rejuvenation. Non-surgical fat reduction was also under the spotlight during the two days, with a session led by US dermatologist and president of the congress, Dr Susan Weinkle. This session sparked much debate over the exact technique of cryolipolysis and its efficacy. Other sessions included a focus on new LED techniques, as well as surgical sessions exploring new approaches to facelift surgery. The sessions on both days were a harmonious amalgamation of medicine and surgery treatments for each individual patient. Addressing these areas of aesthetic medicine without outside influence was of great importance to the co-founders. Paris says, “We work on creating sessions that are on specific topics, asking people to talk about the product, but then having roundtables of experts to discuss cases with complications. Back to the basics – we want this conference not to be a big fayre for sales, but to be a place where practitioners can continue their medical education.”

Aesthetics | October 2014

Insider Conference Report

When founding the conference, Paris, Braccini and Trevidic also founded the Cannes International Aesthetic Film Festival to promote a creative outlet for the industry. Practitioners and industry members submit films in the run up to the congress and during the final evening of F.A.C.E 2 f@ce, awards are given to the three best films from practitioners and the three best films submitted by industry members. These submissions have grown from only a few in the first year to a growing number of varied and high-quality films by 2014, becoming a distinct element of the conference. Of the individual films, Paris says, “Of course, the industry movies are very professional, because they have big funds and so submit beautiful movies. But we have been very surprised to see artistic movies submitted from individuals in Russia, India and this year we received a great movie from Korea. These people are doctors or surgeons by trade, but they are also making beautiful and artistic movies.” Past topics have included romantic films based in aesthetic offices and clinics, as well as films exploring the importance of aesthetics in family lives. Humorous comics have also been submitted, much to the organisers’ delight. Dr Philippe Hamida-Pisal, founder of the Society of Mesotherapy UK, who attended the conference for the second time this year commented, “An aspect of the event this year that struck me as innovative was the prize for aesthetic films. Physical beauty is taken in through the eyes and I think it’s a fantastic idea to award the endeavours of practitioners who use visual art to depict aspects of aesthetic treatments and methods. I am definitely thinking of producing a film for F.A.C.E 2 f@ce 2015.” Next year’s congress will be held on September 25 and 26 in Cannes, as a joint meeting with the European Academy of Facial Plastic Surgery.

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3D-skintech peels and clinical skincare A compact range of medical grade peels and cosmeceutical skincare products complete the Skintech’s unique offering and enables you to both use as a “stand-alone” service or combine with equipment protocols. ‘To compliment our core injectable business the 3D-skintech has added an array of new result driven facial services to our clinic’s menu as well as the combination services for our more curative patients. We recognized that this device offered the stand alone quality of each technology in a unique machine that will ensure that we both deliver the results but equally can make money from the start due its affordability. As a clinician too many times in the past we have invested huge sums of money in a single concept that has proven difficult to profit from. In my opinion this type of system represents the future in our industry.’ Dr Martyn King – GP and Clinical director Cosmedic Skin Clinic

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Tattoo removal With the number of patients looking to rid themselves of tattoos on a steady rise, Allie Anderson speaks to leading practitioners about the evolving method of removal Some do it to emulate celebrity icons; others, to pay indelible tributes to loved ones. Love them or hate them, tattoos have become a representation of western culture. Around one fifth of British adults reportedly have tattoos, with the number rising to 29% among those aged 16 to 44.1 Americans have a similar penchant for getting ‘inked’, with one in five US adults having at least one tattoo, according to a Harris poll.2 What is perhaps surprising – and somewhat worrying – is that there are no national standards in England and Wales requiring qualifications and training of tattooists. As long as premises are registered, anyone can wield a tattoo gun and permanently mark someone’s skin with ink. Lack of regulation of course means the risk of life-threatening infection cannot be properly mitigated. But in the shorter term, it also means there’s a greater chance of someone walking out of a parlour with an unprofessional and poor-quality tattoo. In addition, certain careers – such as those in the services and the police force, or as a flight attendant – prohibit visible tattoos.

Tattoo regret It’s little wonder, then, that so many people live to regret having it done. A 2012 study released by the British Association of Dermatologists revealed that one third of tattooed adults regretted their tattoo.3 Accordingly, as quickly as tattoos themselves are on the rise, so are procedures to remove them, say practitioners. John Sheffield, manager and laser protection supervisor at Royal Tunbridge Wells Skin and Laser Clinic (RTW), has been doing laser tattoo removal for nine years and says there has been a steady rise in people requesting the procedure. Currently, he says, there are around 700 patients on RTW’s books who are undergoing treatment. According to Sheffield, people who have the procedure can be split into four groups: “There are the young females who have had a tattoo they immediately regret, then you have middle-aged ladies who have put up with bad tattoos for a long time and have recently become both aware and financially able to invest in having them removed,” he explains. “The next group is people who are applying for jobs, where they have visible tattoos they need to have removed before they can even get an interview; and finally, there’s older people, who have had tattoos for many years, and have decided they just want to get rid of it.”

Evolving technology Gone are the days when dermabrasion, salabrasion, chemical destruction or cryotherapy were the most readily available options for removing tattoos. Lasers are now the recognised gold standard for tattoo removal, and they work by Aesthetics | October 2014

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reacting with the ink in the tattoo and breaking it down into tiny particles, which are then absorbed into the body and excreted as waste products. For the last 10 years or so, the device favoured by most has been the Q-switched laser, which uses selective photothermolysis – targeting a specific area with a wavelength of light, which turns into heat energy sufficient to break down the pigment with minimal damage to the surrounding skin. Two of the most commonly used types are the Nd:Yag and the ruby laser. All tattoo pigments have a specific spectrum of light absorption so different light wavelengths are needed to target different colours. The Nd:Yag uses neodymium-doped yttrium aluminium garnet crystal (hence its name) as its medium, to produce pulses of 1064 nanometres (nm), which effectively targets black, dark blue and dark brown. Its high-intensity pulse can be doubled to generate laser light at 532nm – the wavelength needed for red, yellow and purple inks. Light blue and green inks are broken down by 694nm, the pulse wavelength provided by synthetic ruby crystal – or ruby – laser.4 These lasers typically transmit pulses at the speed of nanoseconds (ns), although more recently, a new generation of lasers has come to market that deliver shots in the range of picoseconds – one trillionth of a second. Dr Klaus Hoffman, from Katholisches Klikikum Bochum in Germany, explains how the new technology improves the experience for patients. “When you want to test if an iron is hot, you wet your finger and put it very quickly onto the iron plate. If you leave the finger for long on the iron it will burn,” he comments. “The same thing happens with light – because laser is nothing more than light – if you shoot on the skin with the long-shot laser, you transfer light energy into thermal energy, which more or less cooks the pigment in the depth of the skin. This harms the skin. With picosecond lasers, you give an extremely shortened light pulse that still gives very high energy of 280 megawatts. This blows the pigment in the depth of the skin rather than cooking it.” The upshot is that the quicker the beam, the smaller the particles it can break the tattoo down into, meaning more of the tattoo can be effectively removed with fewer treatments. “Think of the particles of the tattoo colours as rocks underneath the skin,” says Reset Room’s laser practitioner Wayne Joyce. “The old machines would break the rocks down into pebbles, but some of the pebbles were still too big for your body to break down so a lot of the tattoo remained. The new ones break the particles into little pieces of sand, making it easier for your immune system to get rid of them.” Dr Arielle Kauvar, director of NY Laser and Skin Care, concurs that the new technology is providing an attractive treatment option for patients looking to remove unwanted tattoos. “Tattoo ink clears approximately twice as fast as with Q-switched/ nanosecond domain lasers, and we can safely treat at intervals as short as two weeks,” she says. 19

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Before

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After six treatments using the PicoSure laser

dark pigment on a light skin,” Sibley adds. “But we use Nd:Yag 1064nm to treat skin types four to six, lowering the settings and using extra cooling to take the heat out of the skin.” The added risk for darker-skinned patients is that, as well as removing pigments from the tattoo, the laser can cause loss of pigmentation in the skin itself, “Which sometimes comes back after a long Before After six treatments using the PicoSure laser time, but not always,” advises Sheffield. Thereafter, there are five main considerations a practitioner should take into account: the tattoo’s size, how old it is, the colours used, whether it was done professionally and its position on the body. Taken together, these factors will determine how many treatments will be needed, over how long, and how successful the outcome should be. As a rule of thumb, Photos courtesy of Dr Rox Anderson and Dr Suzanne Kilmer yellow, green and blue inks are trickier to remove, Dr Harryono Judodihardjo, a dermatologist and medical director of whilst black responds best, and the length of each treatment will Cellite Clinic, predicts that the efficacy of the procedure will improve vary from 10 minutes to up to an hour, depending on the size with smarter technology, too. “The colours break up more with each and the colours used. Becky Crozier, aesthetician at Wilmslow’s treatment, and currently with a black tattoo, patients can expect about Courthouse Clinic, suggests that, “The best results come from the 80-90% clearance,” he says. “In the future, however, the timing of worst-quality tattoos. The easiest ones to get rid of are homemade the beams will get shorter and shorter and they’ll be able to break tattoos that use Indian ink. The higher the quality, the finer the lines up smaller particles, so the chance of getting 100% clearance will be and the harder it is to remove,” she says. higher.” According to Sibley, the tattoo’s age is a significant factor, with older inks that have become blurry and faded over time responding well. Patient selection She adds that the closer the tattoo is to the heart, the better the Whatever the choice of laser, a test patch several weeks results tend to be. “It’s to do with circulation; how well your body in advance is essential. Practitioners must also fully consult can break it down. Ankles and feet are usually more difficult – you with patients before beginning a course of treatments. Most need more treatments and you see more blistering,” she says. important is taking a full medical history, to exclude any medical “Upper body tattoos respond very well, especially the neck, the contraindications. “We don’t treat people who are taking St John’s upper arms and chest.” wort, which some people take for depression, because it’s highly The number and frequency of treatments needed varies greatly, photosensitive and can cause a reaction,” says Lauren Sibley, with practitioners reporting as few as five or six, and up to 15 clinic manager and lead aesthetic practitioner at Juvea Aesthetics. treatment sessions, with intersession intervals of somewhere “Certain other medications can also affect the treatment, including between two weeks and three months. The choice of equipment is Roaccutane, which is used to treat acne.” This drug can cause also crucial, says Joyce. “The new [picosecond] machines reduce exfoliation, dermatitis, dryness and heightened skin fragility5, so the the number of sessions by about half because you’re getting the skin would be more easily damaged by laser treatments. Patients equivalent of three to four treatments in one go. Treatments are on blood-thinning medication such as warfarin should consult with more expensive, but patients will end up spending the same, if not their doctor before undergoing treatment. more, with the older technology, over a longer period of time with Also important is the patient’s general health, that the skin is free more sessions, more down time and more detriment to the skin.” from infection and inflammation, and generally in good condition. The patient’s skin type is assessed, as it’s a good predictor of how Duty of care effective the removal procedure will be. “Paler skin responds better, A practitioner’s job at the consultation stage is to educate patients because the laser ‘sees’ the tattoo so much more easily when it’s a about these variables, to make sure they’re fully prepared for the

Before treatment with the Harmony XL Q-Switched Laser

After 12 treatments with the Harmony XL Q-Switched Laser

Aesthetics | October 2014

Syneron Candela Launches Breakthrough Technology. Again. Introducing PicoWay. PicoWay is a remarkably innovative dual wavelength picosecond laser from Syneron Candela, the most trusted brand in lasers. With both 532nm and 1064nm wavelengths, PicoWay can treat a very broad range of tattoo types and colors and pigmented lesions on any skin type. PicoWay has the highest peak power and the shortest pulse duration of any picosecond laser for superior efficacy, safety and comfort. Proprietary PicoWay technology creates the purest photo-mechanical interaction available to most effectively impact tattoo ink and pigmented lesions, without the negative thermal effects of other lasers. And PicoWay has the reliability and low cost of ownership physicians want.

PicoWay Launch @ CCR Expo, Olympia London October 10th & 11th, 2014 STAND #E10

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ÂŠ2014. All rights reserved. Syneron and the Syneron logo are registered trademarks of Syneron Medical Ltd. and may be registered in certain jurisdictions. PicoWay and Candela are registered trademarks of the Candela Corporation. PB83214EN

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Treatment with the PicoWay Dual Wavelength Picosecond Laser Before

Before

After three treatments

The colours break up more with each treatment, and currently with a black tattoo, patients can expect about 80-90% clearance. journey ahead of them. Part of this, says Sheffield, is to consider whether they have the requisite financial resources. “It’s going to cost someone the thick end of £1,000 to get rid of a large tattoo, so you have to look at whether they can afford to fulfil the course of treatment to the bitter end,” he adds. “The minute you do the first treatment, the tattoo looks less attractive than it did before, so you could end up with a nasty splodge in its place if you give up after three or four treatments.” The psychological impact of what can be a very long-term, and potentially painful process should also be taken into account. “Some people just aren’t ready for the commitment, and with all patients, you have to make sure they’re doing it for the right reasons,” Sheffield continues. While the development of technology means fewer, less intense side effects, some complications can still arise with even the most advanced lasers. “Immediately after the procedure we get a frosting appearance, so the tattoo goes white,” explains Sibley. “That’s an indication that the laser is being attracted to the pigment and is breaking it down. It’s very common to see slight oedema in the area too; we like to see some swelling because, again, that’s an indication that the particles are being broken down.” It’s also common for the skin to become inflamed and blistered, and to scab over. Some scarring can occur, but this is reduced if the patient does not pick at the scabs. For the practitioner’s part, they can minimise the risks of scarring by keeping the settings low to begin with, and increasing them with each session, taking care not to overlap the laser’s shots. “It’s important to make sure the shots are next to each other and not overlapping,” says Crozier. Patients should be advised to keep the area covered and to moisturise, for example with aloe vera or Bio-Oil, 22

in between applying fresh dressings. Tattoo pigments break down over time, with the colours fading gradually over a period of several weeks – so patients should be fully aware of the timescales involved. “Every time the patient comes back for their next treatment, we like to see some improvement in the appearance of the tattoo,” says Sibley. Pain can be reduced by using a topical anaesthetic before each procedure, such as a preparation of lidocaine, with prilocaine (as in Emla cream) or with tetracaine (as in Pliaglis). After seven treatments

A business opportunity The use of lasers for cosmetic purposes was deregulated in England in 2010, so anyone can use them. This has led to a boom in the number of clinics and practitioners offering tattoo removal, and there is certainly demand, both here and internationally. “In my experience it seems as though a huge segment of the population are unhappy with their tattoos. There has definitely been a greater demand for tattoo removal throughout the past five years,” says Dr Kauvar. The advanced picosecond laser technology makes tattoo removal more accessible, she adds. “Knowing that you can remove your tattoo in five to six treatments over a three to four month period, rather than 15 or more sessions over one to two years, makes tattoo removal a realistic possibility for so many people who previously would not consider this option.” Dr Hoffman confirms that the commercial gains are high, too. “We see about 10 to 20 patients a day so we are overbooked for a year. It’s a good business and the return on investment is high,” he adds. Last year, the British Medical Laser Association (BMLA) and the British Association of Aesthetic Plastic Surgeons (BAAPS), called for tighter regulation of the industry and rules governing who can buy and use lasers.6 Responsible practitioners would no doubt support such an action, but notwithstanding, anyone carrying laser tattoo removal should be suitably trained, says Sheffield. As well as educating practitioners how to properly use the equipment, Sheffield suggests that clinic leaders should also train staff to not give in to pressure from patients to increase power or take short cuts, because it almost always causes problems. “Like all medical procedures, you have to deal with your patient selection carefully,” he says. “Otherwise, you’re making a rod for your back and you’ll end up with an unhappy patient.” REFERENCES 1. Jon Henley, The rise and rise of the tattoo (The Guardian: www.theguardian.com, 2010) <http://www.theguardian.com/artanddesign/2010/jul/20/tattoos> 2. Samantha Braverman, One in Five U.S. Adults Now Has a Tattoo (Harris: www. harrisinteractive.com, 2012) <http://www.harrisinteractive.com/NewsRoom/HarrisPolls/ tabid/447/mid/1508/articleId/970/ctl/ReadCustom%20Default/Default.aspx> 3. Aslam, A and Owen, C, Fashions change but tattoos are forever: time to regret (Burnley General Hospital, UK: http://www.bad.org.uk, 2012) <http://www.bad.org.uk/News. aspx?sitesectionid=154&itemid=303&q=Fashions%20Change%20but%20Tattoos%20 are%20Forever> 4. Kirby, W, et al, ‘Causes and recommendations for unanticipated ink retention following tattoo removal treatment’, Journal of Clinical and Aesthetic Dermatology, 6(7) (2013), pp. 27-31 5. NHS, Roaccutane (Roaccutane 10mg capsules) (NHS: www.nhs. uk) http://www.nhs.uk/ medicine-guides/pages/MedicineSideEffects. aspx?condition=Acne&medicine=roaccutane&preparation=Roaccutane%2010mg%20 capsules 6. Kent, Tamsyn, Laser tattoo removal is on the rise, say experts (BBC Newsbeat: www.bbc. co.uk, 2013) <http://www.bbc.co.uk/newsbeat/25103278>

Aesthetics | October 2014

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Laser complications in aesthetic procedures Dr. Firas Al-Niaimi looks at the possible complications that can occur following treatment with laser Laser procedures have become increasingly popular in the aesthetic and dermatology sector. In the majority of cases the treatments are associated with mild transient side-effects and fortunately long-term complications are uncommon. In addition to accurate patient selection, a thorough understanding of laser physics and light-tissue interaction is essential in minimizing the risk of complications. This article explains the possible complications that may arise from laser treatments in the aesthetic practice involving the skin only (ocular hazards are not discussed). Measures to avoid such complications as well as some tips to manage those that can occur will also be discussed. Table one summarizes the common complications per treatment modality.

Table 1 Laser procedure

Complication

Laser hair removal

Hyperpigmentation Hypopigmentation Blistering/Crusting

Folliculitis Scarring

Paradoxical hypertrichosis Acne

Tattoo removal

Blistering Hyperpigmentation Hypopigmentation Scarring Darkening of tattoos Infections

COMMON SIDE-EFFECTS

Depending on the type of laser and procedure performed, temporary and transient side effects are extremely common, and in some procedures they are an expected desired clinical endpoint. These will be discussed here briefly but, strictly speaking, do not fall under the category of complications. Erythema, for example, is almost always present as a result of heat scattering following any laser procedure and tends to fade within 24 hours. This is often accompanied by oedema which similarly fades within 24 hours, except when it involves the peri-orbital areas where it tends to last a bit longer. In symptomatic cases, the use of ice packs and a short course of oral corticosteroids can help. Bruising with the use of pulsed dye laser (PDL) is common, particularly with the use of shorter pulse widths less than 6 milliseconds, and generally tends to fade in seven to 10 Management days. Care should be taken if this occurs in • Sun protection individuals with higher skin types, as well as in • Lightening creams • Narrowband UVB/excimer laser/fractional lasers the lower legs, due to the possible risk of post• Petrolatum-based ointments inflammatory hyperpigmentation (PIH) once • Anti-septic treatment the bruising settles. This can be avoided by • Avoidance of ‘picking’ of the crust using longer pulse widths, lower fluences, and • Antiseptic treatment and in some cases oral antibiotics • Cortiocosteroid injections and PDL for hypertrophic adequate cooling.1 scars Peri-follicular erythema is a desired endpoint in • Fractional ablative or non-ablative treatment for laser hair removal (LHR) and generally tends to atrophic scars fade in few hours. Pain may be experienced in • Adequate fluences with cooling. Adequate pre and post-treatment cooling in particular to the adjacent LHR, as well as many other laser procedures, areas and this can be minimized by local anaesthetic, • Topical and systemic standard acne therapy cooling methods, and the use of longer pulse • As above widths where appropriate to the clinical setting. • • • • • •

Reduce subsequent fluences with less overlap As above As above As above As above Treatment subsequently with 1064 nm Nd:YAG and/or fractional ablative therapy • Prompt systemic anti-bacterial and viral agents • Topical antibiotics (care of contact dermatitis particularly following ablative procedures)

Laser treatment for vascular lesions

Bruising

Hyperpigmentation Hypopigmentation Scarring Indentation

• Longer pulse widths and lower fluences (with PDL) • Short-term use of topical corticosteroids in intense purpura (particularly to avoid PIH in higher skin types) • As above • As above • As above • Filler injections or autologous fat transfer

Ablative and non-ablative procedures

Infection Hyperpigmentation Hypopigmentation Scarring Millia/Acne

• • • • •

Prolonged erythema

Contact dermatitis Line of demarcation

• • • • • • •

As above As above As above As above Switch to light-based topical treatments and standard acne therapy Milia extraction may be performed Sun protection Vitamin C serum PDL/IPL Limit the use of topical agents to non-irritating Avoidance of ‘alcohol-containing’ products ‘Feathering’ the edges with lower fluences and density

Aesthetics | October 2014

COMPLICATIONS Complications that may arise from laser treatments are best defined as undesired events that occur as a result of laser treatments, without intention. These can be divided in minor, intermediate, and major complications.

Minor complications Acne/milia: These minor complications are generally easy to treat and tend to occur most commonly following ablative and non-ablative laser procedures. They are most likely to be due to disruption of pilosebaceous units by photothermolysis resulting in inflammation and follicular occlusion. Individuals with a past history of acne are particularly prone to this. Milia often result due to occlusion of eccrine ducts and follicles secondary to the use of occlusive ointments in the aftercare period of resurfacing procedures. In general, switching to light cream-based emollients, and the passage of time, is all that is required.

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The development of acne has been reported to occur following LHR on the face and, although the exact mechanism for this is unknown, it is likely that follicular occlusion and thermal effects play a role.2 Treatment is with topical and systemic antibiotics. Occlusion folliculitis can occur in LHR particularly on the lower legs in women, and on the back in men. It tends to occur during the first few treatments when the hair shaft is thicker. Treatment with topical and in some cases oral antibiotics is often sufficient. The most common organism responsible is Staphylococcus aureus although in some cases it may only represent a non-bacterial inflammation. Purpura: Purpura is a common expected outcome in many cases with the use of PDL, and in some conditions, such as port-wine stains, it is an expected clinical endpoint. A rare complication of LHR, is the development of purpura, often in the lower legs, which represents the rupture of small cutaneous vessels as a result of gravity and higher hydrostatic pressures.3 Termination of LHR is not required in most cases and leg elevation and the use of compression stockings would suffice. Contact dermatitis: This is a complication that tends to occur as a result of either “irritancy” to the products used following a laser procedure (irritant contact dermatitis) or due to “sensitization” and the development of an allergy to the topical agents (allergic contact dermatitis). This complication is particularly more common following ablative resurfacing procedures, as a result of the loss of epidermal barrier leading to increased penetration of the topical products, together with the “heightened” local cutaneous immunological response as a result of the epidermal barrier disruption.4 Management is with a short course of topical corticosteroids, the use of less irritating topical products (gentle cleanser and light emollients) and the cessation of any culprits in the event of a suspected or confirmed allergic contact dermatitis.

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Intermediate complications Hyperpigmentation: PIH is a relatively common complication of laser therapy and is often observed in individuals with higher skin types, although idiosyncratic cases can occur in any skin type. Common causes for this complication include the use of high fluences, inadequate cooling, and treatment in tanned individuals (often associated with a degree of crusting in the latter group due to increased epidermal absorption of the laser radiation). The mechanism primarily involves an increase in melanin dispersion from active epidermal and follicular melanocytes as a result of the inflammation and, in some occasions, secondary to the damage of the basement membrane, leading to uptake of the melanin by melanophages (sometimes referred to as dermal type of PIH).5,6 It is worth noting that in higher skin types PIH can be caused by the use of excessive cryogen cooling or following marked purpura. PIH generally tends to improve over time and its management involves the use of vigorous sun protection and, in some occasions, the use of lightening creams – of which hydroquinone in my opinion is the most effective. In some cases of intense purpura, a short course of topical corticosteroids post laser therapy can reduce the risk of PIH afterwards.

Koebnerisation: This term applies to the appearance of a dermatosis as a result of injury and, in some cases, this can be due to laser treatment. Examples include psoriasis, lichen planus, and vitiligo. Whilst these conditions do not preclude from laser treatment, it is worth informing the patient about this prior to the procedure.

Hypopigmentation: Fortunately hypopigmentation as a result of laser therapy is far less common than PIH. Though this complication may be transient, in some cases it can be permanent and notoriously difficult to treat. The mechanism involves either complete destruction of both epidermal and follicular melanocytes, as a result of excessive thermal damage, or the suppression of melanogenesis by melanocytes as result of the inflammatory process triggered by the laser injury.7 Immunohistochemical studies have shown a normal number of melanocytes and it is possible that a reduced tyrosinase activity, an enzyme which is heat sensitive, is responsible for this phenomenon.8 Distinction between the two possible mechanisms is not possible, however, in the latter gradual spontaneous recovery may be possible. Temporary hypopigmentation is relatively common following the use of Q-switched lasers, possibly due to targeting the melanosomes in the melanocytes as described above. In some cases the use of narrow band UVB phototherapy or excimer laser may help through the stimulation of melanocytes.9 There are some recent published reports on the use of fractional laser technology with good results.10 Delayed hypopigmentation typically seen in some cases post full ablative resurfacing is fortunately less common nowadays due to the increased use of fractional methods. In addition to the aforementioned mechanisms involved, some authors speculate that the hypopigmented appearance of the skin is the result of opacification of newly formed collagen bundles in the dermis, leading to alteration of light reflection.

Urticaria: Short-term wheals typical of urticaria rarely occur following laser procedures and represent mostly a form of physical urticaria called symptomatic dermographism. A rare variant of cold-induced urticaria can occur as a result of the cooling used during the procedure. Treatment is generally symptomatic and with a short course of antihistamines.

Crusting/blistering: Crusting and blistering both imply epidermal injury. In crusting, often suprabasal (above the basal layer) necrosis of the epidermis occurs with subsequent sloughing off of the necrotic tissue. The mechanisms involved are similar with blistering; the latter can also occur as a result of cleavage at the dermo-epidermal junction, as a result of thermal injury, and often involves full epidermal

Line of demarcation: This complication represents a colour step-off between the treated and non-treated area and typically occurs in ablative and, to a lesser degree, non-ablative rejuvenation procedures. This may not necessarily be due to high fluences and tend to occur more among higher skin types and individuals with actinic bronzing. Measures to minimise this include confining treatments to cosmetic subunits and “feathering” the edges of the treated areas by using lower fluences and densities. In skilled hands the use of high repetition mode in a “painting” fashion are also beneficial.

Aesthetics | October 2014

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separation from the dermis due to damage of the basement membrane. In the majority of cases these complications occur as a result of inadequate high fluences, cooling failure, pulse stacking, treatment in tanned individuals, or inadequate removal of make-up. In some cases debris accumulated at the hand piece can lead to focal areas of overheating of the epidermis which, in turn, leads to crusting. Blistering can also occur in laser tattoo treatments, in particular when the ink density is high, when there is pulse stacking, pulse overlap and the use of excessive fluences.11 Large unilocular blisters tend to occur at distal extremities such as the wrist and ankle. Blisters occurring in the setting of non-ablative fractional lasers are often the result of “bulk heating” and subsequent treatments should be performed with lower densities. Intact blisters should either be left and a non-adherent dressing applied, or drained carefully with the use of a sterile needle and good anti-septic cover afterwards. The management of crusting involves the regular use of a petrolatumbased ointment with the area kept clean (occasionally with the use of anti-septic agents). It is vital that the formed scabs are not picked or removed as this can result in hypopigmentation or scarring. Signs of acute epidermal injury with impeding crusting or blistering include whitening or greying of the treated area, which should be promptly treated with vigorous cooling and the use of lubricating ointments regularly. It is worth mentioning that some cutaneous infections can present with vesicles or blisters and this should be excluded. Paradoxical hypertrichosis: This complication is a relatively common phenomenon in LHR and tends to be of particular problem in individuals with skin types III-V, and in particular on the face. Although the physical consequences of this are minor, it generally tends to cause a lot of distress among its sufferers. The exact mechanism for this “stimulated hair” is unknown, though hormonal influences could play a role, and exclusion of an underlying endocrine disorder in females is recommended. The condition is defined as an increase in the colour, density, and coarseness of hair following LHR. I have distinguished two patterns of paradoxical or stimulated hair growth. Namely one involving the treated area and another involving the surrounding adjacent areas. In the former, this is often due to insufficient fluences leading to photobiostimulation of the hair follicles instead of stem cell damage. In such cases the use of higher fluences or double passes (with adequate care and cooling) may be required. It is also noteworthy that in finer hairs the target for laser (follicular melanin) is reduced, and therefore ideally shorter wavelengths and pulse widths are required. This is often performed by experienced laser practitioners with thorough knowledge of this treatment and potential side-effects. In the second scenario, in which stimulated hairs appear in the adjacent areas of the treated sites, the mechanism here involves diffusion of heat to the surrounding areas at low levels that leads to stimulation in the mitochondria, leading to biostimulation of hair follicles.12 In such cases adequate pre- and post-treatment cooling of the adjacent surrounding areas is required. Prolonged post laser resurfacing erythema: The exact timing for the erythema to be defined as “prolonged” is unclear; however this term defines the presence of prolonged erythema following a laser procedure (most commonly ablative and non-ablative rejuvenation) beyond the expected duration for

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The management of crusting involves the regular use of a petrolatum-based ointment with the area kept clean (occasionally with the use of anti-septic agents). It is vital that the formed scabs are not picked or removed as this can result in hypopigmentation or scarring. such an intervention. Some laser experts define this as 7 days for non-ablative fractional ablation and six weeks post ablative procedures. There is however no general consensus on this. In some cases this prolonged erythema may progress to scarring or PIH. The risk of prolonged erythema is present, in particular, among patients with “plethoric” skin or rosacea. Treatment calls for vigorous sun protection as well as the use of some topical treatments such as vitamin C serum. In some cases, particularly when pruritus is present, a short course of topical corticosteroids can be used. The differential here would include a rare Candida infection, or in the presence of ‘dermatitis’, picture an irritant or allergic contact dermatitis to the topical products used during the aftercare. In many cases, treatment with PDL or IPL in non-bruising settings can further help ameliorate this complication.

Major complications Scarring: Scarring is the most feared laser complication – by both practitioners and patients – and represents the most serious cutaneous complication of laser therapy. Scarring results from irreversible injury to the collagen and adnexal structures, leading to the inability of the stem cells to repopulate the damaged cells. In some patients there is an inherent susceptibility for scar formation. Risks include the use of excessive fluences, inadequate cooling (in particular due to “bulk heating” with the use of deeper penetrating wavelengths such as 1064 nm Nd:YAG), post infection, pulse stacking particularly at purpuric settings, or

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crusting/blistering if not managed promptly. Scarring can also occur, due to irreversible collateral thermal damage, with the use of long-pulsed millisecond lasers in the treatment of tattoos where the chromophore (exogenous ink) is very small. Therefore, procedures such as LHR should avoid treating hairs overlying tattoos. Treatment of established hypertrophic scars is with the use of corticosteroid injections, silicone gel sheets, and PDL. Early treatment with PDL in the event of an incipient scar formation (prolonged erythema for example) can in some cases avert such a complication.13 Atrophic scarring is more challenging to treat, although both ablative and non-ablative fractional treatments can be used with some success.14

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with a burning and tingling sensation. The differential between herpetic and bacterial infections can be difficult at this stage and microbiological investigations may be required. Empirical anti-viral treatment should start promptly as disseminated HSV infections are likely to delay re-epitheliazation and lead to scar formation. It is generally agreed now that prophylactic treatment is given to almost all ablative procedures and in high-risk cases of non-ablative treatments. Yeast infections, most commonly with Candida species are rare and present often with erythema and pruritus, particularly following ablative procedures.17 Treatment is with systemic anti-yeast agents.

Conclusion Indentations: This is a relatively uncommon complication from laser therapy and is almost always a result of excessive fluence use. Indentations that occur following epidermal damage (crusting, blistering, erosions, etc.) are often the result of associated marked collagen damage and shrinkage often as a result of high fluence or inadequate cooling of the skin. Whilst isolated collagen damage and shrinkage can certainly occur with the inadequate use of deep penetrating lasers that generate “bulk heating” such as 1064 nm Nd:YAG (particularly on the face leaving a “grooving” type of indentation), subcutaneous indentation may occur as a result of isolated subcutaneous fat injury with fat necrosis or a panniculitislike inflammation. Such complications were often observed with the use of cryolipolysis or radiofrequency devices.15 The use of devices with “vacuum suction” may also result in such injuries. In some occasions shallow indentations may spontaneously recover over time, however deeper indentations tend to be permanent and, though difficult to treat, filler injections or autologus fat transfer can in some cases offer a remarkable cosmetic improvement. Infections: Cutaneous infections as a result of laser treatment can pose a particular problem due to the risk of scarring that may ensue. The risk of infection increases with any disruption of the epidermal barrier such as crusting and blistering. The risk is the highest among ablative laser procedures. Infections can be divided into bacterial, viral, and yeast infections. Bacterial infections are commonly caused by Staphylococcus aureus and are a particular risk with ablative procedures due to the degree of oozing, crusting and epidermal barrier disruption. Pain is a particular useful diagnostic sign together with evidence of superficial crusting or focal areas of patchy erythema with erosions. The risk appears to be higher after 48 hours from ablative procedures and should be treated promptly with oral antibiotics and appropriate topical anti-septic agents. In highrisk cases such as immunocompromised patients, pre-treatment with oral antibiotics might reduce this risk.11 The use of topical antibiotics post laser resurfacing can lead to an increased risk of contact dermatitis and the clinician should be aware of this. Viral infections are almost always due to reactivation of herpes simplex infections (HSV) and are a risk in both ablative and nonablative procedures, particularly with procedures performed around the mouth.16 The appearance of painful crusting or vesicles following such procedures should alert the practitioner to the possibility of this diagnosis. In cases where there is no reepithelialization this can present superficial erosions associated 28

The use of laser and light devices has increased greatly over the years and, as a result, there has been a rise in complications from the use of these devices. Fortunately most devices available to us are generally safe, and serious complications are rare among trained and experienced professionals. Indeed, a recent published study showed that the majority of laser complications occur as a result of practitioner error.18 Lack of thorough knowledge of laser physics and poor training, coupled with improper patient selection, are unfortunately all too common nowadays. Therefore, in my opinion, a sound knowledge of laser physics – coupled with a thorough knowledge of laser complications and how to avoid them – should hopefully lead to an overall decline in such incidents. Dr Firas Al-Niaimi is a consultant dermatologist and laser surgeon, currently working for sk:n clinics, London.He trained in Manchester and subsequently did a prestigious advanced surgical and laser fellowship at the world-renowned St. John’s Institute of dermatology at St. Thomas’ Hospital in London. He has authored more than 80 publications, including chapters of books, and is on the advisory board for a number of respected journals. REFERENCES: 1. Goldberg D, ‘Laser treatment of vascular lesions’, Clin Plast Surg, 27 (2000), pp. 173-80 2. Carter JJ, Lanigan SW, ‘Incidence of acneform reactions after laser hair removal’, Lasers Med Sc, 21.(2) (2006), pp. 82-5Goldberg DJ, ‘Complications in laser treatment of unwanted hair’ In: 3. Goldberg DJ (ed), Complications in cutaneous laser surgery, (London: Taylor & Francis, 2004) 4. Nanni CA, Alster TS, ‘Complications of carbon dioxide laser resurfacing: An evaluation of 500 patients’, Dermatol Surg, 24 (1998), pp. 315–20 5. Chan NP, Ho SG, Yeung CK, et al, ‘The use of non-ablative fractional resurfacing in Asian acne scar patients’, Lasers Surg Med, 42 (10) (2010), pp. 710–715 6. Lanigan SW, ‘Incidence of side effects after laser hair removal’, J Am Acad Dermatol 49 (2003), pp. 882-6 7. Goldberg D, Laser treatment of benign pigmented lesions. (eMedicine, 2014) <http://www. emedicine.com/derm/topic517.htm>. 8. Laws RA, Finley EM, McCollough ML, Grabski WJ, ‘Alabaster skin after carbon dioxide laser resurfacing with histologic correlation’, Dermatol Surg, 24 (6) (1998), pp. 633-6 9. Alexiades-Armenakas MR, Bernstein LJ, Friedman PM, Geronemus RG, ‘The safety and efficacy of the 308-nm excimer laser for pigment correction of hypopigmented scars and striae alba’, Arch Dermatol, 140 (2004), pp. 955–960 10. Tierney EP, Hanke CW, ‘Treatment of CO2 laser induced hypopigmentation with ablative fractionated laser resurfacing: case report and review of the literature’, J Drugs Dermatol, 9 (2010), pp. 1420-1426 11. Berg D, Nanni CA, Complications of dermatologic laser surgery, (eMedicine, 2014) < http:// www.emedicine. com/derm/topic525.htm> 12. Deasai S, Mahmoud BH, Bhatia AC, et al, ‘Paradoxical hypertrichosis after laser therapy: a review’, Dermatol. Surg, 36 (3) (2010), pp. 291-298. 13. Jin AR, Huang X, Li H, et al, ‘Laser therapy for prevention and treatment of pathologic excessive scars’, Plast Reconstr Surg, 132 (6) (2013), pp. 1747-58 14. Hedelund L, Moreau KE, Beyer DM, et al, ‘Fractional nonablative 1,540-nm laser resurfacing of atrophic acne scars. A randomized controlled trial with blinded response evaluation’, Lasers Med Sci, 25 (5) (2010), pp. 749-54 15. Bogle MA, Dover JS, ‘Tissue tightening technologies’, Dermatol Clin, 27 (4) (2009), pp. 491-499 16. Graber EM, Tanzi EL, Alster TS, ‘Side effects and complications of fractional laser photothermolysis: experience with 961 treatments’, Dermatol Sur, 34 (2009), pp. 301-305 17. Alam M, Pantanowitz L, Harton AM, et al, ‘A prospective trial of fungal colonization after laser resurfacing of the face: correlation between culture positivity and symptoms of pruritus’, Dermatol Surg, 29 (3) (2003), pp. 255-60 18. Zelickson Z, Schram S, Zelickson B, ‘Complications in cosmetic laser surgery: a review of 494 Food and Drug Administration Manufacturer and User Facility Device Experience Reports’, Dermatol Surg, 40 (4) (2014), pp. 378-82

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are not limited to; age, hygiene, nutrition, various disease states, seasonality, and topical product applications.5,6 This leads to the discussion of the pH of skincare products and its role in assessing a product’s efficacy. For this, it is important to remember that the pH scale is logarithmic, which means for every one point shift in the pH of a product there is a tenfold difference in effect.

The value of pH Dr Barry Cohen discusses the importance of pH in the efficacy of skincare Cosmeceuticals and skincare represent a 15 billion dollar a year global industry1, with no foreseeable slowdown in growth. Tens of thousands of products may be found on the market, sold through practitioners’ offices, medical spas, retail outlets, online, and at mass-market venues, with even more money spent on in-clinic and spa treatments in the form of chemical peels. Much has been written about various ingredients in the relevant literature. Most references, however, focus solely on the efficacy of products as a function of concentration of the active ingredients. In fact, even more important than the concentration of the active ingredient is the pH, or level of acidity of the product. The combination of active ingredient concentration and pH is referred to as bioavailability.2 Bioavailability is a term used to describe the actual percentage of active ingredients (AI) delivered and available to act on the skin. Many products tout their percent AI, which is actually an, ‘initial concentration’ – without mentioning the pH. This %AI however, is only of benefit to the consumer when the AI actually reaches and penetrates the skin. Unbeknown to most consumers is that the level of pH of the final product has a direct correlation to the products effectiveness. Skin pH In order to understand the importance of pH in skincare, one first must understand some basics of skin pH. The skin, our largest organ, maintains a healthy pH in the range of 4-4.9.3 The purpose of this relatively acidic pH is to help in the resistance of pathogen invasion, especially bacteria, in the environment.4 Additionally, several crucial enzymes involved in the maintenance of this so called ‘Acid Mantle’ of the skin are dramatically impacted by the pH of the skin.3 Many factors influence the pH of the skin, and these include but

Unbeknown to most consumers is that the level of pH of the final product has a direct correlation to the products effectiveness. 30

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The role of pH in skincare One of the most common ingredients in skincare is the alpha hydroxy acid; glycolic acid. Most products will denote the percentage of glycolic acid in the content list, but few will tell you the product pH. A 70% glycolic acid product can be buffered to be as mild and as innocuous as water at a neutral pH of 7, whereas a relatively low concentration of 20% glycolic acid at a pH of 3 would be quite potent. Clearly, knowledge of both the concentration and pH of a product’s active ingredient is critical in assessing its potential efficacy. So, what is an ideal pH for a treating product, and when is a more neutral pH of a skincare product more appropriate? Fundamentally, many of the active ingredients with known clinical efficacy in anti ageing are various acids: alpha hydroxy acids, beta hydroxy acids, ascorbic acid (vitamin C), retinoic acid (vitamin A derivatives). All of these products have a higher bioavailability and demonstrate greater efficacy as their pH approaches a therapeutic range of 3-4. The creation of a ‘micro burn’ generates an inflammatory process which aids the anti-ageing effect of the product. As an example, if one compares two glycolic acid product preparations, each at a concentration of 10% acid, one at a pH of 3, and one at a pH of 5, the product at the lower pH will be 100 times more effective.7 It is important to remember however, as a treating professional, more is not always better – especially at first. If a patient is started on a product at an ideal treatment pH, it may produce significant initial skin irritation. In fact, it is often wise to gradually increase the bioavailability of an acid to allow the patient’s skin to acclimate to the more acidic environment. Many of the more sophisticated treatment regimens, including Retin-A, have differing available concentrations as well as pH levels to allow a patient the ability to acclimate to an increasing bioavailability. Most patients require 2-4 weeks at various treatment levels to acclimate their skin and, in the early stages of treatment, education of the patient is critical with any potent acid product. Initial redness and mild irritation is not only expected, but also demonstrative of helpful results. Most irritation is ephemeral in the typical patient, and requires only supportive care. When is a higher pH preferable or indicated? Firstly, not every patient can tolerate relatively acidic products. Some patients’ skin demonstrates

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As clinicians we spend significant energy focusing on the percentage of active acid ingredients with which we treat our patients. In fact, it is the pH of most acid based products that influence their efficacy and potency. an ongoing sensitivity to acidic products, precluding them from the various acid treatments on the market. In those cases, there are alternatives. Specifically, product categories such as peptides, cytokines, growth factors, and various moisturisers and sun blocks, do not require an acidic pH to demonstrate efficacy. Particularly, the peptide and cytokine categories, from my experience, have shown real promise in the anti-ageing realm, and can be used on even the most sensitive skin. Of course, many of the mass-market products are intentionally buffered to more neutral pHs to reduce irritation and potential return sales. The truth is, despite higher levels of acid concentration, the products have limited therapeutic effect.8 As a treating practitioner, it is critical to know that as people age their skin pH tends to rise above five, which is higher than a normal physiologic ideal to maintain barrier function of the acid mantle. With this increase of pH comes lower resistance to bacteria as well as an increased risk of certain pathologic disease states. Particularly in the elderly (determined as upper seventies to eighty), use of skincare products in the pH range of 3-4 is ideal.9 PH of skin and skincare products has also been shown to play a significant role in acne treatment. The most common bacterial cause of acne is Proprionobacterium acnes, which flourishes when the skin pH rises above six. Studies have shown that cleansing acne-laden skin with an acidic-based soap reduces the active acne lesions significantly, as compared with a more traditional alkaline soap.10 Common treatments of acne therefore include cleansers at a lower pH. Classic examples include the beta hydroxy acids as

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cleansers in acne care, as well as retinoic acid and its derivatives.11 Interestingly, a survey of pH levels was completed of several dozen common soaps, synthetic detergents (syndets) and cleansers.3 The range of pH was noted to be between 3.61 to as high as 12.35, with the syndets being the lowest. As treating clinicians, we encounter many cutaneous disorders as well as complaints of anti-ageing. Indeed, there are many choices of therapy for these varying complaints. It is critical to remember that the basics of therapy (and sometimes causation) for patient complaints are their cleansers and soaps. Use of highly alkaline cleansers and soaps are frequently contributory to various dermatoses,12 intertrigo, as well as ageing, and therefore the importance of the selection of an appropriate cleanser at a relatively low pH cannot be overstated. In conclusion, we have learned much in the last decade about the importance of pH of the skin as it relates to both ageing and pathologic conditions. Similarly, the role of pH in topical skincare products has emerged as a major factor in product efficacy. As clinicians we spend significant energy focusing on the percentage of active acid ingredients with which we treat our patients. In fact, it is the pH of most acid based products that influence their efficacy and potency. Dr Barry J.Cohen is a board certified plastic surgeon, and senior partner and founder of The Washington Plastic Surgery Group, the largest plastics group in Washington, DC. He is the founder and CEO of Totalskincare.com, as well as being the developer of pH Advantage Skincare, a globally distributed brand. REFERENCES 1. Freedonia Group, Cosmetic & Toiletry Chemicals (www.freedoniagroup.com, 2012) < http:// www.freedoniagroup.com/DocumentDetails.aspx?ReferrerId=FG-01&studyid=2865> 2. Cohen, Barry J. , Total Rejuvenation: From Skincare To Scalpel (New York: MD Publish, 2004) 3. Ali, Saba M, et al, ‘Skin pH: From Basic Science to Basic Skin Care’, Acta Dermato- Venereologica, 93 (2013), pp. 261-267 4. Tobin, DJ., ‘Biochemistry of human skin – our brain on the outside’, Chemical Society Reviews, 35(1) (2006), pp.52-67 5. Chikakane, K et al, ‘Measurement of skin pH and its significance in cutaneous diseases’, Clin Dermatolog, 13 (1995), pp. 295-306 6. Yosipovitch, G. et al, ‘Skin surface pH: a protective acid mantle’, Cosmet Toiletries, 111 (1996), pp. 101-102 7. Linker, Elaine, ‘How pH Affects the Formulation of a Product’, Sink Inc. (2012) 8. Draelos ZD et al, Cosmetic Formulation of Skincare Products, (New York, Taylor and Francis, 2006), pp. 309-351 9. Blaak, Jurgen, et al, ‘Treatment of Aged Skin with a pH 4 Skin Care Product Normalizes Increased Skin Surface pH and Improves Barrier Function: Results of a Pilot Study’, J of Cosmetics, Dermatological Sciences and Applications, 1 (2011), pp. 50-58 10. Saba M. Ali, Gil Yosipovitch, Skin pH: From Basic Science to Basic Skin Care, Acta Dermato –Venereologica, vol 93 (2013), pp. 261-267 11. Korting HC et al, ‘The effect of detergents on skin pH and its consequences’, Clin Derm 14 (1996), pp. 23-27 12. Rippke, F, et al, ‘Stratum corneum pH in atopic dermatitis: impact on skin barrier function and colonization with staph aureus’, Am J Clin Derm, 5 (2004), pp. 217-223

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Hyperhidrosis Dr David Eccleston explores the treatment options for hyperhidrotic patients Hyperhidrosis, or excessive sweating, is thought to affect almost 3% of the population.1 It can occur anywhere on the body or is localised to specific areas, most commonly the hands, feet, groin and armpits. To sufferers, the condition brings daily misery, restricting life style, affecting relationships and sometimes causing depression.2 This article reviews some of the treatments currently available for axillary hyperhidrosis, with a particular focus on the use of the novel modality, electromagnetic energy in the microwave spectrum. Sweat Gland Anatomy A sweat gland is a tube with a coiled base that resides deep in the hypodermis and a duct that extends through the dermis, exiting at the surface of the skin. There are two main types of sweat gland: • Eccrine glands: These produce fluid that is mostly water with some electrolytes that has the primary function of cooling the body. • Apocrine glands: These produce a thicker fluid that includes pheromones. This type of sweat provides an excellent substrate for bacterial growth which can result in the production of molecules such as butyric acid; these have a distinctive smell and give rise to bromhidrosis (body odour).

Fig. 1. Diagram to illustrate the location of eccrine and apocrine glands within the skin.

For the majority of people, sweating takes place as a response to heat or stress. In hyperhidrotic patients, the amount of sweat produced is far greater than is required to cool the body. There are a number of ways to measure the severity of hyperhidrosis in an individual. The simplest is self-assessment by the patient using the hyperhidrosis disease severity scale (HDSS) developed by the International Hyperhidrosis Society.

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Using microwaves in medicine Microwave energy is described as an electromagnetic signal with a wavelength of between 1 mm and 1 m and a frequency of between 300 MHz and 300 GHz. Microwaves travel at the speed of light and are positioned in the electromagnetic spectrum between infrared (lasers) and radiowaves (RF). Microwaves are used in medical applications because of their ability to heat biological tissue, causing ablation (destruction). As early as the 1930s, microwave-based therapy was conceptualised as a thermal therapy3, with the first practical experiments on living organisms taking place in 1946.4 Today, microwave thermal ablation is used in oncology, cardiology, gyneacology, opthalmology and a number of other areas of medicine. The process by which microwaves cause thermal ablation is called dielectric heating, which occurs when an alternating electromagnetic field (the microwave) is applied to an imperfect dielectric material. In the case of tissue, water molecules that are bound within the tissue act as the dielectric material. The water molecules rotate in an attempt to align with the rapidly alternating electromagnetic field. These very fast molecular movements result in frictional forces leading to heating.5 Tissues with a high water content (solid organs, for example) absorb electromagnetic energy better than low water content tissues, such as fat. For medical applications, microwaves are delivered to the treatment area using a microwave generator and an antenna, or group of antennae, to produce the desired absorption pattern in the tissue. Microwave thermolyis of sweat glands Microwave thermolysis of sweat glands as a treatment for axillary hyperhidrosis has been pioneered by Miramar Labs, Inc., a California based company. Miramar Labs launched the miraDry system in January 2012 and it remains the only microwave-based solution for the treatment of axillary hyperhidrosis.

HYPERHIDROSIS DISEASE SEVERITY SCALE “How would you rate the severity of your hyperhidrosis?” 1 2 3 4

My underarm sweating is never noticeable and never interferes with my daily activities My underarm sweating is tolerable but sometimes interferes with my daily activities My underarm sweating is barely tolerable and frequently interferes with my daily activities My underarm sweating is intolerable and always interferes with my daily activities

Fig. 2. The hyperhidrosis disease severity scale developed by the International Hyperhidrosis Society to help patients to self-assess the severity of their disease. The scale is completed before and after any treatment, in order to assess the efficacy of the treatment administered.

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Fig. 3. Diagram to illustrate electric dipole rotation.

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miraDry consists of an applicator hand piece with four waveguide antennae, a cooling system and a vacuum acquisition system. The hand piece is attached to a console containing a microwave generator. Miramar Labs conducted extensive research6 in order to optimise the design of the hand piece so that the microwave energy is delivered precisely to the region of the axilla where it will have maximum thermolytic effect on the eccrine and apocrine glands. A propagating microwave signal travels down the antennae and out through an open face, through the cooling system and into the tissue below. It is known that there is a significant difference in the material properties of microwaves in the dermal/epidermal layer compared to adipose tissue; both velocity and absorption of microwaves are much higher in the dermal layer. When the energy meets the adipose layer, a large proportion of the microwave energy is reflected at the dermal/hyperdermal interface, which produces a region of constructive interference, maximising thermal damage in the region where the target glands reside. At the same time, the hand piece cooling system creates a protection region within the dermis and allows thermal conduction from the microwave region to spread within the target treatment zone. The cooling system consists of a circulating layer of water and a ceramic cooling plate and provides continuous cooling to the superficial layers of the skin, both during energy delivery and for 20 seconds afterwards, preventing surface damage. The hand piece also includes a vacuum acquisition system. As the energy is delivered, the vacuum lifts the skin and underlying fat layers. This helps to physiologically isolate the target region and optimise the heating effect. Results of microwave ablation of sweat glands A clinical study was carried out over a period of 12 months7 with a final assessment made at 24 months post treatment.8 Hyperhidrosis was assessed pre- and posttreatment using HDSS scores and gravimetric measurement of sweat. At baseline, all subjects had an HDSS core of 3 or 4 (indicating severe hyperhidrosis) and a gravimetric measurement of at least 50 mg in 5 minutes in each axilla7. At 12 months, the average percentage reduction of sweat by gravimetric measurement was 82% and 90% of subjects had an HDSS score of 1 or 2 (a 2 point improvement is associated with an 80% sweat reduction).7 At 24 months, the reduction in HDSS score remained >90% and was stable.8 Biopsy samples were taken from one patient before and at intervals after a miraDry procedure and assessed by histology.9 This revealed thermal necrosis and a clear reduction of viable sweat gland structures post treatment, with no significant evidence of adverse effects on other structures. Sweat glands cannot regenerate10, so it is unlikely that thermally destroyed glands will regrow or recover viability. It is therefore predicted that microwave ablation will provide treated patients with a permanent solution for axillary hyperhidrosis.

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treated. The technology is now installed at three clinics in the UK. In May 2014, the International Hyperhidrosis Society updated its Treatment Algorithm for primary axillary hyperhidrosis11 to place microwave thermolysis as a second line treatment option, when topical antiperspirants are found to be ineffective. This is a clear indication of support that this technology has received amongst dermatologists in the USA and elsewhere. Practical considerations for microwave ablation The majority of excessive underarm sweat patients can be successfully treated using microwave ablation. Exceptions include those who are fitted with a pacemaker or other electronic device implant, use supplemental oxygen or have had a previous reaction to local anaesthetic. Skin tags or raised moles must be removed and the patient must shave the armpits prior to treatment. Following treatment, the armpits must be kept clean and an antibiotic cream may be prescribed. Most importantly, the area must be iced immediately after the procedure and regularly in the days following treatment. Two treatments are recommended, at least three months apart. Some patients may find, however, that one procedure is sufficient to produce the desired result. Additional effects of the procedure include a reduction in bromhidrosis due to the elimination of apocrine glands along with the eccrine glands. In most cases there is also a permanent reduction in underarm hair, which is normally perceived to be an additional benefit for female patients. Treatment side effects are swelling, soreness and bruising, which generally lasts for no longer than eight weeks, and altered sensation in or around the treatment area, which usually disappears in about three months.

Other Treatments for Axillary Hyperhidrosis Botulinum Toxin: Botulinum toxin type A provides FDA clearance of microwave ablation temporary relief from the symptoms of axillary Miramar Labs has been granted FDA clearance for the use of miraDry to treat hyperhidrosis and was licensed to treat axillary axillary hyperhidrosis and it remains the only device currently on the market to hyperhidrosis in 2001. The toxin is injected at multiple receive this certification. In the two years since its introduction to the USA, miraDry sites in the armpit, rendering the sweat glands has been installed in around 250 clinics and 20,000 patients have so far been inactive. The treatment usually takes effect within a week but is only effective for about three â&#x20AC;&#x201C; 12 months, with an average duration of seven months12, after which the procedure must be repeated. Iontophoresis: Another temporary treatment for hyperhidrosis is Iontophoresis, where the hands or feet are Fig. 4. Diagram demonstrating the method of targeting the sweat gland layer: (a) an incident signal from the placed in water and a small antenna system radiates through the epidermal and dermal layer, (b) a region of constructive interference occurs in electrical current is passed the dermis at the dermal/hypodermal interface, due to reflection, (c) the epidermal/upper dermal layer is protected through the skin. The underarm by the cooling system and allows thermal conduction to spread to the target zone form the microwave absorption areas can also be treated by region. placing water soaked pads 34

Aesthetics | October 2014

Clinical Practice News

and electrodes under the arms. The exact mechanism of action is unknown. Iontophoresis must be used every other day to start with, then reduced to once a week or so, but if stopped altogether, the symptoms will return. Laser Sweat Ablation: Laser Sweat Ablation (LSA) uses a laser to destroy the sweat glands and was developed in the UK by Dr Mark Whiteley. Performed under local anaesthetic, the laser fibre is inserted between the dermis and the sub-cutaneous fat via two small incisions; the laser is fired, destroying the sweat glands, which are then removed by curettage. LSA does provide a permanent solution, but is to some degree an experimental procedure and at present not widely used in the UK. Surgery: Patients who have exhausted temporary treatments may be considered for surgical intervention, a radical step that should not be undertaken lightly, as complications and side effects may outweigh the benefits gained. Almost every patient who has an Endoscopic (or Video-assisted) Thoracic Sympathectomy (ETS) will experience compensatory sweating on other areas of the body and, in 5% of cases this is severe. During the procedure, the surgeon enters the chest and using video guidance, destroys small areas of the sympathetic chain to interrupt the nerves that stimulate the sweat glands. Conclusion Until the development of microwave ablation of the sweat glands, there was no safe, effective, non-invasive and lasting treatment for axillary hyperhidrosis. Aesthetic clinics can now offer patients an effective alternative to temporary treatments such as toxin injections, without recourse to surgical methods. Microwave ablation is quick and easy to perform and can be carried out in a clinic by a trained aesthetician.

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Dr David Eccleston is a cosmetic doctor and GP based in Birmingham, with a special interest in dermatology. Dr Eccleston is the clinical director of MediZen, a multiaward winning clinic in Sutton Coldfield and is highly experienced in the treatment of hyperhidrosis using toxin injections and the miraDry system. Dr Eccleston has no financial links to miraDry. REFERENCES 1. David R Strutton, Jonathan W Kowalski, Dee Anna Glaser and Paul E Stang, ‘US Prevalence of Hyperhidrosis and Impact on Individuals with Axillary Hyperhidrosis: Results from a national survey’, Journal of the American Academy of Dermatology, 51 (2004) 241 – 248. 2. Katharina M. Gross, Andrea B. Schote, Katja Kerstin Schneider, André Schulz and Jobst Meyer, ‘Elevated Social Stress Levels and Depressive Symptoms in Primary Hyperhidrosis’, PLOS ONE, 9 (2014) e92412. 3. Arthur W. Guy, ‘History of biological effects and medical applications of microwave energy’, IEEE Transactions on Microwave Theory and Techniques, 32 (1984), 1182 – 1200. 4. Frank Hammond Krusen, ‘Samuel Hyde memorial lecture: Medical applications of microwave diathermy: Laboratory and clinical studies’, Proceedings of the Royal Society of Medicine, 43 (1950), 641 – 658 (p. 643). 5. Camelia Gabriel, Sami Gabriel, Edward H. Grant, Edward H. Grant, Ben S. J. Halstead and D. Michael P. Mingos, ‘Dielectric parameters relevant to microwave dielectric heating’, Chemical Society Reviews’, 27 (1998) 213 – 224. 6. Jessi E. Johnson, Kathryn F. O’Shaughnessy and Steve Kim, ‘Microwave thermolysis of sweat glands’, Lasers in Surgery and Medicine, 44 (2012) 20 – 25. 7. H. Chin-Ho Hong, Mark Lupin and Kathryn F. O’Shaughnessy, ‘Clinical Evaluation of a Microwave Device for treating axillary hyperhidrosis’, Dermatologic Surgery, 38 (2012) 728 – 735. 8. Burcu Kim, Naveen Somia, John Pereira and Kurosh Parsi, ‘Long-term efficacy and quality of life assessment for treatment of axillary hyperhidrosis with a microwave device’, Dermatologic Surgery, 40 (2014) 805 – 806. 9. Nobuharu Kushikata, Jinah Kim and Steven Kim, ‘Histological Assessment of Biopsy Samples Taken Before and After the miraDry Procedure Performed on a Patient with Axillary Hyperhidrosis’, (unpublished Case Report, Sera Clinic, Tokyo, Japan). 10. Hai-Hong Li, Gang Zhou, Xiao-Bing Fu and Lei Zhang, ‘Antigen expression of human eccrine sweat glands’, Journal of Cutaneous Pathology, 36 (2009) 318–324 (p. 318). 11. International Hyperhidrosis Society, Hyperhidrosis Treatment Algorithms (sweathelp.org, 2014) <http://sweathelp.org/en/about-hyperhidrosis/clinical-guidelines/hyperhidrosis-treatment- algorithms.html> 12. Markus Naumann, Nicholas J. Lowe, C.R. Kumar and Henning Hamm, ‘Botulinum Toxin Type A Is a Safe and Effective Treatment for Axillary Hyperhidrosis Over 16 Months’, Archives of Dermatology, 139 (2003) 731 – 736, (p. 735).

dermamelan® is a professional whitening treatment designed to eradicate or eradicate or attenuate cutaneous blemishes with melanic origin while it homogenizes skin tone and increases skin luminosity. dermamelan® application inhibits the melanogenesis process paralysing melanin production for a long period of time in which corneum stratum desquamation and the action of macrophage cells drag melanin deposits.

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Aesthetics | October 2014

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Clinical Practice Techniques

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Facial rejuvenation with lasers Debbie Thomas explores the use of combined laser technologies to achieve less irritation and reduced recovery time when performing ablative treatments

Background and objective: To determine the effectiveness of sequential laser-layering techniques (combined Nd:YAG and Er:YAG) to achieve optimal results in a shorter period of time whilst reducing downtime. Materials and methods: Treatments were carried out on 10 patients (nine females and one male â&#x20AC;&#x201C; six facial treatments only, and four face and neck treatments) with varying degrees of skin concerns, from open pores to loss of elasticity, and some fine lines and wrinkles. A combined Nd:YAG 1,064nm and Er:YAG 2,940nm device was used. Each patient had four treatments at two to three weekly intervals. Results: A significant improvement of the skinâ&#x20AC;&#x2122;s tone, texture and elasticity was noticed by the patients themselves and was visible in photographs. Best results can be seen approximately 8-10 weeks after the final treatment.

Materials and methods Patients: 10 patients of Fitzpatrick skin types II-III, affected by mild photo- and chrono-ageing (aged between 36-60 years, with a mean age of 44) were used in our study. Nine females were treated on either their face, or face and neck, and one male was treated on the upper-face, avoiding the beard area. Patients were informed of, and discussed, treatment protocols and their consent for treatment was obtained. Equipment: Nd:YAG (1,064nm) and Er:YAG (2,940nm) laser lights (the SP Dynamis from Fotona) was used in the study protocol. The Nd:YAG was used in full-beam bulk heating and fractional modalities using a scanner, whilst the Er:YAG was used in ablative and non-ablative fractional mode scanner, with the hand piece used. Before

After

Before

After

Conclusion: This combined laser method allows for a very bespoke skin remodelling treatment, which gives results comparable with stronger ablative peels, with several days less recovery time. Patients were pleased with the results and said that they would be happy to continue with treatments to further enhance the skin and maintain results.

Introduction Common problems we face today are patientâ&#x20AC;&#x2122;s expectations versus their willingness to go through an extended period of recovery time. Reducing the strength of the treatment to achieve a more manageable recovery time often leads to a less than satisfactory end result for patients. Studies have shown that the most effective way to balance this is to combine different laser technologies, at lower levels, within one single treatment.1,2,3 Optimum results can be achieved as one technology enhances the results of the other. An excellent example of this is combining Nd:YAG bulk heating and Er:YAG cold fractional ablation in a multi-step procedure, optimised to improve skin tone, texture and colour. It is a gentle alternative for treating fine lines, wrinkles, mild scaring and open pores with minimal downtime and natural results. 38

Aesthetics | October 2014

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Treatment protocol Older ablative skin rejuvenation procedures would either treat large areas of the skin with full-beam ablation, or need a considerable amount of heat in fractional mode to achieve desired results – both of these methods result in a recovery time of 5-14 days. I have been using a two to four step method, which significantly reduces patient’s recovery time down to two to four days – without compromising results – making it a viable option for time-sensitive patients. We understand that heat is a key component in stimulating neo-collagen and extracellular matrix production when properly administered in different skin layers. Thus, using the full-beam bulk heating Nd:YAG laser for deep heating and the fractional Nd:YAG for selective heating, combined with the superficial peeling preformed with the Er:YAG, covers all skin layers and should give excellent results. A topical anaesthetic, that contains the two active ingredients lidocaine and prilocaine, was used on all patients 40 minutes prior to treatment and was covered with an occlusive dressing. Patients were first treated with two passes of short (1.0 ms-35 J/ cm2-scanner operated 6 mm) 1,064nm Nd:YAG laser and one pass of long (50 ms-50 J/cm2 scanner-operated 6 mm spot) 1,064nm Nd:YAG laser. This conditions the skin and bulk heats the area to stimulate deep collagen remodelling, enhancing overall healing and rejuvenation of the skin. Immediately following this is one pass of 2,940nm Er:YAG laser in fractional mode (short pulse – 8 J/cm2- 0.25 mm spot-5% ablated

Laser Pulse Power

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post-treatment redness, as the lasers are commonly used on their own for anti-redness, skin strengthening and vascular lesions. The first pass of the Er:YAG is done using a scanner that can be adjusted from a 1mm spot to 1cm2. It can ablate between 5-20% of the tissue and uses a Variable Square Pulse (VSP) to perform a very clean and precise treatment. VSP technology generates square laser pulses for more controlled energy absorption.4 Pulse durations can be adjusted from 50us up to 1,500us, depending on the strength of peel required. VSP pulse technology minimizes unnecessary laser energy absorption into body tissues and helps to ensure ultimate performance and patient comfort during laser Fotona VSP Technology treatments. For this treatment I set the scanner to 5% ablation, SSP (Super Short Pulse) a short pulse (600nsec), which MSP (Micro Short Pulse) SP (Short Pulse) produces minimal heat and a LP (Long Pulse) low energy, as I only require a VLP (Very Long Pulse) light peel. On its own this setting would be considered a very light, superficial treatment with minimal results.

Standard Laser Technology

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Image courtesy of David Leahy, UK representative for Fotona

area-scanner). The short pulse, mild Er:YAG treatment allows for cold ablation of the skin, meaning there is minimal down time and short recovery time for the patient. Finally a pass of non-ablative fractional 2,940nm Er:YAG (a long pulse-4.2jcm2-12mm-fractional hand piece) has a thermal effect on the surface of the skin – achieving excellent skin tightening. During the treatment the entire area being treated was covered by each laser modality in sequence. For all Nd:YAG treatments, a scanner is used with a 6mm spot-size and a 5% overlap. The area to be scanned can be changed from a 6mm spot to a 6cmx6cm square – this gives a very even and consistent treatment. The fractional Nd:YAG modality allows for a deep but controlled 3D thermal effect that seeks out imperfections within the skin. Targeting only the imperfections allows for a much safer treatment that is very well tolerated by the skin. The full-beam Nd:YAG modality has the deepest penetration and helps to build the required heat to trigger the skins ‘healing’ response. At this stage of the treatment you are looking to get a mild to moderate erythema. The combination of the two settings also helps to reduce

1200

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Efficacy results on the face and neck varied between patients, however in each case there were visible improvements. Patients’ skin was more even in tone and texture, pigmentation issues were improved, pores were more refined and fine lines and redness were reduced. When asked to self assess, each patient verbally communicated happiness with the overall result and felt that the recovery time was manageable. The patients reported that within the first 12-24 hours the skin was tender and erythema was moderate to strong. There was no redness and only mild flaking of the skin for a further 24-72 hours. For the female patients Oxygenetix (breathable, post procedural make-up) was applied daily during this time and so patients felt happy to be out in public, without feeling self-conscious. For both the females and the male patient a post procedure SPF was used. Debbie Thomas has been a skin care specialist for over 11 years. She designs and develops her specialist treatments using cutting-edge equipment fused with a variety of holistic massage techniques. In 2010 she opened the Debbie Thomas Collective and has become renowned for her successful use of lasers.

Aesthetics | October 2014

Clinical Practice Clinical Focus

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Post-procedure protocol We investigate the importance of good aftercare following an aesthetic procedure

As an aesthetic practitioner, you could be forgiven for thinking that your job begins when the patient walks into your clinic and ends when they walk out of the door, post procedure. However, as life and business coach Sloan Sheridan Williams explains, the aftercare that you provide can make the difference between a successful treatment that brings the patient back for more, and a mediocre experience that they may decide is not worth the expense of a return visit. “The expectations of the public are often driven by the media portraying the dramatic results that celebrities have achieved,” says Sheridan Williams. “These results often come from using a range of aftercare options. The reality of the situation is that aftercare provides an integral role in the success of any treatment, be that physical or psychological.” Of course, good aftercare doesn’t merely promote a better aesthetic result; many aesthetic procedures carry a risk of product migration, infection or swelling if patients do not follow correct instruction. In clinic or at home? Most treatments will require a degree of effort from the patient to ensure an effective result, and this will mean complying with certain rules and following an aftercare protocol in their homes. There are, however, some therapies that can be performed in clinic to enhance the effect of certain procedures. Naturopathic doctor Nigma Talib, who has holistic aesthetic practices in both London and New York, believes in the use of light therapy to provide a post-procedure dermal boost. “After most dermatological treatments I use LED, as it helps with inflammation, wound healing and regenerates and repairs the skin,” explains Talib. “Alongside this, I will use a gel with botanical ingredients.” ReCell Spray-On Skin, from Avita Medical, 40

which can be used as an aesthetic treatment in its own right, is now also being promoted for use post procedure to enable rapid wound healing. Developed as an “off the shelf” kit, ReCell is an autologous cell harvesting, processing and delivery technology, which transforms a thin, splitthickness biopsy from the patient’s own skin into a cell suspension that can be sprayed directly on to wounds to stimulate the growth of new skin. One advocate for the use of ReCell in her clinic post procedure is Dr Zahida Butt, owner and director of The Cosmetic Clinic in Kings Lynn and Peterborough. She says, “I use ReCell after fractional CO2 laser resurfacing, fractional micro-needling and fractional micro-needling RF procedures. This helps injure the tissues in a controlled fashion, so that the patient’s cells from the split skin graft can then be activated once injury is perceived.” ReCell itself requires fairly stringent aftercare, with a clear dressing placed over the treatment area, followed by sterile swab dressings. The sterile swab dressings are removed after three days, and the clear dressing removed in the clinic, seven days post procedure. Patients must not remove the dressing themselves and must keep the area clean and dry at all

ReCell Spray-On Skin, courtesy of Avita Medical

Aesthetics | October 2014

times. Whether as a practitioner you prefer to perform post-procedure therapies in clinic, or to send patients away with detailed advice for what to do at home, Sheridan Williams advises that to be successful you should try to ensure consistency across the board: “Specific protocols are very helpful to have in place as they ensure the delivery and continuity of a high standard of care across all patients, no matter who they are.” Specific treatments, however, will require specific aftercare plans. We asked leading voices in the field to share their advice on post procedure protocol following the four most popular aesthetic procedures: botulinum toxin, fillers and chemical peels. Botulinum toxin “In my experience, I believe botulinum toxin requires the most aftercare [of all the injectables],” says Dr Preema Vig, medical director of Dr Preema London Clinic and Beyond MediSpa in Harvey Nichols, Knightsbridge. She explains, “This is due to the fact that if the injected botulinum toxin were to migrate then this may cause another muscle to drop”. Toxin injections are the most popular of all the non-surgical aesthetic treatments, topping the mostperformed procedures lists year after year, but they also have the most extensive list of dos and don’ts if patients really want to get the best result. “With regards to Botox, this is a different kind of aftercare,” says Dr Vig. “You are not supposed to lie down for four hours afterwards; you should not do any exercise that day, because you do not want the muscles to be overactive as that will cause the toxin to wear off more quickly. You should not fly for at least 12 hours, and if you want to be really safe you should avoid facials for at least a fortnight and, for the first couple of days, wash and cleanse the face using an upward motion, to avoid migration of the product.”

Skin Care Management System MD This revolutionary, multi-award winning system utilises synergistic layered technology to comprehensively address all the skin’s needs for measurable improvement in the appearance of common skin conditions such as: • Acne • Fine Lines and Wrinkles • Hyperpigmentation • Rosacea The Skin Care Management System was designed for prolonged use with little to no irritation or acclimation. The System is easy and intuitive to use for the patient with immediate improvement observable from the first application. Over time skin will appear noticeably smoother and healthier. By following the daily regimen, results will be sustained and improved over time.

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Fillers Dr Kathryn Taylor-Barnes, who performs a wide range of filler injections at her practice in Surrey, has the following advice to offer: “Do not apply ice to fillers after injection. This is to prevent the surrounding tissue blood supply from being diminished due to cold blanching. We want the surrounding tissue and its blood supply to embrace the filler, to help it ‘bed down’. Do not massage the area, unless of course Sculptra has just been injected. Massage to HA fillers is not advisable as it may cause position shift and degradation of the new filler, and increase the risk of swelling.” However, opinions differ as to whether HA fillers should be massaged post injection – Dr Vig contends that, “Fillers are of a gel-like consistency and so I massage the area straight afterwards to sculpt the product into position. I advise patients not to massage at all except for when the lips are injected. Only in this case do I advise my patients to massage at home at home once or twice a day to prevent lumps of product forming in the lips.” Most experts seem to agree that arnica offers an effective solution if bruising is likely to occur, although Dr Vig recommends taking an oral dose – “two tablets a day, four times a day, ideally starting a good five days before treatment and continuing for a few days thereafter” – whilst Dr Taylor-Barnes prefers a topical application. “I recommend an overthe-counter arnica gel that has been kept in the fridge so that it is applied cooler for soothing,” she says. “I advise application two to three times daily if bruising post procedure is likely. This is continued until the bruise resolves.” Alternatively, Dr Sarah Tonks, who practices in West Kensington and in Harvey Nicholls Knightsbridge, has a slightly more unusual approach to the problem of bruising. She says, “I tell my patients to eat pineapple – I had an Iranian patient once who told me pineapple is used in Iran for post-operative bruising and it seems to work!” Dr Taylor-Barnes has recently introduced the new USOFT massage gel, from Sinclair Pharmaceuticals, into her practice. Specifically formulated for use after filler injections, USOFT

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contains arnica, aloe vera, ginseng, and tea tree to help soothe the skin. “Now that the new USOFT gel is available I anticipate I will use this routinely in my clinic, applied to injection sites immediately post treatment, with the option for patients to purchase the product to take home,” she says. Shinso Skincare, developed by Nao Tsuruta, is based on Japanese herbal remedies and claims to minimise the appearance of bruising and swelling post aesthetic procedure. Active ingredients in Shinso Essence include argireline (acetyl hexapeptide-8), which according to the manufacturer, acts as a topical botulinum toxin. SOD (superoxide dismutase) neutralises free radicals, whilst Fullerene and EGF (epidermal growth factor), both of which are Nobel prizewinning discoveries, aid detoxification and cell regeneration. Nao recommends that patients apply Shinso Essence morning and night, and spray Shinso Mist on to the treated area at regular intervals throughout the day, for a period of two to three weeks after a treatment. “I was curious about Shinso when it first came on my radar, as I was looking for the ultimate in aftercare for my patients who have had a non-ablative laser treatment,” says Harley Street dermatologist Dr Ariel Haus. “I tried it myself first and was impressed at how quickly it smoothed out wrinkles and softened the skin’s texture.” He explains that, unlike women in his home city of Rio de Janeiro, London women have less time to spend on their morning skincare regime. “My patients tell me that they love Shinso because it’s the only product they require. With one application they can be set for the day. I also like to use it as part of the aftercare for my patients who have had a non-ablative laser treatment, because of the anti-oxidant and anti-inflammatory properties of the ingredients.” Peels Dr Vig believes that, for peels in particular, aftercare should begin at the consultation stage. “You need to find out beforehand exactly what skincare regime they are using,” she affirms. “This is because if a peel is performed and they are already using high strength products – although their skin will be well prepped – you risk aggravating the skin too much. “After a peel, iS Clinical Sheald is perfect with its reparative formula. Whilst calming and soothing the skin, I advise my patients to reintroduce glycolics slowly into their regime as it may over-stimulate the skin.” Both Talib and Dr Tonks recommend the use of SkinCeuticals Epidermal Repair Cream post peel. Specifically formulated for use post aesthetic procedure, the manufacturers claim that the occlusive properties of beta glucan, contained within the epidermal repair cream, form a protective veil over the skin surface to support the reformation of the natural barrier function and prevent environmental aggression. According to SkinCeuticals claim that extracts of medicinal herb, centella asiatica, support epidermal and dermal tissue renewal, while encouraging the remodelling of collagen types I and III. Meanwhile, extracts of a flowering aquatic plant, nymphea alba, are said to provide effective anti-inflammatory action. One product that seems popular with most of the doctors we spoke to is Oxygenetix foundation, which promises to cover and protect sensitive post-procedure skin with an SPF of 25, whilst also allowing it to breathe and heal. Available in 14 shades, which can be mixed to match the patient’s skin tone, Oxygenetix contains a patent-pending technology called Ceravitae. Dr Terry Loong explains: “Ceravitae is a charged oxygen complex that delivers oxygen molecules to the cell in a drip feed throughout the day. Before I started using Oxygenetix, after a peel, skin would get more reactive. Since using this, I’ve not seen that. Skin is still hydrated, oil free and controlled, they [patients] have less downtime.”

From left to right; USOFT massage gel, Sinclair Pharmaceuticals and Shinso Essence, Shinso Skincare, iS Clinical Sheald, Oxygenetix Foundation and SkinCeuticals Epidermal Repair Cream

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Aesthetics | October 2014

A holistic approach Some practitioners believe that aftercare is not just about what you put on your skin, but that what

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you imbibe can also have a big impact on the effectiveness of an aesthetic procedure. “As a general rule, I prescribe vitamin A, C and E supplements to help heal the skin and boost the immune system,” says Talib. “I also advocate a diet rich in fish for all my clients, as omega 3 is such an amazing anti-inflammatory.” There is also a psychological element to ensuring your patient gets the best from their treatment. “It is extremely important to manage the expectations of your patient,” Sheridan Williams asserts. “Good aftercare aids in providing optimal conditions for the treatment to work, while also reinforcing that patience is often needed to see results.” Dr Taylor-Barnes agrees. “My patients are constantly psychologically assessed pre, during and post treatment and reassured regarding the positive but realistic overall outcome aesthetic treatments can achieve. If a patient is anxious at their swollen appearance immediately post-filler injection, I often have to gently remind them that the treatment involved a significant insult to the skin and this causes the usual inflammatory reaction in the short term.” The take-home message In conclusion, whilst some measures can be taken in clinic to improve the results of a treatment, the onus really lies on the patient to maximise the benefits of their aesthetic procedure by adhering to an aftercare regime at home. So how can practitioners ensure that they are motivated to do that? “When suggesting action points, it helps to stick to things that are easy to implement,” says Sheridan Williams. “The easier you make

Clinical Practice Clinical Focus

“I also advocate a diet rich in fish for all my clients, as omega 3 is such an amazing anti-inflammatory.” the positive actions for your patient the more likely they will follow through and better results will be seen by all.” If the use of certain skincare products is an essential part of your prescribed aftercare programme, it can be helpful to include the products in the price of the procedure, so that patients do not feel they are incurring any additional costs. It is also crucial to be available for patients to speak to post procedure, as Dr Tonks confirms: “I see everyone after two weeks. If they have had a reasonable amount of work done, I will usually give them a call myself to clarify and answer questions. Post-procedure care goes on forever if you want to maintain the results – I want them coming back for more.”

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Mr Chris Inglefield explains RF treatment for the treatment of the periorbital region

Open Your Eyes With increasing emphasis on maintaining a youthful appearance whilst upholding a busy social and work calendar, there is a growing demand for safe yet effective treatments that offer minimal discomfort or downtime. This is exemplified by trends in cosmetic treatments, which have shown a 12% decrease in surgical procedures since 2000, yet a 144% increase in minimallyinvasive procedures.1 The periorbital area is a particularly popular area for treatment, being the third highestranking area for cosmetic surgery.1 However it presents a number of difficulties and safety concerns. Eyelid surgery (blepharoplasty) has traditionally been used at a relatively early stage due to the limitations of non-surgical alternatives. This article will review how we at London Bridge Plastic Surgery (LBPS) have adapted the use of a novel radiofrequency technology, multi-source phase-controlled radiofrequency (RF), for safe and effective rejuvenation of the eye area. THE CHALLENGE The periorbital area is one of the first areas to show the signs of ageing; laxity, fine lines and wrinkles. Treatment options are limited, due to the delicate nature of the skin in this area and safety concerns related to proximity to the eyeball. Blepharoplasty, whilst still being the third most common cosmetic surgical procedure, is not an option for many patients due to cost, risks associated with the general anaesthesia, risks of scarring, and the post-operative recovery period.1 Non-surgical options such as botulinum toxin and dermal fillers can be effective in the right hands, but also have inherent risks.2,3 Dermal 44

fillers can lead to infection at the injection site as well as nodule formation or a bluish discolouration beneath the skin (the Tyndall phenomenon) due to superficial injection technique.2 Complications of injecting botulinum toxin include dry eye syndrome, which if unidentified can lead to eyelid swelling, epiphora (excessive tear production) and scleral show.3 Recently we have started using a novel combination of RF procedures using a multi-source RF system (in our case, EndyMed 3DEEP) to carry out a non-surgical eye-lift. With promising results and a high safety profile this procedure has since been termed the ‘EndyBleph’.

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for RF treatment include implanted metal devices, immunosuppression, active keloid scars and recent cosmetic non-surgical or surgical treatments.6 However, due to the high safety profile of the treatment it is suitable for most patient groups and all skin types.7 Multiple RF technologies and devices are available, with varying levels of efficacy and safety.6 Most RF devices use monopolar or bipolar energy. Monopolar RF uses one RF generator and one electrode to deliver the RF energy into the skin, often using a grounding pad. Bipolar RF also uses one RF generator and the energy flows between two electrodes. Results with these technologies can be variable, patients are often exposed to high levels of epidermal heating and discomfort so cooling must be implemented, and there are possible side effects including burns, purpura and hyperpigmentation.6 In my opinion, multi-source RF represents an innovation in RF skin tightening. MULTI-SOURCE RF: CLINICAL EVIDENCE BASE Multi-source phase-controlled RF is a novel, FDA-cleared RF technology that uses six RF generators and six electrodes. Sophisticated software controls how the energy flows between the electrodes, with multiple fields of energy interacting and forcing the energy deep into the skin without overheating its surface. The result is a deep, volumetric heating of the dermis and hypodermis, which delivers high level and predictable clinical results with excellent patient comfort and a high safety profile.7 Multi-source RF can also be implemented for fractional skin resurfacing, providing an epidermal and dermal skin rejuvenation effect. The multi-source RF micro-ablates up to 10% of the treated area with simultaneous volumetric heating of the dermis, resulting in good and predictable clinical outcomes.8,9 The downtime is shorter than traditional laser resurfacing procedures and the risk of side effects is minimal.8

RADIOFREQUENCY: HOW AND WHY RF has been found to be effective in the safe delivery of energy into the skin, independent of skin colour.4 Resistance encountered by the RF energy flow causes a build-up of heat, which induces an immediate contraction of the collagen (an ‘instant lift’) and stimulates a natural wound-healing response, production of new skin cells and collagen.5 When focused in the dermis and hypodermis, RF treatment can lead to improvements in the skin structure Figure 1 shows the different RF technologies. Image © EndyMed Medical Ltd and tightening of lax and sagging skin. In addition to providing skin tightening, RF can be implemented for skin resurfacing and microA Monopolar RF Energy is B Bipolar RF Energy flows C Multi-source phaseneedle dermal dispersed through the skin superficially between the controlled RF Energy is to the whole body; intense electrodes; cooling is needed focused in the dermis and remodelling. The cooling is required to to prevent overheating of the hypodermis, eliminating contraindications prevent epidermal damage epidermis in the contact areas the need for cooling Aesthetics | October 2014

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A 112 0.1mm microablation points are created beneath each electrode

B Volumetric heating beneath the tip heats the dermis to 2.9mm

Multi-source RF has been shown to be a safe and effective treatment for face and body skin tightening and fractional skin resurfacing (FSR).4,5,7,8,9, Harth and Lischinsky (2011), reported on the improvements seen in 30 patients undergoing treatment for facial wrinkles. Three months after completion of the treatment course 100% of patients saw an improvement, with good to excellent results seen in 87% of those patients.7 Clinical outcomes for body contouring are also high, with average circumference reductions of 2.9cm after a course of treatments that is sustained for 12 months.5 Elman et al (2012) and Dahan et al (2013) investigated the efficacy of multi-source RF for FSR. Dahan et al demonstrated an average reduction in 10 patients’ Fitzpatrick wrinkle and elastosis score from 7.3 to 4.1, three months after a course of treatments.8 In a study by Elman et al on the efficacy of combined FSR and skin tightening for acne scarring, 70% of patients had a 51-75% improvement in skin texture, roughness and acne scar appearance one month after the third treatment.9 There were no incidences of infection, hyperpigmentation or scarring in any of the clinical studies. NON-SURGICAL EYE LIFT Earlier this year, Dr Amy Patdu reported on her experience using multi-source RF for eye rejuvenation in Asian skin.4 19 patients completed a course of six treatments with the 3DEEP iFine; a specially designed handpiece for the periorbital area that delivers heat to a depth of 1.8mm. During each treatment the skin temperature was raised to approximately 40°C and sustained for three minutes. Figure 3 shows Dr Patdu’s evaluation of the patients’ improvement three months after the treatment course. Figure 3 Physician evaluation of overall improvement 100

% of patients

75 69% 50 26%

26%-50%

25%

0 >76%

51%-75%

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We have been using the EndyMedPRO at LBPS since 2008 and introduced the 3DEEP iFine in 2012, which has revolutionised our treatment of the eye area. The technology allows pain-free, safe and effective treatment of the delicate and hard-to-reach skin immediately around the eyes and will reduce under eye bags, smooth and tighten the skin and lift the upper eyelid to reveal a more open eye. There is an immediate visible improvement, which disappears after one to two days but is an indication of the longlasting result and is a great hook for first-time Figure 4 Before and two years after eight EndyMed 3DEEP iFine treatments. Images © Dr Isabelle Rousseaux, Loos, France

Clinical Practice Spotlight On

to five days. Potentially irritating skincare products containing Retinoids or Alpha Hydroxy Acids (AHAs) should be avoided until the micro-crusting has resolved and high-level broad-spectrum sun protection should be used daily. Top-up treatments are recommended every nine to 12 months to maintain the results. The ideal patient for this treatment has less severe damage, is younger, or would prefer to avoid surgery for the reasons mentioned previously. To date we have treated 25 patients with the EndyBleph and 80% of patients who I would have previously recommended for blepharoplasty now have EndyMed 3DEEP eye rejuvenation. Overall patient satisfaction for EndyMed is very high, with approximately 94% of patients very satisfied or extremely satisfied with the results they have achieved. CONCLUSION Multi-source phase-controlled RF is a safe and effective option for rejuvenation of the difficult-to-treat eye area. The risks to the patient are reduced, there is significantly less downtime and the cost is also lower. But this is not at a cost of results, demonstrated by the high patient satisfaction rates that have been achieved following 3DEEP skin rejuvenation.

Before

After two years

patients. More recently we have significantly enhanced our protocol and results for periorbital rejuvenation. The EndyMedPRO is a multi-application platform, so we are able to combine in a single treatment periorbital skin tightening and fractional skin resurfacing – now known as the EndyBleph. The skin tightening treatment is carried out according to the standard protocol described in Dr Patdu’s study, then after application of a topical anaesthetic the FSR is used over the area. This provides an additional tightening effect and epidermal ablation for a smoother, brighter result. A course of four treatments spaced four weeks apart is recommended for optimum results. There is minimal patient discomfort and downtime; the FSR causes a mild micro-crusting 0% which develops from one to No answer two days and resolves after four Aesthetics | October 2014

Mr Christopher Inglefield is the founder of London Bridge Plastic Surgery. With over 25 years’ experience, he has been at the forefront of the plastic surgery evolution. Mr Inglefield contributes and has been quoted extensively in medical journals on plastic surgery. He is regularly invited as a guest speaker to conferences worldwide and is a specialist advisor of NICE and leading cosmetic companies. REFERENCES: 1. 2013 Plastic Surgery Statistics Report. American Society of Plastic Surgeons. 2. Fillers: Contraindications, Side Effects and Precautions. Lafaille & Benedetto. J Cutan Aesthet Surg. 2010 Jan-Apr; 3(1): 16-19 3. Dry Eye Syndrome Due to Botulinum Toxin Type-A Injection: Guideline for Prevention. Ozgur, Murariu, Parsa & Don Parsa. Hawaii J Med Public Health. May 2012; 71(5): 120-123. 4. Non-invasive eye rejuvenation of Asian skin using a novel multi-source phase-controlled radiofrequency device. Patdu. PRIME. Jan 2014;19-27. 5. Multisource, Phase-controlled Radiofrequency for Treatment of Skin Laxity. Correlation Between Clinical and In-vivo Confocal Microscopy Results and Real-Time Thermal Changes. Royo de la Torre, Moreno-Moraga, Munoz & Cornejo Navarro. J Clin Aesthet Dermatol; 4(1):28-35. 2011. 6. Skin rejuvenation by radiofrequency therapy: methods, effects and risks. Paasch, Bodendorf, Grunewald & Simon. JDDG; 7:196-203. 2009. 7. A novel method for real-time skin impedance measurement during radiofrequency skin tightening treatments. Harth & Lischinsky. Wiley Periodicals, Inc. Journal of Cosmetic Dermatology; 10, 24–29. 2011. 8. Multisource radiofrequency for fractional skin resurfacing – significant reduction of wrinkles. Dahan, Rousseaux & Cartier. J Cosmet Laser Ther, 2013; Early Online: 1-7. 9. Effective Treatment of Atrophic and Icepick Acne Scars Using Deep Non-Ablative Radiofrequency and Multisource Fractional RF Skin Resurfacing. Elman, Frank, Cohen- Froman & Harth. JCDSA; 2;267-272. 2012.

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My biggest concerns when taking on a new piece of equipment are whether it will deliver good results and how quickly it will pay for itself. The EndyMed™ 3DEEP® has proved itself to be a superb investment with impressive results, a waiting list for treatments and now the questions is where would I put my second machine... DR SAM ROBSON Temple Medical Ltd

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FOR FURTHER DETAILS, SCIENTIFIC & CLINICAL INFORMATION PLEASE CONTACT AESTHETICARE ® 0800 0195 322

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*Intensif RF Microneedle handpiece only available with the EndyMedPRO platform.

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Clinical Practice Treatment Focus

Advanced PRP Consultant plastic surgeon, Mr Taimur Shoaib, explores how PRP, in combination with other treatments, can benefit certain aesthetic indications Summary Platelet Rich Plasma, or PRP as it is more commonly known, has been used increasingly in aesthetic medicine for the past few years. There are several ways of extracting platelets and many manufacturers produce kits to ease their harvesting for delivery into tissues. When activated, platelets release growth factors, which aid the repair and regeneration of tissues, supporting a range of aesthetic indications. PRP’s role in aesthetic treatments is continuously evolving, and while there is evidence to suggest that it will improve outcomes, there are, however, several controversies regarding its use in aesthetics. An introduction to PRP Platelets are formed in bone marrow as fragments of megakaryocytes. Platelets form one of the cellular components of blood within the plasma – the other cellular components include red blood cells and white blood cells. Plasma also has an acellular component, in which there are plasma proteins (albumin, globulins and fibrinogen), salts (electrolytes), water, glucose, clotting factors, hormones, and dissolved gasses. The theory is, by placing platelets in tissues that require repair and regeneration, the cascade of events that result from platelet activation and degranulation will lead to the repair and regeneration of these tissues. Aged tissues may also be rejuvenated as part of this process. Platelets need to be activated for them to release the growth factors contained within them, and this occurs when platelets are removed from their usual surroundings in an intact blood vessel. The endothelial lining of a blood vessel releases substances that inhibit platelet degranulation. Activation can be augmented by salts such as calcium chloride, or by thrombin. The release of growth factors leads to a cascade of events involved in acute inflammation, repair and regeneration. Growth factors within platelets include: PDGF (Platelet Derived Growth Factor), TGF-beta (Transforming Growth Factor Beta), FGF (Fibroblast Growth Factor), IGFs (Insulin-like Growth Factor types 1 and 2), VEGF (Vascular Endothelial Growth Factor), EGF (Epidermal Growth Factor), Interleukins, KGF (Keratinocyte Growth Factor), connective tissue growth factor, along with, possibly, many others. The background to PRP Many treatments that we use in aesthetic medicine have a background in reconstructive plastic surgery. PRP is no different. I first used it in a study setting in 2005, as part of a head and neck cancer reconstruction, following osteoradionecrosis. I subsequently used PRP in aesthetic surgery in 2007 for reducing complications, wound pain, and seroma rates following abdominoplasty. PRP also has a proven background in diabetic foot ulcers and systematic reviews are available on the efficacy and

favourable outcomes of PRP in this disease process.1 In these situations, PRP is topically applied to the wound and a dressing is applied; this process is repeated every few days until the wound heals. PRP is, primarily, an advanced wound therapy, known to be beneficial to both acute and chronic wounds. It emerged into aesthetic medical treatments a few years ago, but has recently become more popular as celebrities undergo treatment and publicise the outcomes. Wound healing has three main phases – inflammation, proliferation and maturation. The inflammatory phase takes place over the first two days, which is followed by the proliferative phase, taking place over the next few weeks, and the maturation phase, which occurs over the course of approximately 12 months. While an acute wound heals in the correct order and time expected – a chronic wound fails to heal in an orderly and timely manner. There can be a repeating cycle of inflammation and proliferation, often to the detriment of wound healing, thus it fails to achieve wound closure. PRP reduces pain and infection rates, leading to a more rapid wound closure in acute wounds.2 Although it is advised that wounds should not be closed under tension, in some plastic surgery procedures they are.

The theory is, by placing platelets in tissues that require repair and regeneration, the cascade of events that result from platelet activation and degranulation will lead to the repair and regeneration of these tissues.

Aesthetics | October 2014

Clinical Practice Treatment Focus

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It is these wounds that are more likely to undergo wound breakdown and loss of epithelialisation, which may benefit from PRP treatment. Obtaining PRP Many manufacturers now produce kits that easily permit PRP to be obtained. A blood sample (often approximately 10ml) is withdrawn from the patient and placed in a centrifuge. It is advised that the blood sample needs to be taken gently with a needle of at least 23G in size to avoid damaging platelets. The centrifuge separates the components of whole blood into layers. Often, the kit will contain a separating gel that acts as a barrier between the red cells and the remaining components of plasma. When red cells are injected into tissues, they create a bruise. Red cells contain haemoglobin and the process by which this is removed may lead to permanent tissue and skin staining, when PRP is injected near the skin. It is therefore exceedingly important to never inject red cells into the skin and subcutaneous region. The centrifuged product contains plasma, white blood cells and platelets. Platelets are concentrated in the buffy layer of the centrifugate near the separating gel. The usual concentration of platelets in the blood is 150-400 billion platelets per litre. Since red blood cells form approximately 45% of the volume of whole blood, the concentration of platelets in centrifuged blood will be approximately 110% higher. Although the bulk of the platelets are located at the buffy coat layer of the centrifugate, many clinicians will gently mix the whole plasma so that the platelet rich layer of plasma mixes with the platelet poor layer of plasma (PPP). It is worth noting that even if the PRP layer alone is used, the PPP component will contain plasma proteins and clotting factors at an increased concentration compared to whole blood, since the volume of the red cells is elimination from whole blood. PPP may also, therefore, support the repair and regeneration of the tissues. PRP in aesthetic medicine When we look for evidence of efficacy of PRP in aesthetic medicine, there are very few good quality and well-conducted clinical trials that support its use. Where there is evidence, the results and techniques are extrapolated to other clinical areas and indications, weakening the data. In current clinical PRP practice the evidence is anecdotal and from small case series of patients treated by individual clinicians. Despite this, the quality of clinical trials is improving and some indications have a reasonably good standard of evidence behind them. Combination treatments with PRP More recently there have been studies that are either complete or are currently underway, looking at the effect of PRP on different treatments that already exist in aesthetic medicine and surgery. Laser PRP Ablative CO2 laser treatments have been used in combination with PRP treatments. The ablative nature of the laser means that the epithelial surface is disrupted in order for the CO2 laser to cause thermal effects at the dermal level. Fractionating the CO2 delivery leads to areas of normal tissue in between damaged tissue, aiding a more rapid recovery. Needle Free Laser PRP As technology improves with time, new devices with ultrasound 48

A fractionated CO2 laser being used to create perforations for application of platelet rich plasma (PRP) into the skin.

technology are now available to deliver topically applied treatments through skin that has been treated with microablation. The Alma Pixel CO2 laser for example, is available with an “Impact” head, which is an ultrasound device, which uses sonophoresis to forcibly push the topically applied substance through to the dermis via the epidermal and dermal ablative pores that have been created by the laser. It is therefore possible to perform fractionated laser ablation of the skin, topically apply PRP and then use sonophoresis to deliver mesotherapy products such as PRP. This can be performed without the traditional multiple injection techniques that are required for delivery of PRP into the dermis. Quicker recovery from Laser treatment Evidence is beginning to show support for the use of PRP to improve wound healing following ablative laser treatments to the face.3,4 Since PRP already has a proven effect in more rapid and complication free wound healing in acute and chronic wounds, it is not surprising that Laser-PRP, as a combination, seems to have the potential to be more beneficial than either of the two modalities on their own. Dermaroller PRP The concept of dermaroller-PRP is very similar to Laser-PRP. The dermaroller is a microneedling device that performs microablative needling to the skin. Dermaroller’s longest needles will enter in to the dermis, creating micro-injury and subsequent acute wound healing. Their ultimate aim is to lay down collagen, eliciting a repair process, and thickening the skin. To deliver PRP via a dermaroller treatment, the current accepted method is to use the “sandwich” technique. In this case, the dermaroller treatment is performed, PRP is topically applied to the skin, and the dermaroller treatment is repeated. The theory5 is that PRP is forcibly delivered to the dermis via the needles within the dermaroller. There is also a theory that the platelets are damaged as a result of being needled, but the evidence to support either the use, or the damage, of platelets in dermaroller treatments is scarce. ReCell PRP ReCell treatment is also known as “spray on skin”. The treatment process involves a small area of skin being removed as a thick split thickness skin graft. The donor site is either left to heal by secondary intention, or the skin is excised to its full depth and the wound closed directly. The amount of skin taken is the approximate size of a postage stamp. Enzymes are used to separate the epidermis from

Aesthetics | October 2014

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the dermis, and the epidermis is subsequently cut into tiny areas of skin. The skin is placed in a suspension of saline and is sprayed on to a fresh wound bed of dermis, or partial loss epidermis. ReCell is indicated for the treatment of acne scars, stable vitiligo, burns scars, and acute burns where it accelerates wound healing. Currently, the use of ReCell is being studied when used in combination with lipofilling and PRP in the remodelling of burns scars, by Professor Jean-Paul Meningaud in Paris, who presented his initial work at the CCR conference in 2013.6 Autologous fat injection and PRP Fat injections are used for cosmetic and reconstructive purposes to restore volume to depleted areas. In aesthetic surgery, the volume loss in aged tissues is usually in the face, where one of the main hallmarks of ageing is atrophy of the facial fat pads. Currently, even when using some of the more accepted techniques – considered the best by many different clinicians (for example the Coleman method), approximately 33-66% of the fat injected will undergo necrosis. Fat necrosis may be complete without any palpable or radiological evidence, but clearly there are potential adverse sequelae from the fat necrosis process when injected fat fails to acquire vascularity sufficient for complete viability. Fat injections have a background in reconstructive surgery, and have been used for facial volume loss in conditions such as: HIV associated lipodystrophy, Parry-Romberg disease, following treatment for childhood facial tumours, connective tissue disorders such as scleroderma and systemic sclerosis, and for various

Clinical Practice Treatment Focus

craniofacial disorders. We know that PRP can help fat grafts survive in rats and in rabbits,7, 8 however the evidence in humans is scarce. Summary This has been a relatively short overview of the treatments that PRP can be used with in combination treatments. As with all of the best aesthetic treatments, it has a background in reconstructive medicine and surgery and I look forward to seeing more research and evidence to support its use in aesthetic treatments. Mr Taimur Shoaib is a specialist consultant plastic surgeon with over 20 years’ medical experience. He runs a cosmetic practice at his clinic in Glasgow, and is a faculty member of the Allergan Medical Institute. REFERENCES 1. DL Villela, VL Santos, ‘Evidence of the use of platelet-rich plasma for diabetic ulcer: a systematic review’, Growth Factors. 2 (2010), p.111-6. 2. Carter, Fylling, Parnell, ‘Use of platelet rich plasma gel on wound healing: a systematic review and meta-analysis’, e-Plasty,com. 3. MK Shin, JH Lee, SJ Lee, N Kim, ‘Platelet-rich plasma combined with fractional laser therapy for skin rejuvenation’, Dermatol Surg, 38 (2012), p.623–30. 4. Jung-Im Na, et al, ‘Rapid Healing and Reduced Erythema after Ablative Fractional Carbon Dioxide Laser Resurfacing Combined with the Application of Autologous Platelet-Rich Plasma’, Dermatol Surg, 37 (2011) p.463–468. 5. Nofal, Eman, Helmy et al ‘Platelet-Rich Plasma Versus CROSS Technique With 100% Trichloroacetic Acid Versus Combined Skin Needling and Platelet Rich Plasma in the Treatment of Atrophic Acne Scars: A Comparative Study’, Dermatologic Surgery, 40 (2014), p.864–873. 6. Avita Medical 7. Pires Fraga, Murillo Francisco, et al, ‘In rats: Nakamura, Shinichiro, et al. “Platelet-rich plasma (PRP) promotes survival of fat-grafts in rats”’, Annals of plastic surgery 65.1 (2010), p.101-106. 8. ‘Increased survival of free fat grafts with platelet-rich plasma in rabbits’, Journal of Plastic, Reconstructive & Aesthetic Surgery, 63.12 (2010) p.818-e822,

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Dermalux LED Phototherapy Dr Simon Ravichandran discusses the use of LED phototherapy for the treatment of photo-ageing LED phototherapy is a novel non-ablative and non-thermal treatment in the management of a wide variety of skin conditions. Unlike LASER therapy, that uses the principle of selective photothermolysis to induce a thermal injury, LEDs operate under the principle of photobiomodulation to influence cellular metabolic processes with a range of therapeutic indications. Medical LEDs are typically referred to by the colour of the light they emit and traditionally have been in the blue, yellow, red and near-infrared spectrum. The process of photobiomodulation is a result of photons being absorbed by molecules in the mitochondria or in the cell membrane of a target tissue called chromophores. The absorption results in a series of cellular signalling pathways that can up-regulate or down-regulate various cellular processes.1 Different wavelengths of light have been shown to have specific actions, and also penetrate tissues to different depths.2 As with LASER therefore, an appropriate wavelength needs to be chosen for a specific indication, and an understanding of the cellular processes involved will assist in selection. Photo-ageing The first skin changes that occur with age tend to present in the late twenties onwards, with wrinkling, pigmentation and fine telangectasia developing early, followed by

increased skin laxity, epidermal thickening and keratoses occurring in later decades. Several intrinsic and extrinsic factors play a role in this, but prolonged exposure to sunlight is felt to be a major contributing factor. Ultraviolet light of <400nm wavelength (UVA) is known to down-regulate the production of collagen and up-regulate the production of matrix metalloproteases which further breakdown collagen and elastin.3 Traditional treatment methods have involved resurfacing techniques, whereby the epidermis is removed and a controlled wound is created that heals with the production of healthier collagen and dermal matrix tissue. These treatments, whilst effective, typically involve a period of post-operative care or downtime and carry risks such as infection, scarring and hyper or hypopigmentation. LED therapies have the advantage of being non-invasive treatments for photo-ageing with little or no risk or downtime involved. Photo rejuvenation The effect of LED light on increasing the production of pro collagen, as well as fibroblast proliferation were noted in 1987 in studies by Abergel et al.4 Several other studies investigating LED therapy for photoageing have reviewed yellow light (595nm), red light (633nm) and near infra-red light (830nm). Lee et al. showed a greatest reduction in wrinkle severity and skin elasticity in a group treated with combination 830nm with 633nm. The histological and electronmicroscopic findings confirmed increases in collagen and elastin with an increase in pro-inflammatory cytokines.3 The evidence currently suggests that both 633nm light and 830nm light initiates a regenerative effect by activating macrophages and increasing pro-inflammatory cytokines which in turn promote growth factor release and fibroblast proliferation. This probably occurs by the activation of cytochrome c oxidase in the respiratory chain of mitochondria.5 The 633nm wavelength has the additional effect of being bactericidal and anti-inflammatory.6 Aesthetics | October 2014

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Spot prone skin LED phototherapy has also been shown to be an effective tool in the management of spot prone skin, with blue light having a bactericidal effect initiating free radical release from protoporphyrin and coproporphyrin, found in proprionibacterium acnes, the bacteria responsible for the pathogenesis of acne. When used in combination with red light a deeper penetration is achieved and the red light activates a further form of porphyin, protoporphyrin IX, as well has having a significant anti-inflammatory effect. 6 Dermalux LED phototherapy The Dermalux® Tri-Wave device uses a combination of three wavelengths, blue (415nm) red (633nm) and near-infrared (830nm) which can be used concurrently or in any combination with adjustable treatment times. The combination of three wavelengths allows treatment at multiple depths simultaneously, with multiple modes of action. As previous studies have shown, a combination of all three wavelengths is an effective tool in the management of acne, and the use of red and near-infrared is an effective and safe treatment for aesthetic rejuvenation of all skin. I have had excellent outcomes in over 1,500 treatments used as a standalone rejuvenation treatment or when in combination with chemical peels, radiofrequency or fractional ablative resurfacing. My preference is to use three wavelengths for 20 minutes immediately after any skin rejuvenating process, including anything from exfoliating peels to deep laser resurfacing, and then a further 5 sessions every 48 to 72 hrs. As a standalone skin rejuvenation process in healthy skin I try to combine treatments on a weekly basis with an evidence-based skincare regime. The Dermalux LED is such a useful addition to any skincare program I offer in my clinic, it is probably the best investment in technology I have ever made. Dr Simon Ravichandran is the clinical director of Clinetix Rejuvenation and the president of the Association of Scottish Aesthetic Practitioners. REFERENCES 1. Goldberg DJ, Amin S, Russell BA, et al. J Drugs Der- matol 2006 ; 5 : 748 – 53 . 2. Barolet, D. Semin Cutan Med Surg 2008 ; 27 : 227 – 38 . 3. Lee SY, Park KH, Choi JW, et al. J Photochem Photobiol 2007; 88 : 51 – 67. 4. Abergel RP, Lyons RF, Castel JC, Dwyer RM, Uitto J. J Dermatol Surg Oncol. 1987 Feb;13(2):127-33. 5. Wong-Riley MT, Liang HL, Eells JT, et al. J Biol Chem. 2005;280:4761-4771. 6. Goldberg DJ. J Cosmet Laser Ther 2006 ; 8:71 – 5.

Clinical Practice Abstracts

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A summary of the latest clinical studies Title: Fractional CO2-laser are as effective as Q-switched-rubylaser for the initial treatment of a traumatic tattoo. Authors: AT Seitz, S Grunewald et al Published: Journal of Cosmetic Laser Therapy, August 2014 Keywords: ablative fractional laser therapy, q-switched-ruby laser, traumatic tattoo Abstract: Q-switched laser treatments are considered the standard method for removing tattoos. Recently, the removal of tattoo ink using ablative fractional lasers has been reported. Ablative fractional CO2-laser and q-switched-ruby laser treatments were used in a split-face mode to compare the safety and efficacy of the two types of laser. A male patient suffering from a traumatic tattoo due to explosive deposits over his entire face was subjected to therapy. The right side of the face was treated using an ablative fractional CO2-laser, whereas the left side was treated using a q-switched-ruby laser. After eleven treatments, the patient demonstrated a significant lightening on both sides of his traumatic tattoo, with no clinical difference. After six treatments, the patient displayed greater lightening on the right side of his face, whereas after another five treatments, the left side of the patientâ&#x20AC;&#x2122;s face appeared lighter. No side effects were reported. In the initial stages, the ablative fractional laser treatment appeared to be as effective as the standard ruby laser therapy. However, from the 6th treatment onward, the ruby laser therapy was more effective. Although ablative fractional CO2 lasers have the potential to remove traumatic tattoos, they remain a second-line treatment option. Title: Diagnosis and management of dermal filler complications in the perioral region. Authors: FR Grippaudo, M Di Girolamo et al Published: Journal of Cosmetic Laser Therapy, August 2014 Keywords: complications, fillers, surgery Abstract: Lip augmentation with injectable materials is a popular procedure. When complications occur, patients often ignore which material was implanted, thus making subsequent treatments difficult. This study aims to present the diagnosis and management of dermal filler complications in the perioral region. The Medical charts of 26 patients with filler complications in the oral region were reviewed. All patients were submitted to High Frequency Ultrasound, often complemented by Magnetic Resonance Imaging (MRI) and White Blood Cell Scintigraphy, to evaluate filler characteristics and complication types. Antibiotic, corticosteroid or surgical treatment was therefore planned. Imaging always identified dermal fillers in the oral region, distinguishing among infections, fibrosis, granulomatous inflammation and product migration. Nine patients received surgery, ten received medical treatments, six received both, and one refused treatment. 80% of the patients presented an improvement after three-year followup. Complications of oral region fillers are similar in clinical presentation but differ in etiology, therefore necessitating different clinical approaches. Imaging techniques add useful information for treatment planning. 52

Title: Topical liposomal Rose Bengal for photodynamic white hair removal: randomized, controlled, double-blind study. Authors: N Samy, M Fadel Published: Journal of Drugs in Dermatology, April 2014 Keywords: lasers, white hair, PDT Abstract: Blond and white hair removal by laser is a complicated task with weak satisfactory results due to the deficiency in laserabsorbing chromophore. The studyâ&#x20AC;&#x2122;s objective was to investigate if repetitive sessions of photodynamic therapy (PDT) using external application of liposomal Rose bengal (RB) photosensitizer followed by intense pulsed light (IPL) exposure enables removal of gray and white hair. Rose bengal loaded in liposomes (LRB) was constructed, prepared in hydrogel, and was studied for some pharmaceutical properties. Topical gel containing LRB was used on fifteen females complaining of facial hair for three sessions at intervals of 4-6 weeks using intense pulsed light (IPL). The treatment area was pre-treated with topical LRB gel, while a control group of another 15 patients applied placebo gel before IPL treatment. Average hair regrowth in the LRB group was 56% after 3 treatment cycles. After six-months follow up, average terminal hair count compared with baseline pretreatment showed 40% reduction and no recorded side effects. A significant difference (P<0.05) was seen compared with the control group. Photodynamic hair removal using rose bengal-encapsulated liposomal gel in combination with IPL treatment showed significant efficacy in the treatment of white hair compared with a control group. Title: Skin texture aging trend analysis using dermoscopy images Authors: YH Choi, D Kim et al Published: Skin Research and Technology, May 2014 Keywords: dermoscopy image analysis, skin feature extraction, skin texture Abstract: Skin damage such as aging and persistent sunlight exposure, has been evaluated based on the experience and knowledge of dermatologists because there is no standard method for objective evaluation. If a standard method were available, patients could obtain more consistent information about their skin condition, and perform more effective treatment of the skin damage. We demonstrate how to establish a standard method using dermoscopy images of subjects of various ages. We focus on the face, neck, and hands, and extract various skin texture features to quantitatively and objectively represent the skin condition. We construct a model for skin damage evaluation based on various skin texture features. To accomplish this, we consider various features from face, neck, and hand dermoscopy images. We demonstrate aging trends by performing linear regression on these features. Based on this result, a quantitative and objective evaluation of the skin condition can be provided. We proposed several new skin texture features and developed algorithms to accurately extract them, demonstrating their age-related change trends by using graphs and charts. We believe that our result can be used as a standard method for evaluating degrees of skin damage and our proposed method can be applied in various areas, such as performance evaluation of certain skin products.

Aesthetics | October 2014

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Aesthetics Awards Special Focus

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Last chance to vote for your winner With voting and judging well underway to decide the winners for The Aesthetics Awards 2014, don’t miss the opportunity to cast your vote for finalists in the following categories: • Cosmeceutical Range/Product of the Year • Injectable Product of the Year • Treatment of the Year • Equipment Supplier of the Year • Distributor of the Year • Best Customer Service by a Manufacturer or Supplier • The Janeé Parsons Award for Sales Representative of the Year, supported by Healthxchange Pharmacy • The NeoCosmedix Award for Association/ Industry Body of the Year Voting and judging will close on 31st October 2014, with the winners announced at The Aesthetics Awards ceremony on Saturday 6th December. The four star Park Plaza Westminster Bridge Hotel will provide the stunning venue for the 2015 Awards, where winners will be honoured, along with highly commended and commended finalists. Tickets to this special event can be booked on the Aesthetics Awards website today!

HOW WILL THE WINNERS BE DECIDED? Select categories will be decided by reader votes, while others will be decided by the judging panel. For each of the categories that are to be decided by judges scores alone, a group of six judges has been assigned based on their expertise, and in order to avoid conflicts of interest. Judges will score the following categories: • The Pinnell Award for Product Innovation • Training Initiative of the Year • The 3D-lipomed Award for Best New Clinic, UK and Ireland • The Syneron Candela Award for Best Clinic Scotland • The Rosmetics Award for Best Clinic North England • The Dermalux Award for Best Clinic South England • The Oxygenetix Award for Best Clinic London • The Sinclair IS Pharma Award for Best Clinic Wales • Best Clinic Ireland • The Institute Hyalual Award for Aesthetic Nurse Practitioner of the Year • Aesthetic Medical Practitioner of the Year • The Church Pharmacy Award for Clinic Reception Team of the Year The winner for The Aesthetic Source Award for Lifetime Achievement will be selected by the Aesthetics judges and there will be no finalists in this category.

VOTING Voting is open on The Aesthetics Awards website www.aestheticsawards.com until 31st October 2014. As a reader of Aesthetics journal you will be able to vote in The Aesthetics Awards. Login to the Awards website using your Aesthetics login, or by creating a new account, to cast your vote. Voting is IP address monitored and each individual can only vote once. Multiple votes under the same name or from the same email address may also be discounted from the final total. Multiple voting from within finalist’s organisations will be monitored.

Aesthetics | October 2014

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Book Now! Saturday 6th December, Park Plaza Westminster Bridge, London Individual ticket: £200 plus VAT Table of 10: £1,900 plus VAT To book your tickets visit www.aestheticsawards.com, call 0203 096 1228 or email bookings@aestheticsawards.com

Don’t miss out on the chance to attend one of the most prestigious events in medical aesthetics. Not only will the evening feature the awards ceremony, during which winners will be invited to the stage to collect their award in front of colleagues, peers and friends, but also fantastic entertainment, music and food. Tickets are selling fast so book your place today to avoid disappointment!

Aesthetics | October 2014

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Media savvy medicine Healthcare PR Tingy Simoes offers advice on how to get coverage in the mainstream press After working in healthcare PR for the past 15 years, I have been able to identify some of the key elements that will make a story successful in the press. My company has a reputation for securing frontpage news. This is not due to a magical formula or, as some might believe, because we have close contacts with the media (although, obviously, we do!). In reality, it doesn’t matter how friendly a journalist is; if the story you’re offering them isn’t any good, they won’t run it. There is a reason why they’re called ‘newspapers’ – they cover news. The story you offer must be new and original, anything that has been reported before will be disregarded almost immediately. The majority of news outlets have specific health sections with medical reporters and editors, which demonstrates that healthcare content is a popular news topic. These journalists are employed to be on the lookout for the next big thing in healthcare news; whether that be a new stoma bag, a trend in shoulder liposuction, or a survey on the nation’s favourite breast shapes. By far, the addition of a case study is the most important element to

By far, the addition of a case study is the most important element to convince the media that what you say is worthy of publishing. Why, you ask? Because it’s the patient’s story. 56

convince the media that what you say is worthy of publishing. Why, you ask? Because it’s the patient’s story. Otherwise it’s just you, the clinician, making a claim – and that claim can be harder to prove. I’m not saying it won’t work, but do feel free to ring the Mail on Sunday or the Times and tell them there is a rise in problems with young people having Botox, or that women are looking for surgery to create dimples on their buttocks. First thing they’ll ask? Show us a case study. Prove it. Often there is huge confusion surrounding what constitutes a ‘case study’ in the eyes of the mainstream press. And by mainstream I mean national newspapers, women’s magazines and morning chat shows. Not peer-reviewed journals. The distinction is important; medical journals will only want the medical facts. They won’t care about the patient’s lifestyle change or emotional journey. They don’t need to know how many kids they have, where they live or what kind of job they hold. Mainstream media does want to know these relatable facts. I remember once a dentist client – when I asked for photos of the patient – sending me X-rays. As if the Evening Standard would know what to do with those – they want the patient grinning on a beach or biting into a crisp apple to show how their teeth have improved. A case study is not a ‘testimonial’. Testimonials are snippets of thank you notes that patients send to their clinic, saying how happy they are with their treatment. They are just quotes which the clinic can use in marketing materials such as leaflets or on their website. Although it is important to canvass these – your next big story could develop from a particularly in-depth thank you note. However, ‘Gratefully, Mrs P in Bury’ is not going to transpire into a national newspaper article. Case study patients are happy to have their story shared in the media, including a face photo. Reassuringly however, those who have had their breasts augmented or their buttocks lifted do not need to show medical before-and-afters. These are usually too jarring for people reading the paper over Sunday brunch. Fully clothed photos, in high resolution, showing a dramatic change are all that is needed.

How to spot a good case study Clinicians will be able to use their judgment as to whether to ask a patient if they’d be willing to participate in publicity. In fact, often it is the front of house staff, such as secretaries or receptionists, who are able to spot an interesting story as they chat informally with the patient before a procedure, or offer them a cup of tea in the waiting area. It is essential that all clinic staff are briefed and on alert for good stories that could appear in the media. Gently probing questions can be worked into conversation – they could ask the patient why they are having treatment, or why now? There could be a variety of Aesthetics | October 2014

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interesting stories lurking about – how the patient is funding the procedure, for example, they could have had a lottery win or a divorce pay-out. Maybe they decided to have the procedure because a friend or family member inspired them, or perhaps the catalyst was a special event in their life. What makes a good case study? Counterintuitively, it’s not always down to the procedure itself. The patient may well be having a run-of-the-mill treatment such as a chemical peel, fillers or Vaser treatment. But the reasons why they’re having it could be successful in national media. They could be having treatment for an upcoming wedding, or maybe they’re recently separated and dipping their toes in the dating pool again. Perhaps their age alone is interesting – we had a huge story, which ran in several national newspapers, regarding an 82-year-old man having his teeth whitened. His view was, just because he was older why shouldn’t he still try to look good? The journalists adored it. Perhaps the treatment helped with an emotional or even physical barrier. We recently placed some fantastic stories in the national press regarding relatively straightforward eye surgery. One involved an active lady in her 70s who loved to ride a motorcycle and kayak (we placed her in the local paper, nationals and over-50s magazines) and a snooker player who – since the op – has been undefeated! Crucially, aesthetic treatments must show a difference in photos and this is where non-surgical

Photography Clear before and after photos in high resolution (usually the ‘best’ setting on a digital camera) are a requirement so they can be reproduced at good quality in a publication. Journalists are looking for case studies that show as dramatic a difference as possible. Photos must also be ‘like-for-like’: I’ve had clinics in the past show the effects with different poses – for example, in the ‘before’ photograph of a fat freezing or liposuction treatment the patient will be leaning forwards, whilst in the ‘after’ shot they will be standing upright. This makes the photographs look staged for effect, and the journalist may think that the treatment does not work. Wherever possible, your patient’s before and after photographs should be in the same location, the same position and with the same lighting. Some magazines prefer to do their own photo shoots. These are normally scheduled around the patient’s diary and, usually, a photographer will visit the case study at their home or at a mutually suitable location. If they are required to attend a studio, magazines will pay the patient’s travel expenses. A good way to obtain high quality photography and motivate patients to take part in publicity is to offer a professional photo shoot, with the patient getting a set of prints in return for allowing the shots to be used publicly.

In Practice Publicity

procedures can be tricky – results tend to be subtle and if the person looks wildly unlike the ‘before’ it probably shouldn’t be considered successful; hence the emotional ‘backstory’. However, if the actual procedure is new – it’s an advanced tattoo removal or skin resurfacing treatment – then the emotional backstory is less important. For mainstream media, the patient MUST show their face. They have to be identifiable – however there are a few points that might help you convince them to take part. Most outlets won’t necessarily care if the name is changed as long as there is a face photo. The advantage of this is that the articles won’t come up if the patient’s name is typed into an internet search engine. However this won’t help people they know recognising them. If it’s radio, again, journalists won’t mind changing names. Obviously the last thing you want to do is be facetious or flippant about someone’s ‘journey’ – and good journalists and PRs will know how to handle the situation well. It is important however that the patient is in a good state of mind and able to answer gently probing questions – this process might not be appropriate for someone who is feeling too emotional after a significant life change or bereavement. The case studies are used to highlight the skills of the clinician or the excellent results of a particular treatment. Your PR can offer some basic media training over the phone, or in a mock interview, if participants are unsure about the process. With regard to payment for a case study some magazines will pay for their stories, but will require the patient to sign an exclusivity agreement, which will ensure that the story does not appear elsewhere. The payments can be anything from £100 to £500, depending on the strength of the patient’s story or ‘journey’. Clinics often offer the patients a discount or ‘freebie’ by way of thanks. It is obviously incredibly important to gain informed consent from the patient before submitting them for publicity, and consent is the responsibility of the clinic or practitioner. Patients sometimes initially agree to take part but then have second thoughts, and ethical PRs and clinicians would never put anyone under pressure to participate if they were not wholly comfortable. It is a great idea to have a standard form explaining the whys and wherefores of the process, which the patient can read through and sign in advance. It is imperative that there is no ambiguity surrounding their involvement. Generally, patients are excited to see their story in print, and the articles serve as a great memento of their experiences. Tingy Simoes is managing director of Wavelength Marketing Communications and author of the first-ever PR manual for plastic surgeons and professionals in cosmetic medicine “How to Cut it in the Media”.

Aesthetics | October 2014

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In Practice Marketing

Should you start paying for Google AdWords? Dan Travis measures the benefits of advertising via search engine results for medical aesthetic clinics Paying Google to display your advert is an interesting option for clinics. The notion behind Google AdWords is that when someone types a relevant keyword into the Google search engine your advert appears and – hopefully – potential patients will click on it, visit your website and make a booking. Google AdWords is the name for this kind of paid-for-advertising system, and ‘AdWords’ is the terms given to these searched keywords. The resulting advert, which appears by this method, is called a Google Ad. This all seems simple enough, but the benefits of this method in terms of profit may not be so clear cut, and clinic owners that I work with find the concept of Google AdWords confusing. This confusion revolves around two key issues: “Is paying for Google Ads going to work for my business?” And “If I don’t use Google Ads, maybe my competition will gain an advantage.”

What is most important to understand before considering such an investment is how people interact with Google searches The use of Google AdWords certainly works for some businesses and clinics and can be very effective in selling products nationally and internationally. They can also be useful when selling digital products such as online courses or business information. But will they work for your clinic? Google Ads are search results that are displayed at the top or to the side of a Google search results page. Businesses pay Google to display the advert when a search term such as ‘Hotel London’ is typed into the search bar. The Ads appear in a box-out on the search results page and, if you have typed in the search term ‘London Hotels’, they usually look something like this: ½ Price London Hotels – Lowest Price Guarantee www.hotelchain1.com/London-Hotels 4.6 advertiser rating Book your hotel in London online Hotel Chain 2 London Sale www.hotelchain2.co.uk/Summer-Sale Book your Summer Holiday at Hotel Chain 2 from only £99 in the Summer Sale!

Google Advertising first became widely available in the UK in 2006. For the first time it offered anyone the possibility of being able to see how many people were clicking on their paid-for advert; this provided instant, useful information to the seller. Up until this point, this kind of information was only available via direct-response marketing agencies that would record the results from print-based advertising – which could take weeks to come through. Google recognized this gap in the market and through the provision of Google AdWords, was able to supply results instantly. This Google advertising system allowed marketers, such as myself, to tweak adverts and test them against each other, to judge the best results. We were able to study the information that the data gave us and discover which words encouraged people to click on the advert, actively displaying interest. This novel approach to advertising was a massive advance in direct marketing and is still of great value to the marketers and businesses that use it. I use Google AdWords to test the potential market share for products and services. Print advertising can be very effective but with Google AdWords clinics can change, remove or update an Ad instantly, allowing for a fluid and more effective method of marketing services to the desired audience.

How potential patients use search engines From the outset it is important to note that your resulting advert will appear in front of potential patients who are searching for your clinic’s services for the first time. These people are the target of your Google AdWords investment, and should be your sole reason for paying Google for this service. However, what is most important to understand before considering such an investment is how people interact with Google searches. The way information is digested is important. If a potential patient is searching for a treatment, clinic or doctor using the Google search engine from a laptop or PC, the results pages will feature the Google Ads relevant to the particular search either on the top of the page or on the right hand side. Below the Ads the potential patient will then be presented with the ‘organic’ or ‘natural’ listings (i.e the non-paid for results, generally those sites with the best traffic results and the best SEO). Below the natural listings, the viewer is shown the local search results, which will have a red pin next to them. Google Ads, natural listings, and local results comprise the ‘anatomy’ of a Google search results page. The table below shows the percentage of clicks that each part produces: Google Ads – between 5% and 10% Organic Search – 55% to 65% Local search – 35% to 40%1

Aesthetics | October 2014

In Practice Marketing

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Using Google AdWords to gain exposure for your business is an on-going process. It’s interesting to note that the figures for Google Ads clicks are relatively small. However, this does not mean they are ineffective. The numbers of click rates for Google Ads are significant when considering the amount of searches carried out. For example, if the majority of your client base comes from a 30-mile radius then you have a local business. Due to the flexible nature of a Google AdWords account (account holders have access to numerous payment methods and numerous ways of tailoring their advertising reach), clinics are able to specify the ‘local’ option within their Google AdWords accounts. This means a clinic can choose to have their adverts shown only to those within a radius of 30 miles of the clinic’s physical location. This targeted method of marketing means that, on average, the number of the targeted audience reached may be higher, and yet the actual number of clicks may be low as the advert is restricted to a specific population.

Using Google Adwords with mobile devices When considering the impact of Google Ads, an important factor to take into account is that, judging by my own research on websites and data from Google Analytics, approximately 65% of online searches for clinics are conducted on a mobile device. Search results on a mobile phone are displayed differently to those on a PC or laptop, and the results will often compress the Google Ads, giving priority to the local Google search results. Crucially, the local results displayed are those where the clinics have registered their businesses with Google Plus. On a mobile phone screen, ‘natural’ listings are displayed first, there is no paid advertising displayed and the local listings take centre stage. This is a display that you will be familiar with and this is what your customers will see when they are searching for you. I would predict that most people would probably phone the company that has the most reviews included in their local listing. Using Google AdWords seems to have little or no impact on a mobile phone, and when it comes to local businesses, local listings here have priority over Google Ads. Take advantage of this, and whether or not you decide to take out a Google AdWords account, you should register with Google Plus Local, which at the moment is free.

Careful monitoring is crucial In order to maximise the impact of your investment you will need to monitor your account and response rate closely, and make every penny you spend count. You need to know how Google AdWords work, or train someone in your company to become competent at running your Google AdWords programme. This article is a broad introduction to this method of marketing, and detailed guidance on how best to utilise a Google AdWords account and its options for tailoring can be found on the Google AdWords website (www.google.co.uk/intl/en/adwords) or via numerous online video tutorials. You may have been approached by a Google AdWords ‘agency’ 60

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that, for a fee, has offered to place you at the top of the search results. Outsourcing your advertising to these agencies can encourage you to simply leave these agencies to it, which could be costly and ineffective. There are far less of these agencies operating than there were five years ago and I often hear that they do not produce results for clinics. The use of Google AdWords can easily become expensive, especially when you are competing for generic keywords like ‘London Skin Treatments’. You only have to look at the search results for ‘London Hotel’ to see that it is the chains and top brands that occupy the top positions.

Google does not operate a meritocracy with AdWords. Instead, the more you pay the higher you reach. I have known businesses pay thousands of pounds per month for the privilege of their Ad being top of a Google search. Fortunately, I have not met any clinic owners who indulge in such wasteful activity. Using Google AdWords to gain exposure for your business is an on-going process, and an initial (large) sum of money will not provide the solution. It is important to recognise the use of Google AdWords as links in a chain, and if these links are not carefully monitored and constantly reviewed (the words in your Ad, your targeted audience, the quality of you website) then money can be wasted. The aim is to carefully use your budget to keep cost per link and conversion rate low. Trying out Google AdWords, even if this method doesn’t ultimately prove to be of enough benefit for your clinic, can be a highly valuable (and not too costly) experiment, in terms of conversions. Google AdWords can give you an insight into what people are searching for online, and this knowledge can be very valuable when you are assessing the local market for your services. Using Google AdWords also offers the opportunity to learn how to handle an advertising budget, as well as providing you with the perfect model to understand how Return On Investment (ROI) really works. Attention to detail and monitoring the process closely is key to its success. Dan Travis is director of The Marketing Clinic and provides business services to clinic owners. Dan specialises in providing business education programmes for the aesthetics industry. He writes and speaks on how clinics can overcome the challenges they face and thrive in the new economy. REFERENCES 1. Goodwin, Danny, Organic vs. Paid Search Results: Organic Wins 94% of Time, (Search Engine Watch, 2012) <http://searchenginewatch.com/article/2200730/Organic-vs.-Paid-Search-Results- Organic-Wins-94-of-Time>

Aesthetics | October 2014

In Practice Presentation

@aestheticsgroup

Aesthetics Journal

Aesthetics

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How to engage, captivate and inspire your audience Pam Underdown advises practitioners on the best methods of delivering a presentation and communicating with an audience. We have all sat through our fair share of mindnumbing presentations. The presentations where the speaker is, quite literally, reading each slide, line by line, in a monotone voice. The presentations where the content is so dull that we drift off – daydreaming at best, nodding off at worst. Engaging today’s audiences can be tough. Our attention span usually lasts for approximately 15 to 20 minutes before our minds begin to wander and we become distracted by our phones, or by wondering what’s for dinner that evening. But what if you are the presenter? Perhaps you are the first speaker on after lunch, or the air conditioning has broken down and the room is hot and humid, or maybe your subject is rather dry? Ultimately, there is nothing more intimidating for a speaker than an audience who looks like they would rather be somewhere else. When you imagine yourself making your big presentation – how do you see your audience? Are they smiling at you and nodding with agreement? Or do they appear distracted? Perhaps you prefer not think about them at all, instead focusing on how quickly you can get the presentation over and done with? Whether you are holding a team meeting, hosting a webinar, delivering feedback, speaking at a conference or exhibition, leading a training session or being interviewed by the media; effective communication is simply not possible without the interest and attention of your audience. Without engagement, it is doubtful that your audience will remember, or make use of your knowledge. In today’s fast paced society, with so many of us short on time, the ability to deliver presentations where real learning takes place is more important than ever before. I’ve been speaking to audiences, large and small, for over twenty years and I am one of those strange people who really enjoys doing so. If you have been avoiding it, remember there are many benefits to public speaking; it’s a great way to gain exposure, increase self-confidence and build upon your success. The chances are, you were asked to speak because you are the expert – and 62

that alone should give you some confidence. Increased confidence comes from practice, and improving each time you speak in public. Here are a few strategies I have learnt from some great teachers along the way. I hope they help you to engage, captivate and inspire your audiences. Audience interaction means you will give more, meaning your audience will learn more – remember it’s a ‘win-win’. Start with two open questions that generate a response and therefore engagement – get your audience to raise their hands by raising yours at the same time. Tell them why you are asking for participation and feedback: incidentally this is to confirm you are teaching your audience well and they understand your message. If you don’t get feedback (we are Brits after all) you can assume that you aren’t teaching well, and you should change your approach. Ask for questions at the end of each section and not in the middle of your flow – this throws everyone off track. Remember a typical audience member actively wants to learn from you and they want you to do well – otherwise it’s just not a good use of their time. Build in a hook from the start, just like Hollywood movies. Find a way to capture your audience’s attention with a teaser, you could ask a question you don’t answer immediately or mention a topic that will be included later. By initially concealing a few facts, you will build suspense and anticipation, ensuring your audience is captivated enough to stay for the answers. They will also feel incomplete until you answer the teasers. Structure your content so that it is easy to follow. Then explain to your audience how they will benefit from your content. Why should they listen to you and why now? Each point should flow naturally based on what the next question is likely to be. Our brains learn in chunks so if you are presenting for a whole day, arrange your content into 90 minute segments and have a break in between each one. This stops you running out of things to stay and will stop you running out of time, or worse – running over time. Use your own personal experiences to explain a point. Share what process you followed to get the desired results – what your ‘ah-ha!’ moments were and what the chain of events was that led up to this point. Position your message so it speaks directly to your audience, solving their problems as you go. Facts tell but stories ‘sell’. Stories are a wonderful way to engage people, especially if you can ask questions that help your audience to resonate with your tale. They will relate to your message through their own personal experiences and start seeing themselves in your presentation. Great speakers can help to change the beliefs of their audience. Using belief-based statements work so well because you Aesthetics | October 2014

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In Practice Presentation

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believe in each point, which means you will naturally deliver it with more energy, commitment and passion. Before you deliver a beliefbased statement, you must tell your audience that you are going to share something important with them. This makes sure they are present outside of their own thoughts and ready to learn. Begin by saying, “I’m going to share with you today something that I promise you, if you really listen and absorb it, will change the way you view [insert subject matter] forever.” Poor speakers simply deliver content that is interesting but doesn’t actually make a difference to their audience. Great speakers, however, have learnt to become fantastic story-tellers. When you master the art of story-telling you can talk about your career, your business, your experiences and your life in a way that influences and inspires your audience to change. Since the beginning of time stories have been used to pass on wisdom; historically, tribes passed on their experience through great storytelling – not through PowerPoint presentations. Interrupt your audience’s thought patterns by asking questions. I am a member of the Public Speakers Academy, where we have been told that your audience will remember less than 30% of your sentences, but more than 85% of the questions you ask. Your questions will help get your audience re-focused, stop them from being distracted and, at the same time, deepen their understanding and conviction. The best questions are ones that get your audience thinking, shock them or get their agreement. You could ask questions such as, “How many of you would agree with me on that?” Don’t rely on your slides or visual aids alone to engage your audience. Use something unexpected to draw attention; a quick activity in their seats or a two to three minute video to illustrate a point works wonders. We all learn through repetition. Whether we are learning new habits, beliefs, values and skills, all are commonly learnt through repetition. Look for creative ways to repeat and revisit the same point – simply saying the same thing over and over again can be frustrating for audience members. Change your tone of voice and vary your speed and volume. When you change how you say something, it has a big impact on your message. Start your presentation in a conversational tone then as you move into your main content use contrasting tones to highlight certain points. Make sure your eye contact is with individuals. Do not sweep the room using ‘aerosol eyes’; connect with one person per sentence and then move on to the next. The more people you look at directly and talk to personally, the more people will feel naturally connected and drawn to you. You will never work out what your audience is thinking, so don’t try to. Don’t allow your performance to be affected by the mood or energy of your audience. Be mindful of the distractive, moody and miserable 64

Aesthetics Journal

Aesthetics

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audience members but focus on the people you can resonate with. This will enable you to deliver your presentation in a more positive manner. Decide what you are going to say and then ask yourself if you really need a slide to say it. Don’t ‘click and read’ as most speakers do. Always be one step ahead of your slides, don’t use them as prompts; instead start by saying a few things about your next point, before you reveal it. Doing it this way means that curiosity and anticipation levels are high and there is motivation and interest in your next slide. Your movement must be purposeful. The bigger the audience the bigger your gestures must be. Stop to make a key statement, and deliver your most important lines by standing still in the centre of the stage and looking directly at an audience member. Do not pace up and down the stage, it can make you look nervous and make your audience feel dizzy. Humour is an effective audience engagement technique, but only when it is used naturally and appropriately. Humour will make your audience more relaxed and responsive. However, it is important not to confuse humour with comedy. There is nothing more uncomfortable than a long, awkward, unnatural joke. Some of the funniest people simply comment on how they see what’s going on around them and it’s their unique perspective that is humorous; although do make sure that the only person you make fun of is yourself. Never say something on stage that you wouldn’t say in a one-to-one conversation. Be the same person, be congruent and don’t put on a ‘stage voice’. By using a conversational tone you will be able to maximise your energy and not wear yourself out. Your audience will also see you as a more approachable and reliable person. After you finish speaking, ask your audience for feedback. This is the best way for you to improve as a speaker. Find out what the audience have learnt from your presentation. Did it meet your goals? What did they like about your talk? What could you improve on? Remember to take the time to recognise your success. It may not have been perfect, but chances are you’re far more critical of yourself than your audience is. Everyone makes mistakes during speeches or presentations. Look at any mistakes you made as an opportunity to improve your skills. Taking on any challenge is empowering and public speaking represents another opportunity to grow and achieve success. Every time you speak, you improve. It’s a boost to your confidence, so make sure you approach your next presentation with an attitude of curiosity and fun. Good luck and happy speaking! Pam Underdown is the owner of Aesthetic Business Transformation. She is a a business growth specialist working exclusively to help medical aesthetic business owners increase their profits and reduce their costs. Pam has been practising public speaking for over 20 years and has over 25 years of business development, sales and marketing experience.

Aesthetics | October 2014

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In Practice In Profile

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Aesthetics Journal

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“Innovation is what drives me to continue to enhance my results.” Wendy Lewis speaks to New York Plastic Surgeon Sam Rizk; a modern, high-tech surgeon who loves a challenge and never changes a face or nose the same way twice. Dr Sam Rizk may be based in New York City, but he has a very global outlook in regards to his work. He began his career in Egypt where his father and mentor, Dr Samy Rizk Senior, encouraged him to become a doctor. Dr Rizk Senior qualified as an anaesthetist in the UK, and was recruited to join Mt. Sinai Hospital in New York City, which brought his family to America. Dr Rizk Junior is a fellowship trained facial plastic and reconstructive surgeon. His training included an accelerated honours programme at the University of Michigan Medical School in Ann Arbor where he received his medical degree. Dr Rizk then did a general surgery internship at Lenox Hill Hospital in New York City, a residency in otolaryngology/ head and neck surgery/facial plastic surgery at New York Hospital and Manhattan Eye, Ear and Throat Hospital, and completed an American Academy of Facial Plastic and Reconstructive Surgery – certified fellowship in Facial Plastic Surgery in California. Upon his eventual return to New York, Dr Rizk opened his private practice. Safety is his number one priority. His private surgical suite maintains certification from the Joint Commission – the highest level of accreditation available. Dr Rizk merges two critical skills to achieve his safe surgical outcomes: a keen artistic eye and attention to detail (which he credits to his mother who is an artist) converged with his uber technical surgical skills. Art incorporates more than just his surgery; his spacious Park Avenue office walls are covered with original art and photography. “I’m an avid art collector,” he says. “I especially like the work of Horst B. Horst, Ormond Gigli, and Warhol.” With a waiting list of up to six weeks, Dr Rizk says he is 100% honest with his patients and explains that he may dissuade some of them from going under the knife. He says, “The benefits of surgery should far outweigh the risk, downtime and expense. I want my patients to be happy.” Dr Rizk has written and lectured extensively on current concepts related to rhinoplasty, revision rhinoplasty and aesthetic facial surgery, and is often invited to speak about his innovative techniques. “I really enjoy the camaraderie of international conferences and exchanging ideas with other surgeons. It’s so rewarding,” says Dr Rizk. His advances in the field include using tissue sealants to avoid nasal packing and facelift drains, the use of high definition 3D telescopes for enhanced precision and visibility, as well as rapid recovery techniques based on hidden, smaller incisions. “My patients need to get back to their lives very fast. We do everything we can to make that happen,” Dr Rizk explains. This attitude has helped him grow a practice that is 25% male, from CEOs to producers and musicians, who appreciate his straightforward, no-nonsense approach. Patients come from all over the world for his trademarked natural-looking results. Drsamrizk.com 66

Q&A What do you consider the most challenging facial plastic surgery procedure?

I offer three operations – face and necklifts, eyelids, and rhinoplasty. Nose reshaping is by far the most complex procedure because it bridges aesthetics and function into a single procedure. Not only does the nose have to look good and suit the other features in harmony, they have to enable the patient to breathe well. About 40% of my practice is dedicated to revision rhinoplasty. Is there such a thing as an ideal nose?

Every procedure must create a nose that is in harmony with the person’s face. When I perform a rhinoplasty, I never use a standard stamped procedure. Everyone is different in terms of their anatomy and proportions, as well as their sense of what looks good. This may be a smaller nose if you are starting out with a disproportionately large one, or it may mean a more subtle result. It can be harder to achieve a subtle result that requires finessing, than to reduce a hump deformity or reset a drooping tip. How do you plan your rhinoplasty procedures?

Bone structure, skin type, age and ethnic background all factor into my surgical planning. African, Middle Eastern/Mediterranean, and Asian patients tend to have thicker skin that requires specialised techniques to resculpt the nasal tip instead of the cartilageexcising techniques used on thin-skinned patients. The nasal tip may be bulbous or lack support, which makes a good aesthetic outcome more challenging. How does your 3D High-Definition Technology lead to a quicker recovery?

With this technology, a 3D telescope is connected to an imaging system so I can see muscles, blood vessels and other structures during surgery. I use tissue glue to provide a faster and more comfortable recovery. Because of increased visibility, the surgery is more precise as tissue is not distorted by swelling during the procedure. My facelift patients can look presentable within a week or so. What other advances in aesthetics excite you?

Regenerative medicine is the future. Platelet-rich plasma (PRP) is a powerful addition to our anti-ageing tool kit. Increasing platelets and growth factors in the blood has regenerative effects on the skin and can slow or reverse the signs of ageing. Platelets and growth factors stimulate stem cells, and PRP contains three to five times as many of these substances as normal blood. I use PRP in areas where soft tissue fillers, toxins and lasers aren’t always effective, such as around the eyes and mouth to improve skin texture. I also combine PRP with fat grafting, which I do extensively in my facelifts. Fat gives surgeons the ability to truly sculpt the face in a way that nothing else can.

Aesthetics | October 2014

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In Practice The Last Word

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Aesthetics Journal

The Last Word Dr Marie Louise von Sperling discusses lessons on cosmetic regulatory requirements in Denmark In 2014, one in four Danes is considering undertaking a cosmetic procedure.1 The number is increasing, along with the demand for, and the availability of, a wider variety of cosmetic procedures performed by doctors. As a consequence, more focus has been placed on side effects, complications, or simply failure to achieve expected results – with requirements coming from patients, doctors and health authorities. Across borders plastic surgery has developed rapidly during the twentieth century. New types of injuries resulting from fire damages and disfigured victims of the first and second world wars, led to an increased need for surgery that could reconstruct appearance. The surgical methods became increasingly advanced, and these techniques were transferred to corrections in healthy patients for beautification purposes. This was the beginning of cosmetic surgery, which started in Hollywood in the early 1920s. It really took hold in the 1960s when Texan Timmie Jean Lindsey became the first woman in the world to receive breast implants.2,3 How popular are cosmetic procedures in Denmark? In Denmark – with its 5.6 million inhabitants – the number of both surgical and nonsurgical procedures is increasing by 30% a year. In 2013, 4,000 purely cosmetic surgical procedures were performed in private clinics.4 The number of injections with botulinum toxin and non-permanent fillers was 110,000. To perform plastic surgery, there are approximately 80 specialists in Denmark,5,6 placed mainly in eight public hospitals and fewer in private clinics. It takes six years of surgical training to specialise in plastic surgery. Complaints At the start of the twenty-first century, cases of malpractice became more visible to the public with an increasing number of enquiries made to the Danish National Board of Health on cosmetic procedures.7 These originated both from patients seeking to complain about their treatment, who were then referred to the Patient’s Board of Complaint, and from doctors reporting serious complications. Furthermore, stories about malpractice, 68

serious complications and unsatisfactory results accumulated in the media. We heard about the 23 year-old woman who received a liposuction of 6.5 litres on her abdomen and developed large skin necrosis. Another patient received a liposuction of 16 litres and also developed skin necrosis. A long list of men consulted a specific plastic surgeon for penis enlargements, and came out with chronic nerve issues. In my own experience, I have seen a patient who required removal of her implants after she asked for an augmentation of 400cc on each side, but received four implants, two 200cc on each side.8,9,10,11,12 New beginning As a reaction to these reports the Ministry of the Interior and Health in 2004 asked the National Board of Health to set up a working group to look at cosmetic procedures performed by doctors in Denmark. In 2007 this led to a new set of rules and regulations on cosmetic practice. The National Board of Health stated in 2007, that only surgeons with relevant specialist training are permitted to perform cosmetic surgery in Denmark.13 Other than plastic surgeons, only surgeons with relevant training are allowed to perform specific cosmetic procedures, such as ENT surgeons, gynecologists and urologists, in the respective organs. The doctor and all assistants who perform any non-surgical cosmetic procedure have to be registered to a central register. The doctor pays a fee of 15,000 DKR (£1,600) once a year to be on the register. The National Board of Health routinely oversees all cosmetic clinics on the register every third year, in surgical as well as non-surgical clinics. Only specialists in plastic surgery, dermatology and neurology, as well as some with special permission, are allowed to prescribe toxins. Registered assistants may inject toxins after the doctor´s indication, and are allowed to inject fillers, do superficial peels and conduct laser procedures after special laser-certification. For all interventions, both surgical and non-surgical, it is mandatory to keep a before-picture in the medical record. Physicians who are registered, must publish their latest control review report made by the health officer on the clinic´s website and have it readily available in the office. Aesthetics | October 2014

Aesthetics

aestheticsjournal.com

Consultation To avoid quick and poorly thought-through decisions in connection with cosmetic surgery, the patient is to have a week’s time for consideration from the time the oral information is received until written consent is given. All preliminary examinations before operations, and information provided before a cosmetic procedure, must be done by the surgeon and cannot be delegated to an assistant. To receive an injection with filler of toxin, the patient is to have a consideration time of 48 hours before the first treatment. Written consent is also mandatory for these types of cosmetic improvements. Higher quality in the future In Denmark regulations on cosmetic practice are strong regarding “who, where and when” procedures are allowed to be performed. The “Danish model” may be useful for other countries to replicate as part of a standardisation process. But did outcomes in cosmetic practice in Denmark improve since 2007? Unfortunately we do not yet have a register with mandatory reporting on complications, outcomes and patient satisfaction. This means that we do not have precise figures on the extent of these parameters. For developing yet higher standards for our patients, the next step would be for cosmetic health professionals to share and report experience and outcomes in a central register. This would hopefully create an honest picture of reality for our patients, colleagues and the public. Dr Marie Louise von Sperling is a resident in plastic and reconstructive surgery and owns AESTHETICA, a non-surgical clinic in Copenhagen. She is a member of the European Plastic Research Council. REFERENCES 1. http://www.privatehospitaler.dk/tal-analyser/kosmetisk- behandling 2. “The First Silicone Breast Implant Patient: A 47-Year Follow-Up”. Momoh, O. et al, PRS, 2010, Vol 125(6) 226-299 3. http://www.bbc.com/news/magazine-17511491 4. http://www.privatehospitaler.dk/tal-analyser/kosmetisk- behandling 5. http://www.regioner.dk/~/media/modernisering%20af%20 plastikkirurgi.ashx 6. https://sundhedsstyrelsen.dk/~/media/ E69E5A4A37A049FF8691C132987B5C41.ashx 7. http://sundhedsstyrelsen.dk/publ/publ2005/kot/cosmetic_ surgery/cosmetic_surgery.pdf 8. www.sol.dk/debat/234-indenrigspolitik/676500/676500?limitst art=0&limit=450 9. http://www.dagensmedicin.dk/nyheder/en-karriere-fuld-af- klagesager-/ 10. www.sst.dk 11. ”Patienter har livsvarige helbredsskader efter operationer hos den kontroversielle plastik kirurg Jørn Ege”, Ebdrup M., Dagens Medicin 2002, Oct 3. 12. http://www.patientombuddet.dk 13. http://sundhedsstyrelsen.dk/publ/Publ2010/TILSYN/Kosmetik/ UKversionStatuaryOrderCosmeticTreatment.pdf

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