Aesthetics September 2014

t ke s tic tic ay ur the od yo es 4 T ok e A 01 Bo Th s 2 to ard Aw

VOLUME 1/ISSUE 10 - SEPTEMBER 2014

IRESOLVEI

EFFECTIVE PIGMENTATION RESOLUTION THAT’S KIND ON SKIN Advanced evidence-based dermatological medical devices, pharmaceuticals & medigrade cosmetics

Radiofrequency CPD article Lee Brine explores the science behind RF in medical aesthetic procedures

Treating Hair Loss

Aesthetics Awards

Collagen supplements

Leading figures share their methods for hair loss treatment in patients

The finalists for the prestigious Aesthetics Awards 2014 are announced

Practitioners discuss the benefits and limitations of orally ingested collagen

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

www.syneron-candela.co.uk | info@syneron-candela.co.uk | Tel. 0845 5210698

Š2014. 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

Contents • September 2014 INSIDER 06 News The latest product and industry news 17 News Special A look at social media in aesthetics 18 Conference Report Dr Raj Acquilla reports on his recent work at international congresses

CLINICAL PRACTICE Radiofrequency Page 26

CLINICAL PRACTICE 21 Special Feature: Treating Hair Loss We ask leading aesthetic practitioners to share their methods for treating patients with hair loss 26 CPD Clinical Article Lee Brine explores the science behind radiofrequency in medical aesthetic procedures 30 Clinical Focus Dr John Quinn looks at the avoidance and management of potential dermal filler complications 35 Techniques Dr Sotirios Foutsizoglou discusses hair restoration surgery for younger patients 39 Clinical Focus Fleur-Louise Newsom explores changes in the skin associated with the menopause 42 Treatment Focus Rebecca Treston provides an overview of laser hair removal 44 Spotlight On Practitioners discuss the benefits and limitations of orally ingested collagen 46 Abstracts A round-up and summary of useful clinical papers 49 Aesthetics Awards Special Focus The finalists for The Aesthetics Awards 2014 are announced

IN PRACTICE 54 Marketing Jill Woods highlights the importance of considering local demographic and competition in your marketing strategy 58 Law Expert witness Liz Bardolph looks into the possibilities for damage limitation with unhappy patients 62 Business Process Gilly Dickons on the benefits of collecting statistics to boost your business 66 In Profile Dr Rita Rakus shares her experiences as a cosmetic practitioner in the UK 68 The Last Word Mr Dalvi Humzah argues for clarity and unity within the medical aesthetics profession

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IN PRACTICE Local Marketing Page 54

Clinical contributors Lee Brine is a qualified engineer from the aero industry, with a career in medical technologies. He works predominantly with lasers and radiofrequency energy sources, covering a range of surgical specialities.

Dr John Quinn is an Irish qualified general practitioner with over 9 years experience in cosmetic medicine. He is a full member of the British College of Aesthetic Medicine.

Dr Sotirios Foutsizoglou is the founder of SFMedica. He specialises in cosmetic surgery and aesthetic medicine, and is a member of the International Society of Hair Restoration Surgery.

Fleur-Louise Newsom is a skincare specialist at Forme Laboratories. With 20 years experience in skincare and healthy living, Fleur works closely with the product development team at Stratum C. Rebecca Treston is a laser specialist and a member of the American Academy of Anti-Ageing. Rebecca’s Dubai clinic, Rebecca Treston @Euromed, offers the latest cutting-edge anti-ageing treatments.

NEXT MONTH

• IN FOCUS: Lasers • Special focus: Tattoo removal • CPD: Laser complications • Engaging your audience

Voting is open for the most prestigious celebration in medical aesthetics Visit m www.aestheticsawards.co today to vote in 14 The Aesthetics Awards 20

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 August and September represent the start of the academic year for many. I am sure with our wide range of readers at Aesthetics we will have ages across the board, with parents of fouryear-olds starting school for the first time, new Amanda Cameron secondary schools, right up to those getting Editor A-level results and going to university or into an apprenticeship or business. We live in a society of continuous measurement and each measurement leads us to another step in life. But how often do we subject our own businesses and practice to the same scrutiny? Do we set objectives when we start our businesses? And do we review and evaluate these as we progress, such as at end of year assessments and points of promotion, growth and expansion? I believe it is crucial to undertake detailed assessment of where we stand annually, if not more frequently. I am sure all your accountants ask for your accounts on a regular basis but take this opportunity to review every aspect of your business.

Aside from complex financial analysis, we should also remember to go back to basics – think about who your customers are, what they need and whether you are fulfilling those needs successfully and effectively. In this issue, Gilly Dickons discusses the statistics that you should be recording and how this can aid your business in

analysing where you are performing well and where improvements can and should be made. Our local marketing feature addresses how important considering your demographic and local competition is in determining your marketing strategy. Is this something that you are currently assessing and evaluating? Education is king throughout our lives so let’s not slow down the momentum in continuing to strive for better results for our businesses, and for our patients.

Hair is the focus of this month’s journal, and in our special feature we ask leading practitioners to discuss effective methods for treating hair loss. Conversely, laser hair removal specialist Rebecca Treston gives an overview of the technology and considerations for implementing this as a treatment in your clinic. An excellent indication of our progress and success is commendation through awards and honours. I’m sure you will all have been eagerly anticipating the announcement of the finalists for The Aesthetics Awards 2014, which are revealed in this issue. The standard of entries this year was even higher than in previous years and I’d like to congratulate all finalists for such a fantastic achievement. Now the voting and judging process will begin to determine the winners and highly commended and commended finalists ready for the ceremony on December 6th in London.

Happy reading and best of luck to all the finalists!

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

Dr Raj Acquilla is a cosmetic dermatologist with over 11 years

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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Insider News

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Talk Aesthetics

Pam Underdown / @AestheticGrowth Price is never the most important thing according to statistics and research. 14% of buying public only ever buy the cheapest Sharonbennettskin / @sharonbennettuk Learn about bio identical hormone treatment @BACNurses confs oct 3/4 Brighton.

Dr Jenna Burton / @DrbJenna Natural Vitamin E in avocados, green leafy veg and vegetable oil will provide much more nutrient than synthetic vitamin E in a tablet Dr Raj Acquilla / @RajAcquilla Excellent day @RATPMasterclass then dinner with @aestheticsgroup for our exciting live symposium plans #ACE2015 @drtapanp @pdsurgery Dr Roshini Raj / @DrRoshiniRaj Argula is highly #alkaline, helping your body to regain its pH balance & preventing inflammation, one of the causes of #acne breakouts.

Emma Davies / @daviesemma5 @aestheticsgroup really impressed with quality of articles old dogs CAN learn new tricks!

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

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Industry

Allergan file lawsuit against Valeant

What you’ve been tweeting about this month Dr David Eccleston /@DavidEccleston ‘Eartox’. Nothing to do with Botox, but involves putting filler in the earlobes to plump them and reduce sagging, so earrings hang better.

Aesthetics Journal

Global pharmaceutical company, Allergan, has filed a lawsuit against Valeant Pharmaceuticals and Pershing Square Capital accusing them of insider trading. They claim that Valeant, Pershing Square and its CEO, William Ackman, violated federal security laws, engaged in fraudulent practices and failed to disclose legally required information. Allergan said that they decided to file the lawsuit to, “Ensure that all of its stockholders have the opportunity to make decisions regarding their investment in the company based on compliant, full and fair disclosures, and to ensure that any stockholders voting on corporate matters acquired their shares in accordance with the law.”

Between February and April this year, Pershing Square purchased Allergan stock and securities, then valued at more than $3.2 billion, from company stockholders. Allergan claim that they did so fully aware of Valeant’s nonpublic takeover intentions – depriving the selling stockholders of value appreciation, worth approximately $1.2 billion, upon Valeant’s initial offer on April 22. Under federal law, it is illegal to buy shares if you have knowledge of such a takeover. Allergan said they believe that, “It is important that the rights of the company’s stockholders not be infringed by the actions of one hedge fund that significantly profited (to the detriment of other stockholders and the market) by trading in Allergan securities, while in possession of material non-public information regarding Allergan.” In a joint statement, Valeant and Pershing Square said, “Allergan’s true purpose in bringing the litigation is an attempt to interfere with shareholders’ efforts to call a special meeting.” They said this intention was made clear in a separate letter, which noted that bylaws provide that any meeting requests are considered ineffective if the requester has violated the law. Pershing Square, Allergan’s largest shareholder, had previously called a board meeting with Allergan, in which it was expected that William Ackman would replace six out of nine Allergan directors. Mr Ackman claimed that Allergan is threatened by Valeant’s takeover progress and said, “Allergan’s determination to waste money on a baseless lawsuit against its largest shareholder further demonstrates why this board of directors should be removed.” CEO of Valeant, J. Michael Pearson said, “We are disappointed that Allergan continues to stand in the way of its shareholders’ right to voice their views on a transaction with Valeant. Despite Allergan’s attempted roadblocks, we remain committed to pursuing this compelling combination, which will create an unrivalled platform for growth and value creation.” In its complaint, Allergan is seeking a declaration from the court that Pershing Square and Valeant violated insider trading and disclosure laws. The company also want Pershing Square to revoke the Allergan shares that they claim Mr Ackman acquired illegally.

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News in Brief

Conference

Brand new conference experience unveiled for ACE 2015 The Aesthetics Conference and Exhibition steering committee have revealed exciting details about the innovative educational conference experience planned for ACE 2015. This cutting-edge conference experience will be tailored for delegates looking to further their practice in medical aesthetics in 2015 and beyond.

With a novel format and style representing a first of its kind for our profession, the main agenda will comprise four highly interactive educational modules.

Delegates will be able to choose to attend individual three-hour learning experiences or the full two-day programme. Each session will take the form of a virtual clinic environment, following the patient journey from consultation, through live treatment techniques, to post-treatment results and follow-up.

Comprising both surgical and non-surgical methodology, the content will be non-promotional and chaired by leading experts, supported by a panel of eminent practitioners in each individual field. The prime Saturday afternoon and Sunday morning sessions will take the form of a two-part injectables masterclass led by Mr Dalvi Humzah, Dr Raj Acquilla and Dr Tapan Patel.These two sessions will cover all the essential elements of an injectables masterclass, supported by multiple live video feeds and interactive audience technology and are guaranteed to provide delegates with the very best learning experience. Saturday will feature the full remit of pan-facial beautification, with injection techniques for specific anatomical areas covered in detail on Sunday. Surrounding this important injectables masterclass will be sessions covering other key growth areas for the broader, successful practice of medical aesthetics. The Saturday morning session will feature experts covering

fat, including weight loss and fat augmentation and reduction, as well as body skin, including treatments for lifting and tightening, cellulite and stretch marks. In the final session on Sunday afternoon, delegates will be able to learn more about skin health through presentations related to both pathology and physiology. A distinguished panel will explore the identification and treatment of dermatological conditions, the latest skin treatments and explanation of cosmeceutical ingredients. In place of traditional lecturn presentations, ACE 2015 has been designed around a programme that utilises exciting new technology to allow videos and apps to engage and educate delegates through enhanced demonstration methods and full interaction. Alongside the main conference agenda, the Aesthetics Conference and Exhibition will feature the return of the popular Expert Clinic, now running in two parallel sessions, as well as the Business Track and sponsored Masterclasses.

ACE 2015 will be held on Saturday 7 March and Sunday 8 March at the Business Design Centre in London. Visit www.aestheticsconference.com to find out more details about the conference and exhibition.

Aesthetics | September 2014

Mesoestetic launches mct injector Mesoestetic Pharma Group has launched the mct injector, a device uniting mesotherapy and carboxytherapy to allow practitioners to complete treatment with one device. The mct injector allows for mesotherapy and carboxytherapy to be performed in the same session or alternate sessions, with precise directional lighting to aid treatment. The injector is CE marked and compatible with all needles and syringes.

Anti-ageing warming cleanser and cooling masque launched by Innovative Skincare Innovative Skincare has launched two new anti-ageing skincare products: Warming Honey Cleanser and Coolmint Revitalizing Masque.

Combining natural honey with papaya enzymes and green tea extracts, the Warming Honey Cleanser aims to cleanse the skin and protect its natural ceramide barrier. Innovative Skincare recommends using the Coolmint Revitalizing Masque after cleansing to soothe skin.

LoveLite launches Lipoglaze Callista cryolipolysis device Lovelite announced the launch of the new Lipoglaze Callista, an extension of its existing cryolipolysis portfolio. The Callista gives practitioners the ability to treat two areas simultaneously, and has the option of six attachments, with sizes to treat four different areas.

Athena Cosmetics promotes breast cancer awareness Athena Cosmetics will give 10% of its profits from the sale of each limited edition Revitalash Advanced Eyelash Conditioner to cancer research during the month of October. The company continues its annual Pink Ribbon Promotion to reaffirm its commitment to compassionate business practices, giving a portion of proceeds from year-round sales of all products to breast cancer research.

SkinBrands partner with ABC Lasers Partner to distribute CoolTech SkinBrands @ Cosmeceuticals have partnered with ABC Lasers to distribute cryotherapy treatment, CoolTech. CoolTech is a method of reducing unwanted subcutaneous fat using a controlled cooling system. Tracy Parkin, SkinBrands managing director, said, “We have partnered with ABC, who are specialists in laser and RF equipment sales, to provide customers with the highest level of customer service and support.�

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Acne

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Conference

PicoSure Focus cleared

by FDA for acne scar treatment Aesthetic manufacturer Cynosure announced that it has received FDA clearance to market PicoSure Focus for the treatment of acne scars.

The treatment uses laser technology that claims to revitalise and rid the skin of imperfections in just 30 minutes. Where other lasers use a photo-thermal action (heat), Picosure Focus’ ultra-short pulse aims to create an intense photomechanical impact, known as PressureWave.

Cynosure claims that this creates shockwaves in the dermis, generating collagen and elastin and resulting in dramatic improvements, without the associated downtime.

As well as being recommended for acne scarring and revitalisation, PicoSure Focus can be used for toning, texture, wrinkles and fine lines. In 2012 it was granted FDA approval for the removal of tattoos and pigmented lesions.

Décolletage

Ultherapy receives FDA clearance for décolletage treatment

BACN to hold conference in October The British Association of Cosmetic Nurses (BACN) annual conference will be held at the Hilton Brighton Metropole, Brighton on October 3 and October 4. The event, called “All Things Bright ‘n’ Beautiful”, will host a variety of speakers discussing the latest aesthetic topics and techniques. On Friday, speakers include botulinum toxin expert, Professor Andy Pickett and chair of the BACN, Sharon Bennett. Saturday will see Dr Raj Acquilla give a live demonstration on using Botox and Juvederm Vycross in the periorbital area, whilst Mr Brian Leatherbarrow will present on periorbital rejuvenation for facial ageing. CEO of the BACN, Paul Burgess, said, “The 2014 BACN Conference comes at an exciting and important time for the industry. It will have the usual top class speakers and practitioners making presentations but will also include the launch of the BACN Strategy Plan for the next three years and lots of exciting news for member services.” Sharon Bennett adds, “It’s a fantastic opportunity to meet up with friends from across the UK, network, share and take away some new skills and learning and all that’s needed to run a safe, successful aesthetic practice.” Dr Acquilla said, “I am delighted to be presenting the Peri-orbital Symposium at the BACN conference, and looking forward to sharing my latest experience and techniques from around the world with the UK’s aesthetic nurses.” Julian Popple, marketing manager at Galderma said, “Galderma are delighted to sponsor the BACN conference again this year. Over the years the BACN has emerged as one of, if not the, leading aesthetic organisations promoting excellent clinical practice, training and education throughout the UK.” A dinner dance will be held on the Friday evening, with wine tasting and a live band.

Skin

The Ultherapy Décolletage Treatment has become the first non-invasive procedure to be specifically indicated by the FDA to treat lines and wrinkles on the décolleté.

The Ulthera system is an ultrasound platform device, previously cleared to lift the neck, brow and beneath the chin.

The treatment purports to stimulate the natural production of collagen and elastin in the skin to gradually smooth wrinkles, with results visible at around three months post treatment.

Matthew E. Likens, president and CEO of Ulthera, said, “Now, the Ultherapy Treatment addresses four total treatment areas – from the brow to the chest – making it apparent that our investment in clinical advancements and dedication to R&D is producing results for our customers.”

Aesthetic Source launches The Skin Fitness Roadshow Aesthetic Source is launching an educational workshop series to support aesthetic practices. Led by Lorna Bowes and a team of experienced trainers, the one-day Skin Fitness workshops will be held at locations across the UK in the autumn and spring of 2015. The sessions will cover skin physiology, extrinsic and intrinsic skin ageing processes, typical skin concerns such as photodamage and hyperpigmentation, and treatment options for improving skin health using cosmeceutical and nutraceutical options. The Skin Fitness workshops will be supported by published clinical data.

beautifully matured The unique CaHA collagen stimulating dermal filler 10 years’ experience with almost 5 million syringes sold FDA Approved

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Vital Statistics

Business

Medisico Aesthetic Medicine launches Body Face Couture This month sees the launch of Body Face Couture, a new aesthetic business model for UK clinics launched by Medisico Aesthetic Medicine, a subsidiary of Medisico PLC. The model offers Body Face Couture branded aesthetic treatments, all based on radiofrequency and laser light technologies, whilst allowing clinics to maintain their own identity. Patients are able to choose their treatments via the Body Face Couture website, which then directs patients to their nearest clinic. The Body Face Couture brand is directly responsible for standards and patient satisfaction, including the management of sales and marketing. All Body Face Couture treatment equipment includes a three-year warranty, and clinics are required to undergo a rigorous accreditation process, including a financial and clinical assessment, as well as an assessment of each clinic’s approach and values.

Microneedling

Lutronic launches new tip for Infini Lutronic has announced the launch of a new 16 microneedle tip for its Infini radiofrequency microneedle system, which it claims will offer more precise treatment for smaller areas, such as the peri-orbital region, as well as being less expensive than the standard 49 microneedle version.

Infini claims to work faster than competing systems by eliminating damage to the surface of the skin and delivering RF energy directly to the dermis.

Its proponents insist that Infini produces reliable results with reduced downtime when compared with similar devices.

Non-invasive procedures in Glasgow are estimated to be worth £10 million by the end of 2014 Azimuth Healthcare Solutions

Facial scarring due to acne affects up to 20% of people.

BBC health news

Normal hair loss is considered to be 100 hairs per day The Belgravia Centre

The psoriasis therapeutic market... ...was worth $3.6 billion in 2010...

...and is forecast to grow to $6.7 billion by 2018

Global Data

11,874,937

nonsurgical aesthetic procedures were performed worldwide in 2013.

Journal

Dr Tapan Patel joins the Aesthetics editorial board Dr Tapan Patel this month joins the Aesthetics journal Editorial Advisory Board. Founder and medical director of VIVA and PHI Clinic, Dr Patel brings over 14 years of clinical experience to the role, and joins seven other leading figures from within the aesthetics profession.

“Having worked closely with the Aesthetics editorial team on numerous occasions in the past I am extremely pleased to be joining the journal’s editorial advisory board,” said Dr Patel. “I hope my contribution will aid the journal to continue to thrive and flourish and maintain an editorial ethos which is now firmly grounded in science and education. In addition to my work on the journal, I will also continue to hold my position on the Aesthetics Conference and Exhibition (ACE) steering committee. This work sees exciting plans already in place to ensure next year’s conference is a truly cutting edge presentation of the very latest developments in aesthetics.”

Aesthetics | September 2014

ISAPS

In 2013, 87.2% of people undergoing cosmetic procedures globally were women.

ISAP

In 2014 there will be an estimated 139,870 new cases of melanoma in America American Academy of Dermatologyv

The global acne market is estimated to reach revenues of $3.02 billion by 2016.

Research and Markets

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Accreditation

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Gynaecology

First clinic receives accreditation as Save Face register prepares to launch A Buckinghamshire clinic, Appearance Based Medicine, has become the first clinic to receive accreditation from the newly launched Save Face initiative. Save Face launched in June in response to the Keogh Review, and claims to be the first register of its kind in the UK aesthetics industry, with every applicant being rigorously checked and interviewed before receiving accreditation. The register of accredited practitioners from across Great Britain will go live at the end of August, with application only open to registered doctors, dentists and nurses who can demonstrate that they are insured and have received certified training. Appearance Based Medicine, which has been open since 2004, is run by Clare McLoughlin RGN INP. Clare said: “Save Face is filling a huge gap in the non-invasive cosmetic treatment market.

For years, the industry has desperately needed some form of regulation and guidance. We are an independent clinic and so it was refreshing to see Save Face working with us to ensure our policies and procedures are up to the highest standards.”

“We are very proud to be the first clinic to be accredited. I know that many more have already followed our example and that’s a very positive move for the industry.” Ashton Honeyball, director at Save Face Ltd, said, “We’ve had a phenomenal response to the register. It demonstrates the very real need there was for accreditation in this market. When the register goes live later this month, it will provide patients with a newfound confidence in the non-surgical cosmetics industry. They know that every practitioner on the register is experienced and has had their qualifications checked, had their premises inspected and operates to the highest standards. It is becoming a new benchmark for the industry. We’re delighted with the positive response and the willingness from the industry to demonstrate their professionalism.”

T H E A R T O F FA C I A L R E J U V E N AT I O N

Aesthetics Journal

New academy launches for laser gynaecology techniques A new academy has been launched to promote the use of minimallyinvasive laser techniques to treat gynaecological problems.

The British Academy of Laser Gynaecology (BALG) will provide its members with education and training in the techniques, which have been developed by Fotona Lasers, and claim to offer rapid, pain-free treatment for issues such as stress incontinence, vaginal laxity and vaginal atrophy.

Kevin Rendell, director of Beehive Solutions Ltd, UK distributor for Fotona Lasers, described the new Academy as a “unique patient information centre and key learning facility for laser professionals looking to offer the best treatment”. He said, “For too long, because the old treatments were aggressive and painful, women have suffered in silence with these debilitating and often embarrassing conditions. Now there is a treatment option that gives long term, pain free, relief.”

Rosacea

Act on Red campaign supports Rosacea sufferers A rosacea awareness programme, Act on Red, has launched alongside new research that assesses the effect the condition has on sufferers. The data from Face Values: Global Perceptions Survey, demonstrated that nearly two thirds (62%) of people with facial redness agreed it embarrasses them and nearly half (46%) believe their rosacea changes others’ perception of them. The survey also found that rosacea affects 77% of people emotionally, 67% socially, 63% at work and 53% in their relationships/dating behaviour.

In addition, researchers analysed how other people perceived rosacea sufferers. They found that they were judged to be less intelligent, reliable, successful and trustworthy compared to people without redness. They were also more likely to be perceived as sick, tired, unhealthy and stressed, as well as less likely to be in a relationship or professional job.

These results align with psychological studies that show a single glance of a face is enough for people to make automatic judgements.

Act on Red, supported by Galderma, aims to provide information, educational resources and where to get to help to people affected by facial redness associated with rosacea.

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Spire Liverpool Hospital offers warning to patients as numbers travelling abroad for surgery soar A study by private healthcare search engine WhatClinic.com has revealed that the number of patients choosing to undergo cosmetic surgery abroad has more than doubled in the past two years.

Cheap air fares and lower surgery costs seem to be fuelling the rise in medical tourism, with Eastern Europe seeing the biggest influx – there has been a 304% increase in nose job enquiries in the Czech Republic in the past year, with Poland experiencing a 57% rise in those looking for breast enlargements.

In light of this, surgeons from Spire Liverpool Hospital have issued a warning to the public about the dangers of travelling abroad. Spire plastic surgeon, Mr Azhar Iqbal, said, “It is clear from these figures that medical and cosmetic surgery tourism is on the rise. Cosmetic surgery like any other surgery requires post-operative follow up, the frequency of which can vary on individual basis.”

He added, “Many places have different regulations to the UK. Standards and safety procedures vary dramatically depending on where you go so research and planning is vital.” Mr Iqbal explained that another common problem with patients travelling overseas for their surgery is that recovery time can often be lengthy.

“Realistically you would have to remain abroad until you were fully recovered. It is important to ask about aftercare plans and what happens if something goes wrong during, or after, the procedure,” he said.

He noted that is was also important to remember that the NHS will only cover medical emergencies and will not cater for cosmetic needs.

Plasma

Plexr launched in the UK Aesthetics distributor Fusion Gt has launched a new non-invasive lifting device in the UK. According to Fusion GT, Plexr can perform all types of non-ablative surgery without risk to either the practitioner or patient. Marketed as a ‘soft surgery device’, Plexr uses the ionisation of the gases in the air, forming plasma, which creates a small electrical arc that treats problem areas – without spreading unwanted heat to the surrounding skin. Plexr is a wireless device, described by the manufacturers as ergonomic. Plexr can be used for numerous aesthetic concerns, for face and body lifting, treating acne and scarring, and to perform blepharoplasty. After initial success in Italy, Fusion Gt are now launching the product in the UK along with free training courses for practitioners. The next course will take place in October.

Botulinum toxin

Botulinum toxin tops noninvasive procedure ranking A report published by the International Society of Aesthetic Plastic Surgery (ISAPS) has shown that botulinum toxin still tops the rankings of non-invasive aesthetic procedures around the world, with 5,145,189 injections having been carried out worldwide in 2013. Fillers came next on the list, with 3,089,686 procedures in 2013, and laser hair removal (1,440,252) was third. America still leads the way with the most cosmetic surgical and non-surgical procedures performed – 3,996,631 in total.

However, Brazil has overtaken the United States this year for the first time ever in terms of the number of cosmetic surgical procedures performed – 1,491,721 surgeries in Brazil last year compared to 1,452,356 in America.

Aesthetics | September 2014

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Andrew Morris, country operations director of Sinclair Is Pharma Why has Sinclair Pharma chosen to make acquisitions recently?

Sinclair Pharma’s long-term objective is to become a first tier player in aesthetic dermatology; we now have a portfolio range built around the market’s needs, both now and in the future.

How does this affect your position within the marketplace?

We have a unique position with a complimentary product range which is focused on various forms of collagen stimulation, including Sculptra, providing gradual collagen stimulation, and Ellansé, for immediate and longer-term bio stimulation. Silhouette’s unique patented products (Silhouette Lift® and Silhouette Soft®) are resorbable collagen-stimulating cones on sutures (‘threads’) which offer a minimally invasive facelift.

The acquisition of Silhouette offers an exciting opportunity to launch several new indications for the body currently unserved by injected fillers, and Ellansé offers longer-term solutions for the hands, deep and sub dermal soft tissue augmentation of the facial area. These products sit alongside a strong offering in the HA filler segment, with Perfectha™, an ideal complement to our collagen stimulators in the rapidly growing dermal filler market, adding a complete hyaluronic acid (“HA”) filler range to our portfolio.

What benefits does this bring to practitioners and patients?

Sinclair Pharma’s comprehensive product range enables us to become the business partner of choice for the clinic. The products in our range offer the patient the most comprehensive and natural-looking solution to anti-ageing. They also provide the most cost effective solution in terms of longevity of results.

What does the future hold for Sinclair?

We believe the future of the market is based around natural anti-ageing through collagen stimulation, and Sinclair Pharma now have the products and organisation to support this growth. The recent build-out of our aesthetics business significantly enhances Sinclair’s technological position and growth prospects in collagen stimulation. Our enlarged aesthetics portfolio provides us with the platform to outperform this fast growth market. We expect to benefit in the near and long term from accelerating growth and significant operating leverage.

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Events diary

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Topical

HealthXchange launches Obagi360

12th - 13th September 2014 F.A.C.E.2f@ce Conference, Cannes www.face2facecongress.com/en

HealthXchange Pharmacy, the UK distributor of Obagi Medical, has launched the Obagi360 range. Aimed at a younger market, Obagi360 has been designed to encourage the idea that prevention is better than cure when it comes to the signs of ageing. The range contains three products: Exfoliating Cleanser, Retinol 0.5% and HydraFactor, a daily moisturiser containing broad-spectrum SPF protection. One key point of difference with Obagi360 is that the products contain entrapped polypore retinol technology, which it’s claimed releases retinol 0.5% slowly into the skin to tone and refine texture.

20th September 2014 British College of Aesthetic Medicine BCAM Conference 2014, London www.bcam.ac.uk 25th - 26th September 2014 The British Association of Aesthetic Plastic Surgeons - BAAPS Meeting 2014, London www.me .baaps.org.uk 3rd-4th October 2014 British Association of Cosmetic Nurses BACN Meeting 2014, London www.cosmeticnurses.org

Psoriasis

Trial results positive for new psoriasis treatment

6th December 2014 The Aesthetics Awards 2014, London www.aestheticsawards.com 7th - 8th March 2015 The Aesthetics Conference and Exhibition 2015, London www.aestheticsconference.com Landmark

Lynton celebrates 20 years in aesthetics and prepares to launch the ProMax Plus

Research published in the New England Journal of Medicine has shown that injections of the antibody secukinumab could significantly improve the symptoms of psoriasis. The study, which was funded by Novartis and headed up by Dr Richard Langley, professor of medicine at Dalhousie Medical School, Halifax, involved more than 2,000 patients at 200 sites across the world. In two separate trials, patients with moderate to severe psoriasis were injected with a subcutaneous dose of secukinumab (either 300 mg or 150mg) once weekly for 5 weeks, then every four weeks thereafter, for 52 weeks. In both trials, around 80% of patients showed a 75% reduction in skin lesions associated with psoriasis. A quarter displayed no sign of the disease after 12 weeks of treatment.

Dermatologists with no connection to the study have said that it is good news for psoriasis sufferers. Langley said it is likely that patients will need monthly injections of the antibody over the long term to control their symptoms. “We’re not curing the disease,” he said. “We’re simply halting its progression in some cases.”

Pollution

Lynton Lasers marked 20 years in the UK aesthetics industry at its annual conference, held at the Didsbury Hotel in Manchester. Jonathon Exley, managing director at Lynton Lasers, commented: “As we have a nationwide based team, it’s always great to get together and discuss new ideas for the future, and this year, reflect on 20 years within the aesthetic technologies market.”

One new launch being discussed at the conference was the ProMax Plus, due to be unveiled in October.

Marketed as “the instant facelift”, ProMax Plus is a radiofrequency skin tightening and wrinkle reduction treatment, designed for use on the face and neck.

12

Study shows Clarisonic more effective than manual cleansing for removing external pollutants L’Oreal has published the results of a study into pollution and its effects on the skin, which it claims show that atmospheric pollution can have a significant impact on hydration, oiliness and desquamation.

The study was carried out as part of a promotional campaign for the Clarisonic cleansing device to investigate the cleansing efficacy of Clarisonic compared to manual cleansing, at removing small particulate matter and cleansing dirt, sebum and oil trapping pollutants. According to L’Oreal, results show that Clarisonic is 30 times more effective than manual cleansing.

Aesthetics | September 2014

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Botulinum toxin

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Skin

Research conducted into the role of botulinum toxin in fighting cancer

Study links smell with skin healing

Botulinum toxin may have a role in the treatment of stomach cancer, according to recent research on animals. Scientists at the Columbia University Medical Centre, New York, and the Norwegian University of Science and Technology in Trondheim, looked at the important role of nerves in tumorigenesis. In a study published in Science Translational Medicine, nerves connected to tumours were silenced in mice models of gastric cancer, either with surgery or via local injection of botulinum toxin. In the study, the authors describe the method as working to “markedly reduced tumour incidence and progression, but only in the denervated portion of the stomach.” Experts have warned that this research is still in early stages, and cannot yet be considered a treatment for patients.

A recent study, published in the Journal of Investigative Dermatology, explores the effect of specific synthetic sandalwood oil on the process of wound healing and skin regeneration. ‘A Synthetic Sandalwood Odorant Induces Wound-Healing Processes in Human Keratinocytes via the Olfactory Receptor OR2AT4’, led by cell physiologist Dr Hanns Hatt at the Ruhr University Bochum in Germany, looks at the link between olfactory receptors and wound healing. The authors report the identification of ORs as a “novel type of chemoreceptors in human keratinocytes”. After cloning the cutaneous OR – OR2AT4 – the study recognised Sandalore (a synthetic sandalwood oil sold commercially) as the most potent in activating targeted OR. In a Dermatology Times article, Dr Hatt reflected on the findings: “Perhaps we will be able to add a sandalwood oil odorant to a topical cream to make wounds heal faster,” he said, “or use it to regenerate aging skin.”

Laser

Awards

Cynosure launches RevLite to UK market Cynosure’s RevLite Q-switched Nd:YAG laser has launched in the UK, claiming to be the new market leader for skin lightening and the treatment of pigmented lesions, such as birth marks and freckles. RevLite uses pulsed beams of light and Cynosure’s proprietary PhotoAcoustic technology to shatter dark pigment, with reportedly minimal damage to the outer layers of the skin, as compared to more traditional photothermal treatments.

“This treatment is a newcomer to the market,” said Dr Maria Gonzalez, of The Specialist Skin Clinic in Cardiff. “Even though I have a CO2 laser I believe the RevLite treatment provides a superior result with less pain and less downtime. It is also much safer in patients with pigmented skin in whom we do a less aggressive treatment known as ‘laser toning’, providing safe and effective rejuvenation and improvement in pigmentation.”

Allergan receives three Prix Galien nomination Allergan research and development department has been recognised with three nominations for the 2014 US Prix Galien Awards. The Prix Galien Awards acknowledge excellence within the biomedical industry, recognising the technical, scientific and clinical research skills necessary to develop innovative medicines and devices. The Allergan products nominated are: BOTOX for Migraines (Best Biotechnology Product nominee); OZURDEX (Best Pharmaceutical Agent nominee) and SERI Surgical Scaffold (Best Medical Technology nominee). “For more than 64 years, Allergan has remained committed to developing innovative products to address unmet medical needs,” said David E.I. Pyott, Allergan’s Chairman and chief executive officer. “We are proud to be recognised for our R&D efforts by the Prix Galien Committee and especially honoured to be the only company to receive nominations in all three of the 2014 Prix Galien Award categories.”

Topical

NeoStrata launch Skin Active Triple Firming Neck Cream NeoStrata has launched a new neck cream to add to its Skin Active line of advanced anti-ageing skincare products. Skin Active Triple Firming Neck Cream is formulated with NeoStrata’s proprietory active ingredients NeoGlucosamine and NeoCitriate, as well as pro-amino acid and swiss apple stem cell extract, and aims to address the three main issues associated with ageing – loss of elasticity, wrinkles and pigmentation.

Dermatologist Dr Sandeep Cliff says, “NeoStrata Skin Active Triple Firming Neck Cream is an essential skincare product to improve the look and appearance of the neck and décolletage areas which can be tricky to treat.

With growing awareness of premature ageing skin caused by sun damage, my patients lavish care on their faces but more often than not, tend to overlook their necks and décolletage. As we age, we produce less collagen and pigmentation becomes more mottled resulting in sagging, discoloured skin. Skin Active Triple Firming Neck Cream helps rebuild the skin’s matrix, encouraging the production of collagen and hyaluronic acid to improve skin health and quality.”

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With the news that the FDA have released draft guidelines for pharmaceutical companies using character and space-limited social media sites, Aesthetics investigates how the UK is responding to these changes

Using social media in aesthetics In 2013, allegedly incorrect advertising of prescription only medicines (POMs) via social media accounted for more than 10% of complaints received by the Medicines and Healthcare products Regulatory Agency (MHRA) in the UK.1 Responsible for monitoring online medical advertising, the MHRA’s annual report recorded 283 complaints, and, consistent with previous years, a high proportion of these complaints related to the advertising of botulinum toxin to the public. Despite the MHRA setting stringent guidelines for digital communications in general, 2013 saw an increase of complaints about advertising on social media, as well as the first complaint relating to advertising via Twitter. 1 Meanwhile in the US, the Food and Drugs Administration (FDA) recognised communication problems with character space limitations on social media sites and internet platforms by releasing draft guidelines. Suggestions include that the prominence of risk information should be comparable to the benefit information featured within each individual character-space-limited communication. An FDA spokesperson, says, “Character-space-limited internet or social media platforms may pose challenges for firms in providing a balanced presentation of both risks and benefits of medical products. This draft guidance aims to aid the industry in effectively communicating benefit and risk information in product promotion.”

Based in the US, global aesthetics industry consultant Wendy Lewis believes the guidelines will encourage pharmaceutical companies to embrace social media, who have until now, been hesitant to engage online because of unclear guidelines. She says, “Some companies have taken a one-way approach to social; they have a presence, as in a page or a Twitter account, but do not engage, share, respond to, or otherwise interact, with the general public. Clearly this defies the very essence of what social is all about.”

UK guidelines relating to the use of social media and digital advertising in the health and aesthetic industry are supplied by the MHRA, Association of the British Pharmaceutical Industry (ABPI) and the Prescription Medicines Code of Practice Authority (PMCPA). However the use of social media for aesthetics is further complicated by the fact that some aesthetic companies will not be governed by the ABPI, depending on whether they supply prescription only medicines POMs, and so companies need to address whether these rules of practice apply to them. Worry lies in the misrepresentation of POMs on social media. Advertising POMs to the public is prohibited in accordance with the Human Medicines Regulations 2012, and, as the MHRA report demonstrates, botulinum toxin is of paramount concern for the aesthetics industry. Publicising POMs is subject to the ABPI Code of Practice, administered by the PMCPA, supported by Government legislation, and enforced by the MHRA. The correct use of social media is a contentious issue for both pharmaceutical companies and individual aesthetic clinics. The Committee of Advertising Practice (CAP) provides some guidance on publishing information about Aesthetics | September 2014

Insider News Special

botulinum toxin online,2 but as Medical PR Tingy Simoes notes, “Social media in our sector is still in its infancy. It’s skyrocketing in popularity but still used clumsily. Reputations can be badly damaged at the click of a button.”

An MHRA spokesperson explains that the MHRA operate a targeted approach to action on clinics, and other services, offering treatments involving botulinum toxin products and other POMs. This focus however, is primarily on the home pages of clinic websites, and not on Twitter posts or sponsored links. With Twitter, along with other social networking sites, being increasingly used as a promotional platform, the character space limitations it encompasses can make it difficult to know how to use it effectively, and most importantly, legally.

Aesthetic doctor, Dr Sarah Tonks, acknowledges these challenges for clinics, and suggests a potential alternative to Twitter. “Google+ is underused,” she says, “But it provides plenty of character space.”

Most importantly, she says, there is room to post any potential risks or side effects the medicine may have. The APBI Code of Practice states that when pharmaceutical companies discuss POMs online, only factual and balanced information must be distributed. The PMCPA published informal guidance last year on these digital communications for the pharmaceutical industry, including a section specifically on social media.3 In their new draft guidelines, the FDA has suggested the use of hyperlinks to allow direct access to a more complete discussion of risk information about the product in question. AJ Barroso, digital marketing manager at digital healthcare agency emotive, says, “The way people access information on the web is constantly evolving, and the suggestion to incorporate the use of hyperlinks is a good first step.

However, more can be done to govern the use of social media in this industry. This could include greater moderation of social content by governing bodies, and even the development of a tweeting template to aid clarity and consistency in the messages published.”

Acknowledging the new guidelines, an MHRA spokesperson said, “We have recently laid regulations to amend the law to permit companies to include a link to the summary of product characteristics, in place of the prescribing information currently required.”

He added, “We will continue to investigate complaints received and take action where a potential breach of the legislation is identified.”

REFERENCES 1. MHRA, Delivering High Standards in Medicines Advertising Regulation

(MHRA, 2013) <http://www.mhra.gov.uk/home/groups/comms-ic/documents/ regulatorynews/con383403.pdf> 2. CAP, Advice and Training (London, CAP, 2014) <http://www.cap.org.uk/ Advice-Training-on-the-rules/Advice-Online-Database/Anti-ageing-Botox. aspx#.U-SSZqOwX11 3. Prescription Medicines Code of Practice Authority, Digital Communications (London: www.pmcpa.org.uk, 2014) < http://www.pmcpa.org.uk/advice/ digital%20communications/Documents/PMCPA%20-%20 Digital%20Communications%20FEB14%20web.pdf>

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Aesthetics worldwide Dr Raj Acquilla’s work as injectables teacher, global key opinion leader and international mentor takes him across the globe. We speak to him about aesthetic themes worldwide Tell us about your recent international experiences.

RA: Over the past three months I have presented at congress and Masterclass tours in Europe, the Middle East, Singapore, Hong Kong, Australia, New Zealand and the USA. Each continent or country possesses a unique aesthetic ideal and market, which makes delivering medical aesthetic education extremely challenging and rewarding.

What have been your favourite countries?

RA: I have worked in Australia four times now and find the AUS/NZ market very exciting. They are where we were 10 years ago but with high levels of regulation, which drives quality and excellence.

Furthermore, they have experienced huge economic growth in recent years, which has accelerated their industry and appetite for knowledge and success. I really see Asia Pacific as being an area of significant growth over the next 5-10 years.

What are the themes that have emerged over the course of recent global congresses?

RA: The past 3-5 years has been the most exciting time in the global industry. Now we know more about facial anatomy, ageing and injection technique than ever before. I see each continent embracing a culture of re-education and application of the latest approaches to help grow their individual practices and overall domestic market.

Have different trends been highlighted in specific regions?

RA: Yes! This is what makes my work so interesting. There seems to be a unique aesthetic model favoured in each region

of the world, such as the popularity of lip and cheek enhancement in Europe & USA, nasal contouring in the Middle East, body reshaping in South America and skin lightening in the Indian subcontinent. Different territories tend to base their aesthetic ideal around popular local trends eg. Asian skin tends to be of very good quality and resistant to ageing, so the demand in Japan, Korea & China is usually for structural augmentation such as forehead, brow, eyelids, nose, chin and jawline.

What experience do you bring home to your UK clinic after attending international conferences?

RA: The sharing of knowledge and techniques amongst peers is a great feature of our industry and I am fortunate to be able to work with, and learn from, the best in our profession at these international events. This certainly helps me to treat my patients with a holistic and balanced approach. What’s more the UK, and particularly London, is a global melting pot of genotypes, therefore the clinical presentation and their aesthetic needs can be complex. I apply my experience in injecting patients of different geographic origins to achieve optimum beauty whilst respecting ethnicity and regional aesthetic ideals.

How have congresses differed in their format, presentation and technology?

RA: The modern cosmetic medical congress usually encompasses the latest in audiovisual (AV) technology to make for a highly engaging interactive learning experience. The most impressive show I participated in was in Melbourne, where we had an IMAX-style screen for an audience

Ageing of the Asian face compared to the Caucasian model

18

Aesthetics | September 2014

of 3500 with four live interactive feeds showing cadaver dissection, anatomy and physiology slide deck, podium and of course live injection (which had six camera angles).

The engagement and feedback from such a large audience was amazing, and confirmed that the visual component of a congress now plays a huge role in the delivery of clear educational messages.

What was the most exciting presentation or demonstration that you saw?

RA: Definitely the guru of beautification Dr Arthur Swift performing a live pan-facial beautiPHIcation when we worked together in Brisbane. Live injection in front of a large audience is always challenging but he delivered something truly exquisite and impactful whilst remaining gentle, precise and with an honest desire to share with humility.

Where are you planning to teach next?

RA: I’m off to present at AMWC Brazil next week, then DASIL / Cosmedica South Africa, Spain, Singapore, Russia, Turkey, Colombia and India. I will be bringing my experience back to the UK for a Masterclass series, the CCR Expo, BCAM and the BACN conferences. We also have very exciting plans for an impressive live injection symposium at ACE 2015, which will encompass the latest knowledge and injection techniques with cutting edge AV delivery.

How do you follow up with the international audiences you teach?

RA: Sometimes I won’t visit the same country again for over a year so it’s difficult to offer mentorship and continue to give educational support to the delegates. My colleagues in this country will offer local training to follow up their progress and I often welcome international trainees to my clinic in the UK for internships or Masterclasses. I recently launched an online academy, which allows delegates to view injection techniques as a series of webinars, to use as a supportive tool. This form of remote education has been very well received around the world.

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Hair loss treatments According to the NHS, male-pattern baldness (androgenic or androgenetic alopecia) affects half of all men by the time they turn 50, whilst femalepattern baldness affects an estimated eight million women in the UK. David Jacobs asks practitioners how to best treat these patients.

Dr Sherif Wakil, a cosmetic doctor and hair transplant surgeon at the Royale Skin Clinic, says the number of patients attending his clinic for hair loss therapies is increasing.

“Over the past 10 years, hair loss treatment has grown dramatically. The recession meant a lot of redundancies, and men in their late 40s or 50s or even 30s [with hair loss] look much older than their age. These people have found themselves competing with a younger generation who have hair on top of their head and skin that looks better. At a disadvantage, these guys started having Botox and fillers, and Platelet Rich Plasma (PRP) injections for hair loss.”

Dr Wakil suggests that there may be another reason for the increase in demand. “In the past, people depended on shampoos or moisturisers. But numbers have increased because patients understand that other treatments are now available, both surgical and non-surgical.” A similar explanation is offered by Dr Britta Knoll, president of the German Society of Mesotherapy, “There’s growing interest because of more information regarding the possibility of treating these forms of hair loss with mesotherapy,” she says.

According to Mr Michael May, a specialist

surgeon at the Wimpole Clinic, as awareness of new procedures has grown, so too has public confidence. This, he believes, has not only encouraged more patients to visit clinics, but has also prompted more clinics to open.

The initial consultation Dr Wakil, whose treatment of choice is PRP and AQ growth factor, explains his approach: “I undertake a hair analysis and a full history. I examine the patient’s hair under a microscope and a special camera.

This gives an indication of how many hairs a patient has per square centimetre, and their hair loss. Then I test the hair at the back of the head and check the health of the scalp to see if there’s dandruff or other problems, such as psoriasis.

“The history is very important, it gives an indication about the type of alopecia the

Clinical Practice Special Feature

person has. There’s an obvious relationship between general health and hair loss, so I look to see if there are any underlying problems. If so, I advise that these are addressed before treatment starts. I also ask about any family history. Then I examine the patient and ask about any earlier treatments and whether these made any difference.”

Dr Knoll, who sees around 20 patients a week, explains the protocol of mesotherapy treatment to her patients and details the ingredients. She checks for severe autoimmune disease and whether patients have allergies to the ingredients or signs of infection on the scalp. She also takes photographs for comparative purposes. She explains, “First we do an examination and take a medical history – we need to know what kind of treatment has been carried out before. We also need to know if there has been a laboratory check and everything is okay with the blood and hormones. We clean the skin and give a mixture of specific bio revitalisers that are composed for mesotherapy.”

CEO of Dermagenica Dr Gabriela Mercik, who typically uses the Dermaheal HL hair growth programme containing nano-peptides before hair transplants, to improve hair condition, establishes the pattern and type of hair loss, the level of vitamin D and the patient’s genome to diagnose the problem.

Mesotherapy treatment First described by the physician Michael Pistor, mesotherapy is an injection treatment that nourishes layers of the skin where there is cell repair and growth. Treatment is primarily carried out on the top of the head and only works if the hair bulbs are still alive. Compared to other techniques, Dr Knoll finds that the main advantage of mesotherapy is that it is a gentle treatment, involving little pain. “We very rarely see any side-effects. Patients may have some bruising or itching, and if there are only a few hairs left they must take care not to go out in the sun – micro-injection points create hyper-pigmentation when in contact with the sun. Patients have to cover their heads and wash their hair before they come for treatment but then avoid washing or

Treating hair loss with mesotherapy. Images courtesy of Dr Britta Knoll

Aesthetics | September 2014

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Date of preparation: August 2014 UK/SIPGEN/14/0001

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Clinical Practice Special Feature

not only benefits the patient but also the practitioner, since you don’t have to buy expensive equipment and lasers. In my opinion, because the market changes so quickly, it’s best to invest in a product with a proven track record in order to minimise your risk.”

Treatment with Dermaheal HL. Images courtesy of Dr Gabriela Mercik

colouring for three days after.”

Dr Knoll explains that the treatment protocol is once a week for six weeks and then monthly. Although a long-term treatment, individual sessions take less than five minutes, making it convenient for most people. Whilst the long-term nature of the therapy might put some patients off, Dr Knoll has found it produces very good results that regenerate the hair scalp and fight against the atrophy of the hair bulb; she encourages her patients to follow through with the procedure, saying that 80-90% of those she sees are happy with the results.

With many mesotherapy products on the market, Dr Knoll and others are clear that practitioners looking to use them should find a good manufacturer, a good product to inject and use the right technique. But, as a note of caution, Dr Wakil advises patients and practitioners to be careful what they use, emphasising, “Not everything does exactly what it says…”

Dr Knoll explains that she finds Toskani products produce the best results.

However, she adds, “There are other products on the market – some practitioners undertake the treatment with PRP, which has good results too – but in my opinion there is more preparation work. By contrast, mesotherapy is quicker and very effective. The first results may be after three or four treatments; initially patients may see less hair loss, then after around two months new hair appears. Initially small or weak, by the next month they will be stronger and thicker with good volume.”

Asked if there are there any patients unsuited for the procedure, Dr Britta explains, “In the case of total hair loss in males the alternative is a hair transplant.

In patients with total or sub-total hair loss caused by alopecia areata that’s very difficult to treat, we do a natural holistic treatment for the immune system to try to get it functioning normally.”

Another mesotherapy solution, Dermaheal

is a simple non-surgical treatment comprising a series of shallow injections in the scalp that, according to Dr Mercik, can be repeated for several trials without adverse effects or complications. “The two-pronged approach of stopping hair loss and stimulating hair growth makes it a complete”, she says. She describes it as, “A treatment that can be performed before hair transplants to improve hair condition and wound healing; it shortens the downtime after transplants. It can also be used for women with greasy hair because the treatment improves the pH of the scalp. Furthermore, Dermaheal blocks the conversion of testosterone to dihydrotestosterone (DHT) in the scalp and delays the process from anagen (hair growth) to catagen (cessation of growth).”

The procedure is supported by the use of shampoo and conditioners that contain nano-peptides. In the first month there is a set of weekly injections followed by three bi-weekly sets of injections. A top-up of one set of injections is recommended after six months although, according to Dr Mercik, “One course of treatment will generally improve the patient’s hair to the desired extent.” She explains, “The injection protocol is based on findings that suggest specialised nano-peptides act as growth factors in the applied areas and this counteracts the gradual reduction of endogenous growth factors.”

Asked what advice she would offer other practitioners, Dr Mercik counsels, “The best treatment is the least invasive. Simplicity

Hair transplant surgery As Dr Wakil explains, “Sometimes hair transplant surgery is a must if a practitioner is to meet a patient’s expectation. However, even in these cases, improving the quality or prolonging the life of existing hair with other non-surgical treatments can help, meaning a shorter hair transplant session.”

According to transplant surgeon Mr May, the current situation is positive. “We’ve been through some fairly tough times but things seem to be getting a bit better now,” he says.

Typically seeing seven or eight cases a week, he believes that the success of the procedure is due to the fact that people believe it is a worthwhile procedure to undergo.

Mr May uses two extraction methods and advises each patient what would be best: either Follicular Unit Extraction (FUE), where a group of two or three hairs are taken out individually using a small 1mm punch, or Follicular Unit Transplantation (FUT), where a narrow strip is taken from the back of the head. From a patient’s point of view, although it is more expensive, FUE offers the advantage of no downtime and no scarring at the back of the head, although there are often little marks and scabs where each graft is placed and, as with any minor surgery, there can be some bleeding. As there’s no long-term scarring, Mr May feels it is often the most suitable procedure for younger men who may want a short haircut or to shave their scalps.

Patients undergoing FUE have a large numbers of grafts, around 2,500, and this can take as long as seven or eight hours.

Whilst not a complicated procedure, Mr May explains, “Every member of the team has to be meticulous in their contribution, so it does take time.” But it’s usually worth it: “Results

Hair transplant surgery. Images courtesy of Mr Michael May

Aesthetics | September 2014

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are very good: we give a man a very nice, natural cover. In the years I’ve been doing it, hair transplants have moved from that rather strange look of 20 years ago, to being almost undetectable, which is what everyone wants.”

Asked to share some advice, Mr May highlights a common professional problem: “You have to go to a clinic or join a doctor where you can do almost an apprenticeship. This isn’t easy. As it stands at the moment there’s no formal training for doctors in most cosmetic procedures – you have to get someone to show you how to do it or assist someone.”

Platelet Rich Plasma (PRP) The treatment of choice for Dr Wakil is PRP. “It’s something that has been around since the 1970s and was first used in 1987 in an open heart surgery procedure to promote healing,” he explains.

“The platelet has growth factors and each growth factor helps

Treating hair loss with PRP. Images courtesy of Dr Sherif Wakil

in cell regeneration of a certain place in the body,” explains Dr Wakil. “I don’t think it’s as precise as it could be, but we know more now and scientists are able to reproduce the specific growth factor that helps the hair follicle and offer it as a hair solution to use at home.”

Dr Wakil usually combines PRP with AQ growth factor. “The response varies: some patients come and they’re thrilled; with others, results take a little more time. There’s no rule to how fast hair will grow. The most remarkable thing I’ve seen is with patients who lose their hair constantly: when they wash it, when they sleep, when they brush it. The first thing they tell me is that their hair has stopped falling out. That’s what I want to hear when they come back.”

As far as long-term results are concerned, Dr Wakil explains, “Hair in men aged 30 plus is under constant pressure. I try to avoid the need for a hair transplant. I make patients aware that it’s not like having a ‘nose job’; I’m not fixing a nose that’s going to be fixed forever.”

Dr Wakil prefers PRP to mesotherapy and sometimes combines it with carboxytherapy as part of his total “attack theory”. As he explains, “The problem with mesotherapy is that it’s the practitioner’s responsibility to check what’s in the cocktail. Every company comes up with a solution, but you need to investigate this because your patient trusts you.”

One of the reasons Dr Wakil enthuses about PRP, he explains, is that, “It’s extremely safe and requires little aftercare. The important thing is to advise patients not to drink alcohol the night before or take aspirin – these thin the blood and can cause the patient to bleed a little more.

Afterwards I tell patients not to touch their hair until their hands have been properly cleaned. The only thing I worry about is the risk of infection in a patient who’s immunecompromised. The procedure is very sterile, but with an 24

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Images courtesy of Tracie Giles

Medical tattooing/permanent makeup Tracie Giles is a London-based medical tattooist. Although her work also includes permanent cosmetic makeup, she treats patients with alopecia, those undergoing chemotherapy, and people with distressing hair pulling disorders. Tattooing eyebrows, but not the scalp, Ms Giles uses a normal cosmetic pencil, or uses pigment and a very fine paintbrush, to draw symmetrical eyebrows before applying a gentle topical anaesthetic to the area. Ms Giles then tattoos the area using an acupuncture needle and/or permanent make-up needles to create a 3D effect to the eyebrow. She says that infection and allergic reactions are rare – an allergy test is performed before the process begins. Afterwards, patients are advised to keep the area clean and dry, and use Vaseline as a barrier cream.

Giles, like other practitioners interviewed, stresses the positive psychological impact her work can have on her clients. “You can empower somebody to take some control over conditions they otherwise have no control over. It’s such a lovely thing when someone sits up and cries because they’re so happy they’ve got eyebrows back again. You definitely get the feel-good factor.” immune-compromised patient you can actually create infection with the smallest amount of bacteria in the air. For this reason I don’t treat immunecompromised patients.”

Dr Wakil’s advice to his peers is to find the cause of the hair loss. “This is very important because you won’t get good results otherwise. Secondly, take a proper history and immerse yourself in hair loss treatments. For some, it’s something extra they do in a clinic, but it’s actually a whole world.

So if you want to do it, do it properly and benefit your patient by offering different treatments. If you’re just using one treatment your patient may miss the chance of having thick hair. A good medical practitioner is one that, if they don’t know something, they refer it to a colleague. My first priority is the patient. That’s my first and most important principle. I think we should all act in this spirit.”

The future of hair loss According to Mr May, “At the moment we’re just relocating existing hair and that’s a finite resource. University departments and pharmaceutical companies are all looking for ways of growing hair using stem cells/tissue engineering – after all, it’s a billion dollar product. However, it’s still some time away. This is a sentiment echoed by Dr Wakil: “We are all waiting for the stem cell research that has been going on for over 30 years; waiting for the miracle of taking hair follicles from the patient, replicating it, and injecting it into the scalp to produce hair everywhere. This is the future everybody’s waiting for.”

Aesthetics | September 2014

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1. BEL-DOF3-001_01. 2. Tran C et al. in vivo bio-integration of three Hyaluronic Acid fillers in human skin: a histological study. Dermatology DOI:10.1159/000354384. 3. Taufig A.Z. et al., J Ästhet Chir 2009 2:29 – 36. 4. Prager W et al. A Prospective, Split-Face, Randomized, Comparative Study of safety and 12-Month Longevity of Three Formulations of Hyaluronic Acid Dermal Filler for Treatment of Nasolabial Folds. Dermatol Surg 2012, 38: 1143 – 1150.

5. Buntrock H, Reuther T, Prager W, Kerscher M. Efficacy, safety, and patient satisfaction of a monophasic cohesive polydensified matrix versus a biphasic nonanimal stabilized hyaluronic acid filler after single injection in nasolabial folds. Dermatol Surg. 2013; 39(7):1097-105.

BEL092/0314/FS Date of preparation: April 2014

Clinical Practice CPD

one point

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Radiofrequency Lee Brine explores the science and application of RF in non-invasive aesthetic procedures The use of radiofrequency (RF) in surgical applications is far from new, with records of early work in basic surgical cutting going back some 50 years. Radiofrequency energy exposure is a wellestablished method for generating heat in tissue to incise, excise, ablate or coagulate the targeted tissue for a vast array of surgical applications. However, in the last 10 years there has been an explosion of RF applications in non-invasive aesthetic applications leading to many conflicting and confusing elements surrounding RF. In order to understand this widely used energy form the following review will discuss: • Technology • Applications • Tissue response • Methods of tissue application • Clinical results Technology Radiofrequency is an oscillating current of electricity. Whereas electricity from your domestic outlet operates at around 50 Hz, the RF used in various clinical and surgical applications oscillate at rates between the frequencies ranges of 3 to 24 kHz, with the whole band of radiofrequency being between 3 kHz to 300 GHz. It is these oscillations that cause vibrations and collisions between charged molecules and charged ions that create controlled heat.1 RF current is simply an electrical current, and acts in similar ways to our common understanding of the properties of electricity, with the fundamental principle of note being that if the passage of energy meets resistance it will create heat. Consider a tiny light bulb filament that is highly resistive, which is why it heats up to give light. The main idea behind using RF on the skin is its ability to deliver heat to tissue non-specifically. Lasers are able to generate heat, but when controlled, they do so in a chromophorespecific manner (selective photothermolysis). To expand upon this part of the theory we need to look at laser light and tissue interaction. Lasers are unique from normal light in that they consist of a single wavelength whereas white light is a mixture of a whole spectrum of wavelengths. The wavelength of the laser Absorption

Absorption Coefficient (cm-1)

HPS Diode (532nm) (980nm)

Nd: YAG (1064nm)

Thulum (2013nm)

Ho: YAG (2120nm)

1000 100 10

Applications Laxity is a skin disorder that occurs with natural or accelerated aging and is structurally linked to diminished collagen production.

The number and vitality of fibroblasts decrease, and both the dermis and the fibrous septa undergo partial loss of their natural ability to replace themselves. The morphological changes that appear are a consequence of diminished biosynthesis of collagen and elastin and abnormalities of the extracellular environment with a decrease in the concentration of hyaluronic acid.2 Skin laxity is an aesthetic problem that usually occurs between the ages of 35 and 40 years, although it generally only starts to become visible from age 40 onward. Issues with skin laxity and quality can start to appear in younger people due to pregnancy or sudden weight loss. The impact of these problems on the patient’s self-esteem can become important enough to affect quality of life in psychological terms.3,4 The demand for treatment of skin laxity is growing rapidly across the globe.5 Skin laxity is associated with lack of physical exercise and rigorous dieting, and often appears in combination with cellulite.

Cellulite is an inflammation of the subcutaneous adipose tissue and has several causes. It occurs mainly on the legs, buttocks, hips, breasts, arms, and neck.6 The fibrous structure of the interlobular septa that divide female subcutaneous cell tissue into compartments is arranged perpendicular to the skin surface.

This structure enables fat lobules in each septum to move toward the skin surface, which is the only structure that contains them.

Some authors consider that cellulite visible to the naked eye is caused by lengthening and weakening of connective tissue fibers accompanied by fat protrusion.7,8

1 0.1 0.01 IE-3 IE-4

400

Wavelength (mm)

800

1200

1600

2000

Oxyhemoglobin

Water

Graph illustrating the different absobtion levels various lasers in water (tissue main component) and oxyhemoglobin

26

is the principal factor in determining what reaction is created with the various body structures. An example is CO2 laser; this wavelength is highly absorbed by water and thus it is absorbed as soon as it strikes the skin and creates a very superficial reaction and thus is used for resurfacing the skin. Another example would be frequency double YAG at 532 nanometers (Green) which has an absorbtion peak in Oxyheamaglobin and thus is very useful in surgical applications, such as prostate surgery, where a greater degree of heamastasis is required. RF delivers heat to tissues based on the properties of the tissue itself and is not dependent on chromophores; thus the tissue effect does not seem dependant on skin colour as with lasers and IPL, i.e. light application.

Tissue response The basic premise of RF devices is electrical resistance causing heat. There is initial collagen contraction and destruction through both mechanical and biochemical pathways. As a result of the energy delivered deeply into the skin, collagen remodelling through a controlled wound healing response occurs over time with associated neocollagenesis. This collagen remodelling also yields the desired tissue tightening that is seen with RF devices.

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RF devices typically are not intended to resurface the skin but rather to induce thermal damage to dermal collagen while sparing the epidermis Appropriate cooling is also required for these devices, since the energy delivered needs to penetrate to the deep dermal and subcutaneous fat layers without damaging the more superficial structures.9 RF can be used for the heating and reduction of fat by inducing apoptososis (cellular death) in the fat structure. By raising the temperature of the fat cells to at least 46 degrees the process of cell destruction will commence.9 Global incidence of obesity is at an all-time high.10 This growth is in line with the rapid increase in the methods that can be used to non-invasively remove these pockets of fat. Multiple non-invasive modalities to induce adipocyte apoptosis in pockets of fat are now widely used. These modalities primarily aim to target the properties of fat that differentiate skin from muscle, thus resulting in the selective removal or dissolution of fat, otherwise known as lipolysis. As seen in the table below, fat is highly resistant (i.e. less conductive by a factor of up to 30 times) compared to other structures in the body. As a result, RF heating occurs irrespective of chromophore or skin type and is not dependent on selective photothermolysis. Depending on the level of accumulated fat, devices can target the fat at different levels. RF-generated tissue heating has different biological and clinical effects, depending on the depth of tissue targeted, the frequency used, and the cooling of the skin to prevent discomfort. The different effects range from reducing the extra cellular fluid, heating the dermal layers to disrupt collagen or heating subcutaneous fat to induce apoptosis Tissue Type

Tissue’s Conductivity

Tissue’s Ease of Polarization

Conductivity; σ [S/m]; (higher number means more conductive)

Relative Permittivity; ε; (higher number means that material is more easily polarized)

Fat

0.032909

8.4678

Blood

1.158 (35 times more than in fat)

126.96 (15 times more than in fat)

Skin

0.3283 (10 times more than in fat)

165.59 (20 times more than in fat)

Muscle

0.654 (20 times more than in fat)

95.947 (11 times more than in fat)

Values measured at radio frequency and tissue temperature 37°C.

Before

Clinical Practice CPD

After

Dermal remodelling and neocollagenesis following radiofrequency treatment at pre-treatment (A) and 10 weeks post treatment (B).

At 10 weeks, dermal thickness was increased over pre-treatment and subcutaneous interstitial collagen also was thickened. Both observations can be attributed to dermal remodelling and ongoing neocollagenesis following radiofrequency treatment.

Histology pre treatment

After

Histology post four applications of RF clearly demonstrating healthy fat cells in the top slide with visible destruction of the cellular structure in the right slide

The released fatty acids and triglycerides are processed through the normal metabolic pathway. 11 RF devices typically are not intended to resurface the skin but rather to induce thermal damage to dermal collagen while sparing the epidermis. Resistance and the resultant degree of thermal damage is determined by the depth and composition of the treated tissue. When applied over a period of time, thermal energy contracts and thickens collagen fibres, disrupts hydrogen bonds, and alters the conformation of the collagen triple helix. It also induces a more prolonged wound-healing effect that is associated with sustained remodelling, reorientation, and formation of new collagen bundles over subsequent months.12 Because RF energy uses an electrical current rather than a light source, it does not affect epidermal melanin; therefore, patients of all skin types, including darker skin types and those with a predisposition to develop post-inflammatory reaction due to a rise in skin temperature can be treated with RF. As discussed, the heating of the fat is due to the fact that the fat is far more resistant to the passage of the radiofrequency, this resistance is what generates controlled heat. The table quantifies this level of resistance to RF in fat compared to other structures.

The basic principal of physics is that resistance to the passage of electrical energy creates heat. The table to the left represents the differences in conductivity in the various tissue structures.

Methods of application Radiofrequency current can be applied to the skin in various manners. Monopolar devices have a single electrode that is placed on the treatment area. A grounding pad is placed in an area distant from the treatment area, generally on the back of the patient. The depth of penetration of monopolar radiofrequency

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depends on the impedance of the tissue and on the size of the electrode. Depth of penetration of monopolar systems can easily reach the subcutaneous fat at some settings, typically for a large applicator approximatly 100 watts is sufficient.

Bipolar devices consist of two electrodes placed over the treatment area. The depth of penetration of the RF is based on the tissue impedance and the distance between the two electrodes.

The further the distance between the electrodes, the deeper the penetration. Bipolar RF is more superficial than monopolar RF. To summarise the difference between monopolar and bipolar, we must understand that electricity will seek the path of least resistance. Monopolar: the energy passes from the applicator through the body to a return grounding pad, thus enabling the heating of deeper structures. Bipolar: the energy passes between the negative and positive pole within the applicator head, the depth of penetration is determined by the distance between these two poles. The depth is approximatly half the distance of

Results Porcine model demonstration volume fat reduction after RF application

Pre four applications of RF

Post four applications of RF

Pre and post application of three non-contact RF applications

10/07/2013 Pre four applications of RF

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13/07/2013

26/07/2013

Post operative four applications of RF

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the space between the two poles. For effective treatment of fat, deeper penetration of heat is needed, hence a monopolar system would seem to be more efficacious. However, where less depth of thermal zone is required, for example when remodelling the dermal layer, then bipolar will have sufficient depth of penetration for tissue tightening and collagen production. A number of devices will use some form of suction in order to pull the tissue into the delivery head in order to allow deeper penetration of the bipolar energy than one would achieve by normal application.13 It is imperative that tissue temperature of 42 degrees in the dermis and 45 degrees in the fat are achieved and maintained for a period of time in order to invoke the structural changes discussed above.14 In early RF devices, the incidence of pain was reportedly quite high. However, in the very latest systems one will find a variety of technical solutions to artificially cool the skin whilst raising the temperature of the structures below.15 Conclusion There are many different types of RF systems currently in use globally for both body contouring and skin tightening. Depending on your requirements in your clinical setting, consideration should be given to the following key components depending on what you are trying to achieve. In treating deeper layers of fat, consider monopolar over bipolar in order to create deeper thermal profile increases in temperature. In achieving therapeutic temperatures some form of cooling at the application interface should be employed to improve patient comfort. To achieve consistent results the skin temperature should be measured to ensure that the therapeutic temperature has been reached. Prior to this the indication of erythema was the only endpoint, which varies from patient to patient.

Lee Brine is a qualified engineer from the aero industry, with a career in medical technologies. Lee works predominantly with lasers and radiofrequency energy sources, covering a wide range of surgical specialities.

Lee is currently a consultant for BTL aesthetics, advising on the clinical applications of the latest developments in RF for aesthetic procedures.

REFERENCES 1. Curtis, Thomas Stanley, High Frequency Apparatus: Its Construction and Practical Application,

(USA: Everyday Mechanics Company, 1916), p. 6 2. Uitto J, ‘The role of elastin and collagen in cutaneous aging: intrinsic aging versus photoexposure’, J Drugs Dermatol, 7 (2 Suppl) (2008), S12–S16.

3. Sarwer DB, Magge L, Clark V, ‘Physical appearance and cosmetic medical treatments:

physiological and sociocultural influences’. J Cosmet Dermatol, 2 (2003), pp. 29–39 4. Hexsel D, de Oliveira Dal’Forno T, Cignachi S, ‘Social impact of cellulite and its impact on

quality of life’. In: Goldman MP, Bacci PA, Leibaschoff G, Hexsel D, Angelini F, (editors), Cellulite:

Pathophysiology and Treatment, (New York: Taylor & Francis; 2006), pp. 1–5 5. Body Contouring Devices Market - Global Industry Analysis, Size, Share, Growth, Trends and Forecast, Transparency Market Research (2013 – 2019) 6. Avram MM, Avram AS, James WD, ‘Subcutaneous fat in normal and diseased states: 1.

Introduction’, J Am Acad Dermatol, 53 (4) (2005), 663–670.

7. Nürnberger F, Müller G. ‘So-called cellulite, an invented disease’. J Dermatol Surg Oncol. 4

(1978), pp. 221–229 8. Piérard GE, Nizet JL, Piérard-Franchimont C, ‘Cellulite: from standing fat herniation to

hypodermal stretch marks’, Am J Dermatopathol, 22 (2000), pp. 34–37 9. Vander Vorst, Andre; Rosen, Arye; Kotsuka, Youji, RF/Microwave Interaction with Biological Tissues, (New Jersey: John Wiley and Sons, Inc., 2006) 10. WHO. Obesity: preventing and managing the global epidemic. Report of a WHO Consultation.

WHO Technical Report Series 894, (Geneva: World Health Organization, 2000.)

11. M. Berg, Jeremy; L. Tymockzo, John; Stryer, Luber, Biochemistry 7th Edition (New York: W.H

Freeman, 2011) 12. Hsu TS, Kaminer MS. ‘The use of nonablative radiofrequency technology to tighten the lower

face and neck’, Semin Cutan Med Surg, 22 (2003), pp. 115–23 13. Hollmig, S. Tyler; Hantash, Basil M., Radiofrequency in Cosmetic Dermatology: Recent and

Future Developments , Cosmetic Dermatology, 26 (2011), p. 568 14. Welch, Ashley J., van Gemert, Martin JC (Eds.), Optical-Thermal Response of Laser-Irradiated Tissue, (New York: Springer Science & Business Media, 2011) 15. Fitzpatrick R, Geronemus R, Goldberg D, Kaminer M, Kilmer S, Ruiz-Esparza J, ‘Multicenter

study of noninvasive radiofrequency for periorbital tissue tightening’, Lasers Surg Med. (2003),

pp. 33:232

Aesthetics | September 2014

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Dr John Quinn addresses the complications that can occur when treating patients with dermal fillers

Filler complications Complications are, unfortunately, inherent to any medical procedure. When they occur in the NHS, there is a degree of understanding amongst patients and medical professionals. In the private sector where cosmetic medicine exists, complications are less accepted and there is a propensity for the incident to become a story in a daily newspaper. With so much of our education being sponsored by drug companies, complications have previously been glossed over and many of us have personal experience of insufficient or no support at all in the event of a poor outcome.

General considerations There are some simple steps that a practitioner can take to reduce the risk of complications. My personal view is that dermal filler procedures should be done in a regulated healthcare setting, ideally a Care Quality Commission regulated clinic. Adherence to aseptic and ‘no touch’ techniques is essential. The importance of hand washing cannot be overstated. I use a sterile pack, swabs and gloves for each procedure I perform. I cleanse skin with chlorhexidine. There is evidence that this provides better, more prolonged anti-microbial action than with alcohol.1 Either way, I advise using an additional substance other than the one you use to remove the patient’s makeup. I personally use multiple needles or cannulas per procedure, and this is of particular importance with deep, volumising injections.

On training days, I frequently see practitioners touch or wipe their needle with a swab before injection. This is not sensible and should be avoided. If I touch my glove with a cannula, I change the cannula.

In terms of injection technique, go slowly and inject small amounts per injection point. Slow injections are less uncomfortable for the patient and reduce the risk of bruising and swelling and will likely make late complications less frequent.2 After the procedure, I have my patients apply some alcohol gel to their hands, instruct them not to rub their face and, ideally, avoid makeup for the rest of the day. If they must apply make up (I am a realist!), then I ask them to make sure that it is brand new and therefore does not harbor any bacteria.

Early complications Early complications – within a few days of the procedure – are generally related to the physical act of injection itself. Bruising and swelling may be seen as side effects rather than as complications.

I consider them a complication if the patient has to avoid social events. This is somewhat arbitrary, as patients will obviously differ.

To reduce the risk of bruising and swelling, I try to use the smallest needle possible and, in danger areas, I choose a blunt tipped micro cannula to place my product. An awareness of vascular anatomy aids in locating where large vessels may sit and is important, but in reality there is considerable variation. The facial artery runs a tortuous course just lateral to the nasolabial fold, where it changes its name to the angular artery. The angular vein is a small vein near the eye. It is formed by the junction of the frontal 30

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vein and supraorbital vein, runs obliquely downward, on the side of the root of the nose, to the level of the lower margin of the eye socket, where it becomes the anterior facial vein. Branches of the facial vein frequently run along the marionette fold and this is a very common area for noticeable bruising, in my experience. For this reason, this is an area where I almost exclusively use a cannula.

When augmenting the lip, it is important to remember that the labial artery runs deep in the body of the lip. Thus injection on the wet dry border is likely to bruise.

Usually, swelling will settle within a few days. Certain products tend to swell more, related to their hygroscopic properties.3 The lips are a particularly common place to see noticeable swelling, and therefore I warn patients of this. My standard practice is to use no more than 1ml in an initial lip enhancement, and I frequently use a 0.5ml syringe. My experience is that patients often prefer their lips when swollen. I then retreat the area, at least two weeks later. Using an ice pack post procedure is sensible and oral steroids for early swelling are sometimes used. However, bruising is hard to predict.

I try to ensure that my patients have no major social engagements for a week post procedure. When severe bruising occurs, it is possible to hasten the resolution by use of a vascular laser. This has been looked at using a pulsed dye laser4 but I have also had some success in my clinic using my Lumenis One IPL. The most catastrophic potential complication is intravascular injection of filler, leading to tissue necrosis and potential scarring.

This is not an issue that was spoken about on any early dermal filler course that I attended. A sound knowledge of the surface anatomy is essential when injecting dermal fillers. However, as previously mentioned, there is very considerable variation and so awareness of the danger areas and some simple tips can reduce your risk.

The most common problem areas are the glabella, the nasolabial folds and the nose.5 The glabella is an issue because the supratrochlear and supra orbital arteries, both branches of the internal carotid artery system, are end arteries. This means that there is little collateral circulation in the event of cannulation and inadvertent injection. There is also little distance between the skin and periosteum of the frontal bone in this area. The patients with the deepest frown lines are the patients most at risk. These are the very patients who are often less impressed with initial toxin treatment and thus request fillers. My practice is to try and identify these patients pre treatment. I communicate to these patients that their static lines will improve but will not be eradicated by one toxin treatment. The use of photographic documentation is extremely important here, and is a practice that should be applied to all aesthetic procedures.

I tell these patients that their lines will improve on repeated treatment as per the original FDA approval study for Botox in the USA demonstrated. If the patient remains unhappy after three treatments, then filling only becomes easier as the glabellar lines will be less deep after treatment with toxin. It is also possible to create a problem by compression of the glabellar arteries, as well as by cannulation and embolisation.6 This is again because of there being little space between the skin and periosteum in this area. These patients will later present with signs of necrosis, a point discussed later in this article.

The nasolabial fold is one of the first areas that we learn to inject as cosmetic practitioners. As previously mentioned, the facial artery, a branch of the external carotid artery, runs a tortuous course, usually just lateral to the fold. It gives off labial branches, upper and lower, just lateral to the oral commissure. At the base of the nasolabial fold, the nasal ala, there is frequently a branch that passes medially.

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Clinical Practice Clinical Focus

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I am always watching for signs of arterial compromise, namely; pain and pallor.

Inadvertent injection into this artery can potentially cause embolism and produce an infarction affecting the nose.7 It is also possible to compress the artery. As with the glabella, this will tend to present slightly later. I always warn my patients that pain is not normal post fillers, and to call the clinic if they have any concerns. An emergency contact number is essential.

Recently, nose reshaping has become a not uncommon procedure.

My personal opinion is that this should be done by specialists, and not by a practitioner following a one-day course. Nasal tip necrosis can occur post fillers; this relates to the compression of vessels in the area.8 Proximal embolisation can occur, particularly at the nasal bone, which can cause permanent blindness.9 Practical considerations include injecting slowly and to constantly move the tip of the needle. Avoid bolus injections in these areas. I have seen some practitioners advocate aspiration but I have never felt dexterous enough to be positive that my needle tip stays in the exact same position post aspiration. Also, although it may be possible, I don’t think that it is easy to withdraw blood with a 30g needle. Despite this, I always aspirate when injecting a bolus. I tend to do this in the midface only. In this situation I use a 27G needle, advancing towards the periosteum. I steady my syringe with my left hand and aspirate. I inject very slowly and tend to avoid any more than 0.2ml of product per site. I am always watching for signs of arterial compromise, namely; pain and pallor. If the catastrophic event of vascular compromise is apparent, treatment includes massage, heat, topical GTN (if available) and hyaluronidase. If arterial emobilisation has occurred, then hyaluronidase is unlikely to be of great benefit, but I would still advocate its use. Early referral to a plastic surgeon is essential. Superficial areas of necrosis may heal well but appropriate wound care is paramount. I would not patch test in this situation – it is an emergency.

Blindness post dermal fillers has been reported in the literature in recent years.9 In reality, most of the cases have been related to fat injections but it is possible with most materials. The bulk of the arterial supply of the face comes from the external carotid artery system. The exceptions are, as previously mentioned, the arteries of the glabella, supratrochlear and supraorbital. These emerge from the orbit as branches of the internal carotid artery.

They thus communicate with the retinal artery. There are multiple anastomoses between the external and internal carotid systems in the areas of the base of the nose, the temple and even the tear trough. These are all areas where I urge extreme caution.

Infection is a risk post implantation of any medical device. Fillers are no exception. Increasing tenderness or erythema are signs 32

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and patients should be warned of this. Prompt intervention with bacteriocidal antibiotics is essential. Sensible options are macrolide antibiotics such as clartihromycin 500mg bd or ciprofloxacin 750mg bd. Treatment is for two weeks, at least.

Medium term complications After a few weeks, hyaluronic acid fillers should be integrated into the host dermis. Palpability of product at this stage is possible but may indicate a problem. Over injection into an area can produce palpable nodules. These may simply be massaged if they are small and not inflamed. Any sign of infection should prompt early treatment with antibiotics. Hyaluronidase may be used to dissolve hyaluronic acid filler if it is visible or unacceptable from a cosmetic point of view. Common areas that I am asked to treat include the lip, the tear trough and cheeks.

Injections into the body of the lip frequently lead to unevenness.

Presumably muscular contraction of orbicularis oris compounds this problem and collects the product into pockets. It may simply be injection related also. Bluish discolouration can occur with any HA filler. This tyndall effect is related to refraction of light off the HA particles. I have seen this with all the fillers that I use, apart from Belotero.10 I now use this as my first line product for superficial injections. The discolouration can last for years, long past when one would expect the filler to have been degraded by the patient. My experience has been that the more superficial the filler is placed, the longer it tends to last. I have used hyaluronidase several years after implantation and resolved the tyndall effect in a number of referred patients. Most recently, I saw a patient with swelling under her right eye, which she’d had for four years. Her practitioner had told her that she was allergic to the filler. After three sessions with hyaluronidase, she felt happy to be photographed on holiday again.

When using hyaluronidase, it is important to discuss with the patient that it is unlicensed for dissolving filler. It is an animal product so there is a risk of hypersensitivity. There is debate, but standard practice is to patch test on the forearm before injecting into the face. Hyalase is a commercially available product in the UK. It comes in 1500 iu vials and is used mainly in anesthesia. To dissolve HA filler, 10-15 units are usually sufficient per 0.1ml of HA. I add 1.5ml to the vial, then withdraw 0.1ml and draw this up to 1ml. This gives me 10 units of hyalase per 0.1ml. I allow 24 hours between patch test and treatment. I tend to start with small amounts as there have been reports of the product dissolving the patient’s innate HA.11 I haven’t seen this in my practice however. Repeated treatments may sensitise the patient, so I try to do what is required within a small number of treatments. I always have hyalase in my clinic in case of an emergency, as discussed previously. This is crucial to have onhand, in my opinion.

Late complications Thankfully the risk of late reaction to commercially available nonpermanent fillers is very low.12 There is really no reason to use permanent fillers in my opinion. Apart from the difficulty in removing them, should there be a problem, the fact that facial ageing is a dynamic process means that anything permanent may not be as aesthetically attractive several years later.

It is increasingly recognised that late reactions to dermal filler are related to low-grade infections known as biofilms.13 These entities are well known in medicine and dentistry. They consist

Aesthetics | September 2014

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of aggregations of, usually, relatively low pathogenic bacteria, collected onto a matrix of implanted material. The foreign body acts as an anchor for colonisation and subsequent secretion of protective polysaccharides. This shields them from antibiotic treatment. Patients presenting with late nodules should be empirically treated with high dose bacteriocidal antibiotics.

Otherwise the biofilm becomes more resistant and difficult to eradicate. It is often required to remove the implanted material for resolution of the problem. This is why, now, I only use hyaluronic acid fillers for facial revolumisation.

In my practice, I have seen two cases that I have treated as biofilm.

Both presented several months after cheek enhancement with slight swelling and discomfort in the treated areas. I prescribed clarithromycin 500mg bd for 4 weeks and used hyaluronidase while on antibiotic cover. Both settled on this regime. Dr K De Boulle from Belgium has suggested using ciprofloxacin 750mg bd for one month in the first instance.14 There is a risk of tendonopathy with this so patients must be warned against vigorous physical activity. Others have advocated using dual therapy. Either way, a prolonged course of high dose antibiotics is indicated.

Given the trend for deep volumising injections and the variation in training/ability and inappropriate venues for treatment, there is, unfortunately, every likelihood, that we will see an increase in these biofilm reactions in the future. As discussed, complications are sometimes inevitable, but taking a stringent approach to technique and delivery will ensure that any unnecessary complication in an aesthetic procedure is avoided.

Clinical Practice Clinical Focus

Dr John Quinn is an Irish qualified general practitioner with over 9 years experience in cosmetic medicine.

He is a full member of the British College of Aesthetic Medicine and has completed the Post-graduate diploma in Clinical Dermatology at Queen Mary University, London. He has a clinic in Bristol and Greenwich.

REFERENCES 1. Edwards, PS, A Lipp, A Holmes, Preoperative skin antiseptics for preventing surgical wound infections after clean surgery (Review), (onlinelibrary.wiley. com, 2004) < http://onlinelibrary.wiley.com/store/10.1002/14651858.CD003949. pub2/asset/CD003949.pdf;jsessionid=74C4104CC225C8A110CFC110400AD6F0. f03t03?v=1&t=hyvmz0gq&s=9266307ef6dc10089cbf77181867901df2bbc7c1> 2. Boulle, K De, ‘Management of complications after implantation of fillers’, Journal of cosmetic dermatology, (2004) 3. Kablik, Jeffrey, et al., ‘Comparative physical properties of hyaluronic acid dermal fillers’,

Dermatologic Surgery, 35.s1 (2009), pp. 302-312 4. DeFatta, Robert J, Srinivasan Krishna, and Edwin F. Williams, ‘Pulsed-dye laser for treating

ecchymoses after facial cosmetic procedures’, Archives of facial plastic surgery, 11.2 (2009),

pp. 99-103.

5. Glaich, Adrienne S., Joel L. Cohen, and Leonard H. Goldberg, ‘Injection necrosis of the

glabella: protocol for prevention and treatment after use of dermal fillers’, Dermatologic surgery, 32.2 (2006), pp. 276-281 6. Narins, Rhoda S., et al, ‘Clinical conference: management of rare events following dermal

fillers—focal necrosis and angry red bumps”’, Dermatologic surgery, 32.3 (2006), pp. 426-434.

7. Grunebaum, Lisa Danielle, et al., ‘The risk of alar necrosis associated with dermal filler injection’, Dermatologic Surgery, 35.s2 (2009), pp. 1635-1640 8. Humphrey, Clinton D., John P. Arkins, and Steven H. Dayan, ‘Soft tissue fillers in the nose’,

Aesthetic Surgery Journal, 29.6 (2009), pp. 477-484 9. Kim, Young Jun, et al., ‘Ocular ischemia with hypotony after injection of hyaluronic acid gel’,

Ophthalmic Plastic & Reconstructive Surgery, 27.6 (2011), e152-e155 10. Kühne, Ulrich, et al., ‘Five-year retrospective review of safety, injected volumes, and longevity

of the hyaluronic acid Belotero Basic for facial treatments in 317 patients’, Journal of Drugs in Dermatology, 11.9 (2012), pp. 1032-1035 11. Brody, Harold J, ‘Use of hyaluronidase in the treatment of granulomatous hyaluronic acid

reactions or unwanted hyaluronic acid misplacement’, Dermatologic Surgery, 31.8 (2005), pp.

893-897 12. Andre, P., et al. “Adverse reactions to dermal fillers: a review of European experiences.”

Journal of Cosmetic and Laser Therapy 7.3-4 (2005): 171-176 13. Rohrich, Rod J, et al., ‘Soft-tissue filler complications: the important role of biofilms’, Plastic and

reconstructive surgery, 125.4 (2010), pp. 1250-1256 14. CODE Meeting, Toulouse, France, September 2013

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Clinical Practice Techniques

Hair Transplantation in Younger Patients Dr Sotirios Foutsizoglou discusses the benefits, limitations and controversy associated with performing hair restoration surgery on younger patients

For years, hair transplant surgeons have debated whether young balding individuals could be candidates for a hair restoration procedure, and the effects of Follicular Unit Extraction (FUE) and Follicular Unit Transplantation (FUT) on their donor zone. The problem lies in that it is very difficult, if not impossible, to identify the safe, permanent donor area when a person is young. In fact, at a young age, it is not always possible to determine with certainty if any of oneâ&#x20AC;&#x2122;s hair will be permanent or what the ultimate quality of that hair will be.1 But what constitutes a â&#x20AC;&#x2DC;youngâ&#x20AC;&#x2122; patient? As a general rule, when treating androgenetic alopecia, most surgeons consider 25 to be the minimum age for hair transplant surgery. Before this age the evaluation of the alopecic patient, made usually by a thorough medical history, family history, and detailed physical examination, complemented by selective laboratory investigations and densitometry, used to measure hair miniaturisation, proves very hard to predict the pattern of female or male baldness and the degree of ultimate hair loss. Patterned hair loss, the most common type of hair loss affecting men and women, is characterised by a process of progressive hair miniaturisation whereby large, pigmented, terminal hairs are replaced by fine colourless vellus hairs.2 Androgens play an important role in this process of miniaturisation, hence the reason both male pattern hair loss (MPHL) and female pattern hair loss (FPHL) are collectively referred to as androgenic or androgenetic alopecia.

In patterned hair loss there is a gradually shortening anagen phase resulting in affected hairs becoming shorter and finer.

The recession observed in androgenetic alopecia follows a pattern and therefore the degree of hair loss is somehow predictable, allowing hair transplant surgeons to assess and plan treatments accordingly.

In men, this condition preferentially affects hair on the superior and anterior temporal areas of the

scalp, whereas in women it more commonly presents in a diffuse pattern in the crown, with or without sparing of the frontal fringe. Patients who go bald at a very young age (i.e. under the age of 25 years) are prone to developing more extensive and occasionally non-pattern hair loss than those who thin later in life.

Diffuse un-patterned alopecia (DUPA) is a contraindication for hair restoration surgery as the instability of the donor area increases the risk of scarring becoming visible (whether it is the linear scar of FUT or the small, round scars of FUE). The simple solution would then be to not operate on younger patients.

However, no one likes losing his or her hair and it is particularly upsetting when it occurs in the second or third decade of life. Visible thinning in teens and early twenties often progresses to advanced alopecia by the end of their third decade.

This can cause great personal stress, especially due to the fact that the majority of their peers maintain the appearance of a full head of hair.

Arbitrarily not transplanting these patients, because of their age, could be considered unfair. Every case is different and should be judged on its merits.

Some doctors may argue that conservative surgery would be less harmful to these young hair loss sufferers than condemning them to many years of low esteem.3 Their argument is based on the fact that a large majority of men who will eventually develop type VI male pattern baldness (MPB) will still have long-term donor-recipient area ratio that is adequate to transplant a cosmetically acceptable density of hair. Interestingly, FPHL is less difficult to predict in younger patients. We know from experience that while frontal female hairlines frequently become more sparse with time, they are never entirely lost.4 Therefore it is safer to transplant Fig. 1 - The Hamilton/Norwood classification of degrees of severity of Male Pattern Baldness with Type I the least severe and Type VII the posterior to the hairline. most severe.

In addition, women tend Aesthetics | September 2014

35

Clinical Practice Techniques

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to maintain fairly good density in the occipital scalp, so their surrounding hair can easily cover whatever donor area scars may result from hair transplantation surgery.5 Notwithstanding the above, it cannot be overly emphasised that the hair restoration surgeon should, ideally, take a conservative approach with women, and men in particular, in their early 20s, especially if they have Norwood Types III-vertex, IV, or V MPB (Fig. 1). It is wise to assume that a younger male patient will probably progress to at least a Norwood Type V balding pattern and plan accordingly. Ominous signs in a young hair loss sufferer that point to the possibility of a very advanced stage of alopecia (i.e. Norwood Type VII), which is an absolute contraindication to surgery are the following:6 • • • •

A father or maternal grandfather with a Norwood Type VII pattern or worse The presence of whisker hair, around the ears The absence of dense fringe hair The presence of diffuse non-pattern (or un-patterned) alopecia presenting as rapidly progressive, generalised thinning at a young age • Repeatedly higher than average miniaturised hairs in potential donor areas • MPB beginning in teenage years

Case Study Patient JB is a 30-year old male complaining of progressive hair loss and a visible donor scar. He had two hair transplant procedures at ages 21 and 22.

At the time, he was told he was a good candidate for surgery. Following his procedures he was started on finasteride and minoxidil. In spite of a hair transplant and medical therapy, the patient’s hair continued to thin. Within a few years, his donor scar became obvious, presenting a cosmetic problem far greater than his hair loss. On physical examination, JB had a persistent frontal hairline, generalised thinning, and a readily visibly donor scar. Densitometry revealed a donor density of 1.2 follicular units /mm2 and 90% donor miniaturisation consistent with a diagnosis of diffuse unpatterned alopecia (DUPA) which is a contraindication to hair restoration surgery (Fig. 2). Current surgical options for this patient remain extremely limited, as there is no permanent zone to harvest hair. Scar revision surgery may improve but will not eliminate his existing scar.

Scalp micro-pigmentation can be discussed, but will give only partial Fig. 2 - Visible donor scar in a patient with DUPA cosmetic improvement.

Discussion The age at which to perform a hair transplant procedure on a young man or woman has been a controversial topic for decades.

The decision making process, as to whether surgical hair restoration is appropriate for the presenting young patient, should include being on the lookout for certain red flags that could influence the physician’s evaluation.

A thorough understanding of the pathophysiology of hair loss, the limitations of hair restoration surgery, its risks and benefits, as well as short- and longterm consequences can help establish whether or not a young patient is an appropriate candidate for a hair transplant procedure.

Establishing a proper diagnosis is indispensable in determining prognosis and making treatment decisions. The case study young man could have been spared a failed hair transplant procedure and an unsightly donor scar if DUPA was diagnosed in the first place. Transplantation provides consistently natural results and if a patient understands the long-term cosmetic limitations of hair transplantation, all patients are potential candidates for surgery. Transplanting or not transplanting based on arbitrary age limits is unfair to patients, and has little 36

Aesthetics | September 2014

Aesthetics

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As with all patients, young patients must have realistic expectations as to the ongoing nature of their hair loss or no medical basis.3 As with all patients, young patients must have realistic expectations as to the ongoing nature of their hair loss, the limited amount of donor hair available, and how this will impact the future cosmetic appearance and extent of their transplanted areas. Although no rigid age limit should exist with regards to hair restoration surgery, in my opinion, no matter what the cause of the hair loss problem may be, targeted pharmacotherapy, following a pertinent diagnosis, is the best initial choice for all patients under the age of 25. For instance, the combination of finasteride and minoxidil can slow down, and to some extent, prevent the progression of androgenetic alopecia into an advanced stage. Thus it gives patients time to think about their options and to adjust to the fact that, regardless of surgical or medical treatment, they will never have a full head of hair or the low hairline that they once had.1 Dr Sotirios Foutsizoglou is the founder and medical director of SFMedica. He specialises in minor cosmetic surgery and aesthetic medicine. He is a member of the International Society of Hair Restoration Surgery (ISHRS) and performs hair transplant surgery on Harley Street, London. He is also the senior instructor in facial anatomy and lead trainer in advanced non-surgical procedures with KT Medical Aesthetics Training Group.

REFERENCES 1. Bernstein RM, ‘Age and the donor zone in FU hair transplants’, Hair

Transplant Forum, 23 (2013), Number 3.

2. Paus R, Cotsarelis G, ‘The biology of hair follicles’, N Engl J Med, 341 (1999),

pp. 491-7 3. Reich J, ‘The surgery of appearance: psychological and related aspects’,

Med J Aug, 7 (1989), pp. 5-13.

4. Shapiro J, ‘Clinical Practice. Hair loss in women’, N Engl J Med, 357 (16)

(2007), pp. 1260-30 5. Avram MR, Rogers NE, Later and Older. Hair Transplantation, 5th Edition.

Informa Healthcare (2011) 6. Unger W. Planning and Organisation. Hair Transplantation. 5th Edition.

Informa Healthcare 6A (2011), pp. 106-150.

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Clinical Practice Clinical Focus

Menopause Fleur-Louise Newsom explores the various physical and emotional symptoms associated with the menopause, and how these can be managed Menopause naturally occurs in women aged between 45 and 55, although it can also start slightly earlier or later in a woman’s life. The beginning of menopausal symptoms is often known as the perimenopause. The symptoms can vary, and not all women experience each of the symptoms. Regardless, the menopause is a life-changing event for all women, and one that requires special care and attention from an aesthetic medical professional.

One of the first signs of the menopause is a change in a woman’s monthly cycle. It can become heavier or lighter, and become more irregular as time goes on. Amongst the symptoms of menopause are a few that can cause much discomfort. These can include hot flushes, headaches, urinary tract infecions, osteoporosis, vaginal dryness, pain and itching, cardiac issues, weight gain and skin ageing (amongst others).

These symptoms often last for a period of two to five years, during which time the body is accepting the fact that it will no longer be ovulating. This is caused by a natural change in the body’s sex hormones, as levels of oestrogen start to decrease. This prevents ovulation and marks the start of the symptoms stated above. There are, however, several coping strategies for dealing with the indicators of menopause. These are often dependent on the patient’s individual preferences; patients can opt to treat menopause medically with HRT (Hormone Replacement Therapy)1 or more holistically with alternative therapies such as herbal supplements, choosing a healthy diet and also with health care products designed for menopause issues such as Promensil, Menopace, Stratum C Menopause Skin Care, A.Vogel products, Balance Activ, and Wild Yam Cream.

Changes in appearance During menopause, the reduction in oestrogen can cause the body to make permanent changes in its appearance and function, hence this time is often known as

‘the change’. Some noticeable differences include the hair becoming thinner and more brittle, often breaking more easily. The skin becomes drier, often becoming itchy and uncomfortable and there is a period of accelerated skin ageing as collagen and elastin levels begin to decline. Some women can experience further skin irritation and sensitivity due to the skin becoming thinner.

For example, rosacea can occur, which sometimes appears as permanent redness and spots and can cause the person to feel that their skin is burning. The cause of rosacea is unknown, but it is reported2 that menopause is one of the possible triggers. The physical symptoms that occur as a result of menopause are often the most distressing, and the lack of oestrogen can initiate further health problems, such as higher risk of osteoporosis3 and heart-related illnesses2. This is caused because oestrogen usually regulates the body’s ability to maintain healthy levels of bone mass, and also helps to maintain blood pressure and cholesterol. Studies have shown that whilst hormone replacement therapy (HRT) can be used to prevent osteoporosis in women that experience early menopause3, it is not recommended for women with an increased risk of cardiovascular issues (also relating to many other external factors such as family history, for example)4.

Physical changes Skin care can become more of an issue at this stage of life. It seems to me that ageing is something that we accept as time goes on and most of us understand that wrinkles are just an unfortunate part of dealing with ‘getting old’. However, as well as this, menopause can also initiate changes in the skin that are less ordinary and often uncomfortable such as itching, redness and dryness5. This change is caused by the body’s lack of oestrogen, which in turn causes your body’s natural supply of collagen (the structural protein of connective tissues in the body), elastin (protein found in the body’s connective tissues such as skin and organs) and Hyaluronic acid (found in the eyes and Aesthetics | September 2014

joints as a lubricant) to decrease as you age6.

These three naturally occurring substances help to keep your skin plump and moist.

We always recommend that our customers sample new skin care products before they are applied to ensure that the products are suitable for their hormonally changing skin.

We encourage people to read more about what they are putting on their skin, taking care to note down any ingredients that they may find problematic. The best products to keep the skin moisturised and to retain elasticity are those that stimulate natural synthesis of the body’s own supply of collagen and elastin, as actual collagen molecules are too large to penetrate the skin7 and so topical collagen will not have any effect. Though this is not the case for HA which will penetrate the skin and provide intense moisture where needed8.

Education here is key to helping women understand the fundamental changes to their bodies and how to increase awareness of ways to reduce worsening symptoms. Some of the most common physical symptoms are hot flushes and night sweats, which can lead to further skin problems, such as itching5 due to raised stress levels, and can generally be an uncomfortable experience and often quite inhibiting for the sufferer. Another common symptom of menopause is drying of the vaginal membrane, also known as vaginal atrophy (VA)9. This occurs because of lack of oestrogen and can be very uncomfortable, sometimes even painful for the patient. VA causes issues when it comes to sex and can be treated with a lubricant or vaginal moisturiser that will help to restore levels of moisture to the area, relieve the dryness and bring normality back to a woman’s everyday life. The lack of libido during this time can often cause further psychological difficulties such as a lack of confidence and depression, which can be treated with the 39

Clinical Practice Clinical Focus

advice of a medical professional. Amongst the symptoms listed above, fatigue and mood swings are said to be associated with a decrease in hormones, though there is varying scientific evidence to support this10.

Emotional support can be sought/provided to accommodate the needs of women on whom menopause may have had an emotional effect, such as counselling, and also to help them to adjust to the changes and manage the symptoms that menopause can bring.

Treatments for menopause vary depending on the severity of symptoms suffered by an individual, and is dependent on their existing health. Many women opt for HRT if they have experienced an early menopause, though some sources11, would recommend that this does not need to be taken by all women and that cessation of HRT treatment should occur at the age of 50, as taking HRT for longer than necessary (average between two to five years) can cause unnecessary side effects, including an increased risk of breast cancer2. HRT is usually prescribed to help prevent osteoporosis, though it can also help to prevent or at least ease hot flushes and vaginal dryness.

Treatment One of the key aspects of managing menopausal symptoms is a healthy balanced diet. Many women have found that they are able to manage the various symptoms by eating certain types of food and avoiding others. These might include dairy in high quantities, alcohol, sugar, caffeine, spicy food, processed foods/saturated fat and hot food and drink when suffering severe flushes.

This is to help relieve and prevent symptoms that can often be exacerbated by eating these particular foodstuffs. Women should generally eat a healthy and balanced diet as part of their lifestyle, which will help to improve their physical wellbeing and also help to prevent weight gain, which is reportedly common during this stage of life.

There are many foods that are said to help during menopause, but the research on these is inconclusive and arguably lacking in substantial scientific evidence. However, large numbers of females who have incorporated these foods into their diets have claimed that they made a significant difference in helping them to cope with their menopause symptoms, including black cohosh, red clover, wild yam, evening primrose oil and angelica sinensis. I’m not saying that menopausal women should stock up on supplements.

Numerous people worry about their calcium and vitamin D levels, but it is clear that these 40

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can be managed successfully with a balanced diet of fruit, vegetables and healthy fats and proteins found in foods such as avocado, nuts, legumes, fish and many other food types12.

Another important factor to help prevent ageing is to drink enough water. This of course applies to all patients, and not just to menopausal women, as drinking water can not only help improve your digestive health, but can better the appearance of skin13 and make the patient feel revitalised and refreshed. I have mentioned that skin ageing is a great concern for many women and it is important for patients to know that there are many ways in which this can be controlled.

Eating and drinking well is a prominent factor as skin excretes the toxins we put into our bodies, and the physical signs of this can be blemishes, oiliness and wrinkles14.

Skin can also be cared for using the correct skincare products and cosmeceuticals, ensuring that they contain no harmful ingredients and that they suit the patient’s skin type, which changes during this stage of life . Products that contain alcohol based ingredients are often too harsh for sensitive, thin or dry skin and can cause allergic reactions or cause the skin to become oily15. Using specific products targeted for menopause will assist in caring for changing skin and also help to prevent the accelerated ageing that is expected during this period.

Many women choose more invasive procedures, however this can often be problematic due to the high sensitivity and thinning of the dermis during menopause.

In the optimum quantities, and according to the latest scientific research, Matrixyl helps to increase collagen levels by up to 70%.16 Matrixyl 3000 (a combination of the peptides: Palmitoyl Oligopeptide and Palmitoyl Tetrapeptide 7) has been used in many ‘antiageing’ products, but is often not used in the correct quantities to make an impact on skin ageing. The correct quantities used should be between a 3-8% concentration, as per the research published in the Journal of Molecular Pharmaceutics16. Products tailored to treat menopausal skin should, in my opinion, contain high levels of quality ingredients that replenish vitamins and anti-oxidants. Skincare products targeted at menopausal women also often contain high levels of hyaluronic acid, a naturally occurring substance that helps keep your skin hydrated and improve elasticity8. It is essential to care for the skin with high quality products to prevent it from becoming dry, itchy and above all, wrinkly. The skin is, after all, the largest organ in the body, and must be Aesthetics | September 2014

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taken care of, particularly during this period.

Menopause is a time for change, but it does not have to be a change for the worse. By advising your patients as to the right way to care for their bodies, and realising the importance of managing symptoms properly, women can navigate their way through the menopause whilst paving the way to an overall healthier lifestyle.

Fleur-Louise Newsom studied ITEC and City & Guilds in Beauty Therapy and quickly realised her passion was in skincare. With 20 years experience in the industry and with her vast knowledge of skincare and wellbeing, she works closely with the product development team at Stratum C and answers queries relating to menopause skincare.

REFERENCE 1. British Menopause Society, Managing the menopause.

British Menopause Society Council consensus statement

on hormone replacement therapy. (London: Journal of

British Menopause Society, 2003) Vol.9, No.3: (p129-131) 2. NHS Choices, Symptoms of the menopause. (London: NHS

Choices, 2014) < http://www.nhs.uk/Conditions/Menopause/

Pages/Symptoms.aspx> [accessed 25 June 2014] 3. Currie, Dr Heather, Osteoporosis. (Scotland, Menopause

Matters, 2011) <www.menopausematters.co.uk>[accessed

25 June 2014] (p.1) 4. The John Hopkins University, Menopause and the

Cardiovascular System. (Maryland, USA: The John

Hopkins Univeristy, 2014) <http://www.hopkinsmedicine.org/ heart_vascular_institute/clinical_services/centers_ excellence/womens_cardiovascular_health_center/patient_ information/health_topics/menopause_cardiovascular_

system.html> [accessed on 26 June 2014] 5. Durward, Eileen, Why is the menopause giving me itchy

skin? (Irvine, Scotland: A. Vogel, 2013) <http://www.avogel.

co.uk/health/menopause/symptoms/itchy-skin/> [accessed

25 June 2014] (p.1) 6. J.B Schmidt. The influence of hormone replacement therapy

on skin ageing in Maturitas: The European Menopause

Journal. (Ireland: Elsevier Inc, 2001) Vol 39, pp 43-55.

7. C. W Lynde. Moisturisers: What they are and How They

Work (Toronto: University of Toronto, 2001) < http://

www.skintherapyletter.com/2001/6.13/2.html> [accessed on 15.08.2014] 8. Journal of Drugs in Dermatology. Efficacy of cream-based

novel formulations of hyaluronic acid of different molecular

weights in anti-wrinkle treatment. 2011 Sep;10(9):990:1000.

9. North American Menopause Society, Sexual Health &

Menopause Online. (Ohio: NAMS, 2014) <http:// www.menopause.org/for-women/sexual-health-menopause-

online>[accessed 25 June 2014] (p.1) 10. Hicks, Dr Rob, The menopause, an emotional rollercoaster.

(Nottingham: Boots UK and Web MD, 2012) <http://www. webmd.boots.com/menopause/guide/emotional-roller-

coaster> [accessed 25 June 2014] (p.1) 11. Dr Louise Newson, Menopause – Alternatives to HRT, (Tyne

and Wear: Patient.co.uk, 2013) <http://www.patient.co.uk/

health/menopause-alternatives-to-hrt> [accessed on 25

June 2014] (p.1) 12. Lewin, Jo. Eat to ease the menopause (London: BBC,

2013) <http://www.bbcgoodfood.com/howto/guide/eat-beat-

menopause> [accessed on 27 June 2014] 13. Kathleen M Zelman, 6 Reasons to drink water, (WebMD,

2013) <http://www.webmd.com/diet/features/6-reasons-to-

drink-water> [accessed on 27 June 2014] 14. Katharine Waldman, Is your diet sabotaging your skin?

(Prevention.com, Dec 2013) <http://www.prevention.com/

beauty/beauty/how-your-diet-affects-your-skin> [accessed

on 27 June 2014] 15. Paula Begoun, Alcohol in skin care: The Facts

(Paulaschoice.com, 2014) <http://www.paulaschoice.com/ expert-advice/skin-care-basics/_/alcohol-in-skin-care-the-

facts> [accessed on 27 June 2014] 16. Hamley, Prof Ian. Collagen effect of peptide amphiphile

C16-KTTKS on human fibroplasts. Journal of Molecular

Pharmaceutics. (Washington DC: ACS Publications, 2013)

Mar 4;10(3):1063-9.

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Clinical Practice Treatment Focus

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Laser hair removal Rebecca Treston shares her technique and advice for best practice in removing hair with laser While it seems that laser hair removal (LHR), one of the most popular and therefore profit-yielding aesthetic treatments, is readily available at an abundance of clinics, it is the expert touch and technique of individual practitioners that determines how great a reputation an institution has for the treatment, and which in turn will influence the volume of LHR patients coming through the door. In general, it is those practitioners that hold an in-depth understanding of the science behind the procedure that are most proficient at carrying out the treatment, and boast the highest patient satisfaction rate. The primary principle behind laser hair removal is selective photothermolysis (SPTL), or heating up a target chromophore. In the case of LHR, the chromophore is melanin: the chemical that gives skin and hair its colour. Because of the selective absorption of photons of laser light, only black or brown hair can be removed. By matching a specific wavelength of light and pulse duration it is possible to safely and thermally destroy the melanin in the area that causes hair growth – the follicle – whilst not heating the surrounding tissue (skin) and therefore causing no damage to the skin. Since its widespread introduction in the 1990s, constant research has led to safer, more effective LHR treatments with dramatically less downtime, pain and exponentially improved results. For instance, although white skin with coarse dark hair was the ideal subject for the treatment, the latest generation of LHR treatments offer a variety of right wavelengths and varying parameters to ensure treatments for all skin types. That said, on darker skin types it is very important that the practitioner understands the treatment’s limitations and that these skin types are much more susceptible to burning and post inflammatory 42

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pigmentation. When treating Tips for best practice dark skin, it is vital to change the wavelengths and parameters to • Undertake regular conferences and allow for this sensitivity. For skins courses to update your knowledge that are tanned or measure four and ensure you are a qualified, to six on the Fitzpatrick Scale, experienced practitioner.

• Become a licensed laser specialist.

I use ND-YAG 1064nm laser; • Check the credibility of your laser and while for skins that measure one manufacturer. to four on the scale, a 755 nm • Always do a thorough consulation Alexandrite laser can be used. with extensive medical history and I also have a Q switch NDYAG offer pre and post-care advice. which is perfect for dark, fine, • Always carry out a patch test, and velous hair which would not when increasing fluence perform be affected by LHR, and this further patch tests. technique is particularly brilliant • Educate patients on the importance of SPF and avoidance of sun for the for bleaching or for post-LHR duration of treatment. maintenance. I have worked • Update medical notes after each in the Middle East for the past treatment.

15 years, so when treating darker skin patients in this hot humid environment, it is possible to suffer post inflammatory pigmentation. By educating my patients in what they should do before and after the treatment, however, I am able to minimise this occurrence. I often advise patients that would be prone to these side effects to use topical solutions to minimise the melanocytes in the skin, stop all peeling creams two weeks prior to treatment and very importantly, to have no sun exposure before the treatment and to always wear a broad spectrum UV SPF. One major advance in LHR treatments as they have grown in popularity is their now relatively pain-free nature, which is due to cooling systems. I use the Zimmer cooling system which is effective in counteracting the heat that is felt during the treatment. To ensure the patient feels no pain, I also apply a thick layer of topical anaesthesia one hour before a treatment, which acts to reduce the discomfort considerably. I find that this combination is more than adequate to ensure that the patient will be relaxed throughout the treatment. Prior to offering any individual a treatment at my clinic I will carry out a full and thorough consultation, and in the case of LHR this first step is no different. During this, we can learn about the patient’s medical history, and we might even carry out further blood tests if we suspect the patient has hormone-related problems such as polycystic ovaries. It is important to understand the effects of any medications that the client might be taking. For example, a supplement such as St John’s Wort can make the skin photosensitive to laser and result in burning or post-inflammatory pigmentation.

A consultation also allows us to assess the patient on an individual basis – to discover the reasons why they have chosen the treatment, to ensure their suitability, to outline any possible side effects they may experience and to explain to them the realistic results that they can expect. Once the patient fully understands the different stages of hair cycles and protocols of the treatment, a consent formed is signed, and this is followed by a patch test to ensure the patient does not have an adverse reaction. In my experience, there are certain areas of the body that yield the best results due to the hair being thicker, denser and darker. These include the bikini line, the underarm, the lower leg – and for male patients the neck. The number of treatments needed varies between areas but in general, the face will require between four and eight sessions, while the body will need four to six. Maintenance treatments may also be required but these will be one or twice per year.

Rebecca Treston is a licensed medical aesthetician and laser specialist, and a member of the American Academy of Anti-Ageing. In 1999, she relocated to Dubai and founded her eponymous clinic. Today, Rebecca Treston @Euromed has a reputation as Dubai’s premier aesthetics clinic and offers the latest cutting edge anti-ageing body and skin perfecting treatments.

Aesthetics | September 2014

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Clinical Practice Spotlight On

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The collagen supplement debate Little in the field of medical aesthetics divides opinion more than collagen supplements. The arguments from both sides are equally convincing when considered on their own, but when measured against the counter claims and held up to scrutiny, the waters become slightly more muddied. Allie Anderson asks the question: are supplements really the silver bullet to youthful-looking skin?

The best things come in small packages?

One of the most commonly used methods of increasing collagen levels is hydrolysed collagen supplements. According to the protagonists, what makes this form preferable is its reduced molecular size.

“The average molecular size of collagen itself is about 300 kilodaltons (kD), and the average collagen supplement is somewhere between 30 and 90kD, which is still quite large for your body to process,” explains nutritional therapist and supplement supporter Eva Escofet. “In clinic, I have always used a particular type that’s only 3kD, so it’s extremely tiny and it’s truly predigested.” With such a small, lightweight molecule, Escofet adds, the collagen can be passed straight through the gut without having to be broken down by the stomach, meaning it is more readily absorbed into the body. Medical doctor and nutritionist Dr Vidhi Patel also promotes the use of hydrolysed collagen in liquid form, citing its high absorbability as crucial. “Any active ingredient will only be absorbed if it’s digestible,” she comments. “The size of the molecule is imperative – if it’s too large you won’t digest it. In hydrolysed collagen, the molecules are tiny but multiple in number, so you can easily digest and absorb them.”

Practitioners have suggested that the amount of collagen that appears to produce optimum skin improvement in their experience is around 10g when ingested as a solid, but Dr Kathryn TaylorBarnes suggests that due to the increased absorbability rate in a drinkable formulation, this reduces the amount to around 6g.1 According to Escofet, a protein-rich diet contains an insufficient concentration of hydroxyproline, the specific amino acid needed for collagen synthesis.

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However, Rick Miller, a sports nutritionist and spokesperson for the British Dietetic Association, disagrees. “The synthesis of collagen is unique in that there are about five different forms of collagen in the body and they’re all composed from the same base – amino acids,” he explains. “All proteins start from that base, and lysine and proline [from which hydroxyproline is derived] are the two essential amino acids that are needed for the production of collagen. There are 7g of lysine in a 3oz portion of beef, and 7g of proline in a 3oz portion of turkey. I don’t think that’s outwith a normal diet.”

The message from the sceptics is that the human body is mechanised to process protein in the food we eat, contradicting the idea that dietary protein is insufficient.

“We have hydrochloric acid and pepsin in our stomachs; we have the enzymes we need to break down those foods and digest amino acids, to convert them into proteins that benefit the skin,” says nutritionist Kim Pearson. “Protein from food can be quite difficult for the digestive system to process, but that’s ultimately what it’s designed to do.”

The science behind the claims Concerns regarding the efficacy of collagen supplements are often centred on the lack of reliable data. Dr Andy Pickett, a microbiologist and expert in botulinum toxin, asks: “What evidence is there that they help people in any way? And is there any basis in fact that an oral collagen supplement ends up effectively depositing collagen in the places it’s needed?” Cosmetic dermatologist Dr Raj Acquilla is concise in response. “There is no credible evidence to suggest that oral collagen is prioritised to the dermis in preference to another part of the body,” he says. “A collagen drink is no more effective at skin rejuvenation than adequate Aesthetics | September 2014

dietary protein intake and forms no part of my clinical practice.” However, there are a handful of studies that have convinced many that hydrolysed collagen works. For example, scientists in Germany conducted a trial among 69 women aged 35 to 55. Those who were given animal-sourced hydrolysed collagen over an eight-week period showed improved skin elasticity compared with that of participants who were given a placebo.2 Hydrolysed collagen was also shown to produce significantly reduced eye wrinkle volume of between 20 and almost 50%, in a group of women aged 45 to 65 who took the supplement once a day for eight weeks as part of another study conducted in Germany.3 Miller argues that such studies are methodologically flawed. “They haven’t taken into account the dietary component [of protein], which is a huge confounding factor in skin viability and the progression of collagen synthesis,” he comments. The inherent problem in using objective markers – such as wrinkle size – in assessing how successful the supplements are in these trials, is that it’s impossible to rule out the effect of other variables. “Participants could have gone away and eaten better in that eight weeks period,” Miller adds, “and Skinade: Effect on acne after 60 days of use

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Clinical Practice Spotlight On

“The skin is the last organ to be prioritised for any nutrient because it’s at the extremity”

Skinade: effect on eczema after 30 days of use

that’s quite a long time to make some good nutritional changes to your diet.”

Other practitioners, including Dr Patel, suggest that trials conducted in rats can be used to demonstrate that marine collagen peptides, administered orally, improve the deposition of collagen fibres.4 But there is difficulty in extrapolating those findings to humans, says Miller, as rats are known to have very different enzymatic activity and typically, much faster metabolisms than humans. “Often, you see results a lot quicker, but if you try to transpose that data to a human model you aren’t going to see the same effects.”

Active ingredients Among the supplement enthusiasts, opinion on the best source of collagen differs.

Some practitioners, Escofet included, prefer bovine collagen. “The big difference is that animal-sourced proteins resemble human collagen in molecular structure, so the body recognises it and the bioavailability is better,” she says. “In addition, fish is a prevalent allergen, whereas bovine collagen is hypoallergenic.” Dr Martin Godfrey, a GP and medical writer and broadcaster, argues that marine collagen is better. “Made from skin and scales, it seems to contain good antioxidant activity and improves the water-absorbing and water-holding capacity of the skin,” he says. “There is also less potential risk from pathogens such as BSE.” Supporters and opponents seem to agree that in order to boost collagen in the body, additional nutrients are necessary. Miller says these nutrients are abundant in a balanced diet. “Amino acids are the bricks to build your health – so how do you start building it?” he asks. “You need vitamin C and iron. If you eat red meat you’re going to get a very good bioavailable, highly absorbable source of iron. Vitamin C is plentiful in a high intake of fruit – in

citrus fruits, kiwi fruits, berries, and even vegetables.”

Dr Godfrey suggests that a hydrolysed marine collagen supplement that’s packed with additional ingredients produces optimum results in the skin. “Hyaluronic acid is particularly beneficial to the skin because it slows down water evaporation and provides something of a barrier to water loss,” he comments. “There are other additional elements such as borage oil and other vitamins, which individually have a variety of effects and seem to work well together to support the action of the collagen.” However Dr Taylor-Barnes points to a study demonstrating that HA shows poor absorption when taken orally and suggests that it is not expressed in the skin.5 Vitamins C, A, E and B1, zinc and copper are important in a supplement, says Dr Patel, who also suggests that lysine and threonine – amino acids that are not produced by the body – alongside BioPerine, a patented black pepper extract, should be included as well.

Skinade: Effect on crow’s feet lines after 30 days

Not just skin deep Supplementary collagen has been shown to be absorbed in the intestine and accumulate in cartilage, producing beneficial effects in people with osteoarthritis.6 Escofet points out that this hydrolysed collagen is also used to treat gut permeability, or leaky gut, which is the root cause of many allergies and digestive complaints.

For medical aesthetic practitioner Dr Toni Philips, this is evidence enough that such supplements could also increase dermal collagen, but admits that the added ingredients could be playing a role. “You could argue that the vitamins and hyaluronic acid are what’s making Aesthetics | September 2014

the difference, but anecdotal evidence is good and clients see a positive result,” she says. And clients in search of an elixir to improved skin are often happy with a trial-and-error approach – as long as don’t believe that they are spending over the odds. “There isn’t a great deal of published science behind it, but at around the £1 a day price bracket, many people are willing to at least give it a try to see if it works,” Dr Philips adds. “There are some supplements at around triple that price, and that’s a lot of money if a client finds three months down the track that it doesn’t work.”

The anti-supplements camp stands firm, though, claiming that money is better spent elsewhere. “The skin is the last organ to be prioritised for any nutrient because it’s at the extremity, so yes, people will see results by boosting protein from the inside,” says Pearson. “In the UK we don’t eat enough protein so whether you give someone a form of protein supplement or feed them chicken, then you’ll see an improvement in their skin. I would suggest the latter.”

Focusing on diet means more than simply increasing protein foods, according to Miller. Equally important is avoiding activity that inhibits protein synthesis – notably chronic dieting and stress, which stimulate the production of cortisol and disrupt the hormonal milieu of the body.

Are collagen supplements the panacea for smoother, wrinkle-free skin? Perhaps greater investment in scientific research that rules out the interplay of dietary protein and other variables will convince even the most sceptical in the future. But for now, it seems the jury is still out.

REFERENCES 1. Schrauzer GN, ‘An Evaluation of Liquid Vitamin-Mineral

Supplement Technology’, Journal of Medicinal Food, 1 (3), (1998) 2. Proksch E, Segger D, Degwert J, Schunck M, Zague V,

Oesser S, ‘Oral supplementation of specific

collagen peptides has beneficial effects on human skin

physiology: a double-blind, placebo-controlled study’, Skin

Pharmacol Physiol. 27(1) (2014), pp. 47-55 3. Proksch E, Schunck M, Zague V, Segger D, Degwert J, Oesser

S, ‘Oral intake of specific bioactive collagen peptides

reduces skin wrinkles and increases dermal matrix synthesis’,

Skin Pharmacol Physiol, 27(3) (2014), pp. 113-9 4. Zhang, Z., Wang, J., Ding, Y., Dai, X. and Li, Y., ‘Oral

administration of marine collagen peptides from Chum Salmon

skin enhances cutaneous wound healing and angiogenesis in rats’, J. Sci. Food Agric., 91 (2011), pp. 2173–2179 5. Laznicek M, Laznickova A, Cozikova D and Velebny V,

‘Preclinical pharmacokinetics of radiolabelled hyaluronan’, Pharmacological Reports, 64, (2012), pp. 428-437 6. Bello AE, Oesser S, ‘Collagen hydrolysate for the treatment of

osteoarthritis and other joint disorders: a review of

the literature’, Curr Med Res Opi, 22(11) (2006), pp. 2221-32

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Clinical Practice Abstracts

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A summary of the latest clinical studies Title: The relationship between alopecia areata and alexithymia, anxiety and depression: a case-control study.

Authors: R Sellami, J Masmoudi, et al Published: Indian Journal of Dermatology, July 2014 Keywords: Alexithymia, alopecia areata, anxiety, depression Abstract: Alopecia areata’s (AA) aesthetic repercussions can lead to profound changes in patient’s psychological status and relationships. The goal was to investigate a possible relationship between AA and alexithymia as well as anxiety and depression.

Fifty patients were seen in the Department of Dermatology of Hedi Chaker University Hospital, were included in this study.

Patient’s mean age was 32.92 years. 52% of patients were females.

Depression and anxiety were detected respectively in 38% and 62% of patients. There was statistically significant difference between patients and control group in terms of depression (P = 0.047) and anxiety (P = 0.005). 42% of patients scored positive for alexithymia. No significant difference was found between patient and control groups (P = 0.683) in terms of alexithymia. Anxiety was responsible for 14.7% of variation in alexithymia (P = 0.047).

Our study shows a high prevalence of anxiety and depressive symptoms in AA patients. Dermatologists should be aware of the psychological impact of AA, especially as current treatments have limited effectiveness.

Title: Tarsodermal suture fixation preceding redundant skin excision: a modified non-incisional upper blepharoplasty method for elderly patients.

Authors: H Yoon, B Park, K Oh Published: Archives of Plastic Surgery, July 2014 Keywords: Blepharoplasty, Blepharoptosis, Eyelids Abstract: In aging patients, non-incisional blepharoplasty is not effective due to more severe blepharochalasis. Incisional blepharoplasty is a common surgical method used for older patients, but blepharoplasty in elderly patients typically results in prolonged recovery times, and final blepharoplasty lines may be located in unintended or asymmetrical positions. Ten patients were treated using a new combination method. We performed nonincisional blepharoplasty using tarsodermal fixation. Incisional blepharoplasty with additional elliptical excision of the upper eyelid skin was performed. We removed pretarsal tissue, fat, the orbicularis oculi muscle, and orbital fat. Telephone surveys were administered to all patients for follow-up, to which 90% responded.

All cases of moderate to severe blepharochalasia were corrected and there were no major complications. Patients who underwent blepharoplasty had higher satisfaction scores. All patients were satisfied with the postoperative shapes of their eyelids. The advantages include: ease of obtaining a natural-looking fold with symmetry at the desired point; reproducible methods that require short operation times; fast postoperative recovery that results in a natural-appearing double-eyelid line; and high patient satisfaction.

Title: Quantitative assessment of growing hair counts, thickness and colour during and after treatments with a low-fluence, homedevice laser: a randomized controlled trial.

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Authors: D Thaysen-Petersen, M Barbet-Pfeilsticker, F Beerwerth, JF Nash, PA Philipsen, P Staubach, M Haedersdal.

Published: British Journal of Dermatology, July 2014 Keywords: At-home laser, IPL, low-fluence Abstract: At-home laser and intense pulsed light hair removal continues to grow in popularity and availability. A relatively limited body of evidence is available so our objective was to assess growing hair counts, thickness and colour quantitatively during and after cessation of low-fluence laser treatment. Thirty-six females with skin phototypes I-IV and light to dark-brown axillary hairs were included. Entire axillary regions were randomized to 0 or 8 selfadministered weekly treatments with an 810 nm home-use laser at 5.0-6.4 J/cm2. Thirty-two females completed the study protocol.

During sustained usage, there was a reduction in growing hair that reached a plateau of up to 59% while remaining hairs became up to 38% thinner and 5% lighter (P<0.0001). The majority of subjects (77%) reported ‘moderately’ to ‘much less hair’ in treated than untreated axilla and assessed remaining hairs as thinner and lighter (≥60%). After treatment cessation, hair growth gradually returned to baseline levels and 3 months after the final treatment, count and thickness of actively growing hair exceeded pretreatment values by 29% and 7%, respectively (P≤0.04). Sustained usage of low-fluence laser induced a stable reduction of growing hair counts, thickness and colour. The reduction was reversible and hairs regrew beyond baseline values after cessation of usage. Computer-aided image analysis was qualified for quantification of hair counts, thickness and colour after laser epilation.

Title: A double-blind, randomized, multicenter, controlled trial of suspended polymethylmethacrylate microspheres for the correction of atrophic facial acne scars Authors: Dr Jwala Karnik, Dr Leslie Baumann et al Published: Journal of the American Academy of Dermatology, April 2014 Keywords: Acne, Scarring, PMMA-collagen Abstract: Polymethylmethacrylate (PMMA) microspheres in collagen (ArteFill, Suneva Medical Inc, Santa Barbara, CA) have shown long-term benefit for nasolabial fold treatment. A pilot study has shown benefit for PMMA-collagen in atrophic acne scarring.

We sought to demonstrate the safety and effectiveness of PMMAcollagen for acne scarring in a controlled, blinded trial. Subjects with at least 4 moderate to severe rolling, atrophic scars randomly received PMMA-collagen or saline injections. Subjects underwent up to 2 injection sessions and were followed up for 6 months. Efficacy was assessed using a validated rating scale for each scar. 147 subjects underwent injections. Success was achieved by 64% of those treated with PMMA-collagen compared with 33% of control subjects (P = .0005). The treatment showed excellent safety with generally mild, reversible adverse events. No significant differences in efficacy or safety were noted between genders, for darker skin types, or in older age groups. PMMA-collagen demonstrates substantial effectiveness in the treatment of atrophic acne scars of the face while maintaining an excellent safety profile. Further follow-up should be undertaken to demonstrate longer-term benefit and safety.

Aesthetics | September 2014

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Aesthetics Awards Special Focus

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The finalists are announced Following months of anticipation, the finalists for The Aesthetics Awards 2014 can now be revealed. Given both the exceptional quality and sheer volume of entries received this year, reaching the finalist stage is a fantastic achievement and a wonderful demonstration of the commitment of so many to raising standards within the medical aesthetics profession.

Voting is now open on The Aesthetics Awards website www.aestheticsawards.com 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. Select categories will be decided by reader votes, while others will be decided by the judging panel.

Please see each category below for clarification. Voting and judging will close on 31st October 2014. 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 finalistsâ&#x20AC;&#x2122; organisations will be monitored.

Winners will be decided either by Aesthetics reader votes or by our Awards judging panel. The voting and judging process is open from the 1st September until the 31st October, with the winners announced at The Aesthetics Awards ceremony.

To be held at the four star Park Plaza Westminster Bridge Hotel, London, the awards will honour the winners and, where appropriate, highly commended and commended finalists in twenty categories. The night will also feature the presentation of the special Lifetime Achievement Award, a guest presenter, comedian and music.

Tickets can be booked on the Aesthetics Awards website, or by contacting our Customer Service team by phone 0203 096 1228 or by email bookings@aestheticsawards.com.

The judging panelâ&#x20AC;Ś

A panel of 18 judges have been selected to consider those categories that will be decided by judges scores. For each of these categories, a group of six judges have been assigned. These groups have been chosen specifically for their knowledge and expertise in that particular area, as well as to ensure the avoidance of any conflicts of interest in the judging process.

Amanda Cameron

Dr Stefanie Williams

Mr Dalvi Humzah

Wendy Lewis

Dr Raj Acquilla

Dr Christopher Rowland Payne

Dr Tapan Patel

Dr Johanna Ward

Mr Adrian Richards

Dr Tracy Mountford

Marie Duckett

Dr Mike Comins

Dr John Curran

Aesthetics | September 2014

Dr Patrick Bowler

Mr Chris Inglefield

Dr Sarah Tonks

Dr Beatriz Molina

Sharon Bennett

Dr Paula Charlesworth

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Aesthetics Awards Special Focus

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The finalists…

COSMECEUTICAL RANGE/ PRODUCT OF THE YEAR Winner decided by: votes Medik8 Range Heliocare; Advanced, Color & 360 (AesthetiCare) Epionce (Episciences Europe LLP) Obagi Systems (Healthxchange Pharmacy) NeoStrata Skin Active Cosmeceutical Range (Aesthetic Source Ltd) Dermamelan by mesoestetic (Mesoestetic UK) SkinCeuticals Range Retriderm - Retinol Protein-Rich Serums (AesthetiCare)

TREATMENT OF THE YEAR Winner decided by: votes Aqualyx (Healthxchange Pharmacy) INTRAcel (Healthxchange Pharmacy) Dermalux LED (Aesthetic Technology Ltd) 3D-lipomed (3D-lipo Ltd) NeoGen Plasma Skin Regeneration (Energist Medical Group) VelaShape III (Syneron Candela) Sculptra (Sinclair Pharma) Ultherapy (CoachHouse Medical)

DISTRIBUTOR OF THE YEAR Winner decided by: votes Medical Aesthetics Supplies Harpar Grace International AesthetiCare Healthxchange Pharmacy Church Pharmacy Medfx

INJECTABLE PRODUCT OF THE YEAR Winner decided by: votes Belotero (Merz Aesthetics) Juvéderm VOLIFT with Lidocaine (Allergan) Aqualyx (Healthxchange Pharmacy) Emervel Deep (Galderma UK Ltd) Sculptra (Sinclair Pharma) Stylage (Rosmetics) 50

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EQUIPMENT SUPPLIER OF THE YEAR Winner decided by: votes Lumenis (UK) Ltd ABC LASERS Solta Medical 3D-lipo Ltd BTL Aesthetics Syneron Candela

Aesthetics Awards Special Focus

THE 3D-LIPOMED AWARD FOR BEST NEW CLINIC, UK AND IRELAND

Winner decided by: judging panel Radiance MediSpa Elite Aesthetic Treatment Clinic Cosmex Clinic Rosmetics Skin Clinic Specialist Skin Clinic Dr Leah Cosmetic Skin Clinic Changes Clinic Limited PHI Clinic

BEST CUSTOMER SERVICE BY A MANUFACTURER OR SUPPLIER Winner decided by: votes AZTEC Services Merz Aesthetics Galderma Lynton Lasers Ltd Boston Medical Group Ltd. Aesthetic Source Ltd BTL Aesthetic Medisico Aesthetics Ltd

THE ROSMETICS AWARD FOR BEST CLINIC NORTH ENGLAND

THE JANEĂ&#x2030; PARSONS AWARD FOR SALES REPRESENTATIVE OF THE YEAR, SUPPORTED

BY HEALTHXCHANGE PHARMACY Winner decided by: judging panel Air Aesthetics Clinic Botastic Aesthetics Ltd Cosmedic Skin Clinic Diane Nivern Clinic Ltd Soul Care Aesthetics Good Skin Days Smileworks Myskindesign Ltd

Winner decided by: votes Emma Barlow (Healthxchange Pharmacy) Belinda Aloisio (Loreal - SkinCeuticals) Iveta Vinklerova (Boston Medical Group Ltd.) John Campbell (Allergan) Daniela Mighall (Merz) Linda Wormald (Healthxchange Pharmacy) Louise Taylor (Aesthetic Technology Ltd) Paula Dene (Merz Aesthetics)

THE NEOCOSMEDIX AWARD FOR ASSOCIATION/INDUSTRY BODY OF THE YEAR

Winner decided by: votes BACN (British Association of Cosmetic Nurses) SOMUK (Society of Mesotherapy of the United Kingdom) PIAPA (Private Independent Aesthetic Practitioners Association) Aesthetics | September 2014

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Aesthetics Awards Special Focus

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THE SYNERON CANDELA AWARD FOR BEST CLINIC SCOTLAND

THE SINCLAIR IS PHARMA AWARD FOR BEST CLINIC WALES

Winner decided by: judging panel

Winner decided by: judging panel

Dermal Clinic Innocent Aesthetics Age Refined Medical Cosmetic Centre Clinetix Temple Medical Spire Edinburgh Hospital Face and Body Cosmetic Clinic La Belle Forme

Peaches skin Clinic Transform Cardiff Specialist Skin Clinic

BEST CLINIC IRELAND Winner decided by: judging panel River Medical Dundrum laser & skincare clinic Medi-Cosmetic ClearSkin

THE DERMALUX AWARD FOR BEST CLINIC SOUTH ENGLAND

THE CHURCH PHARMACY AWARD FOR CLINIC RECEPTION TEAM OF THE YEAR

Winner decided by: judging panel Persona Cosmetic Medicine Lumley Aesthetics LLP Health + Aesthetics Medikas Jill Zander Skin Rejuvenation Clinic Spire Southampton Hospital The Skin Clinic Sevenoaks Firvale Clinic

Winner decided by: judging panel

THE OXYGENETIX AWARD FOR BEST CLINIC LONDON

Gemma Knight, Georgina Parker and Juliet Goodsell (Persona Cosmetic Medicine) Radiance MediSpa Reception Team Hana Te Reo, Lucia Krivonakova, Ema Slavikova and Camelia Rahoui (Harley Street Treatments Ltd) Temple Medical Reception Team Rebecca Raynor, Charlotte Crilly and Rose Garth (Jill Zander Skin Rejuvenation Clinic) Laura Zito (The Skin Clinic) Carol Smith and Christine Hockney (Firvale Clinic) Lynda Thompson, Jack Gibson, Emma Clarke, Jessica Girvan, Libby Warlow (PHI Clinic)

TRAINING INITIATIVE OF THE YEAR Winner decided by: judging panel Winner decided by: judging panel Harley Street Treatments Ltd. London Bridge Plastic Surgery EF MEDISPA harpal clinic Aesthetic Skin Centre Dr Leah Cosmetic Skin Clinic The Rejuvenation Clinic and Medispa PHI Clinic Sponsorship Partner

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CanuSCULPT (Dr Linda Eve) European Medical Aesthetics Ltd (Dr Kate Goldie) The Galderma Facial Anatomy Course Cosmetic Courses Obagi Medical System Training (Sharron Lister for Healthxchange Pharmacy) RA Academy (Dr Raj Acquilla) Mr Dalvi Humzah Facial Anatomy Teaching The Facial Aesthetics Masterclass (Dr Tapan Patel and Dr Raj Acquilla)

Aesthetics | September 2014

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Aesthetics Awards Special Focus

THE MERZ AESTHETICS AWARD FOR AESTHETIC MEDICAL PRACTITIONER OF THE YEAR

THE INSTITUTE HYALUAL AWARD FOR AESTHETIC NURSE PRACTITIONER OF THE YEAR

Winner decided by: judging panel

Winner decided by: judging panel

Dr Terry Loong Dr Linda Eve Dr Kate Goldie Dr Martyn King Dr Beatriz Molina Dr Simon Ravichandran

Sharon King Eve Bird Helen Hannigan Frances Turner Traill Malti O’Mahony Louise Sommereux Trudy Friedman Ros Bown

Mr Christopher Inglefield Dr Raj Acquilla Dr Johanna Ward Dr Tracey Bell Dr Tapan Patel Dr Askari Townshend

THE PINNELL AWARD FOR PRODUCT INNOVATION

THE AESTHETIC SOURCE AWARD FOR LIFETIME ACHIEVEMENT

Winner decided by: judging panel ResurFX module of M22 (Lumenis UK Ltd) 3Dose BoNT Syringe (TSK Laboratory Europe B.V) Restylane Skinbooster SmartClick System (Galderma UK Ltd) Aneva Derma (Aesthetic Source Ltd) 3D-lipomed (3D-lipo Ltd) Regenlite Transform (Chromogenex) VANQUISH (BTL Aesthetics) miraDry (Aesthetic Business Partners LLP)

This award recognises the outstanding achievements and significant contribution to the profession and industry by an individual with a long career in medical aesthetics. The winner of this category will be selected by the Aesthetics judges from within the profession. Individual entries have not been accepted for this category.

Book Now! Don’t miss your chance to attend the most prestigious event in medical aesthetics.

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

Aesthetics | September 2014

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In Practice Marketing

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Three simple ways to boost your local marketing Jill Woods explains how to make the most of business in your local area Marketing any business that is geographically anchored to one town or local area generally makes the whole process easier.

Providing there are enough of your ideal patients within 10 miles of your practice, marketing should, in theory, be straightforward.

Your ultimate goal is to become well known, and doing that in a relatively small geographical area is much easier than achieving the same level of fame nationally. Even with the odds stacked in their favour, many practices struggle, or at least find it difficult, to attract the numbers of patients they would ideally like to see coming to their clinic. To get the phone ringing and increase the footfall in your practice, there are three key elements of marketing that you need to execute successfully. Once you do, you will find that you have a whole host of new patients making enquires and booking appointments.

Many people misunderstand marketing as just advertising or promoting their practice. In doing so, they miss out on a huge amount of important marketing activity.

Marketing actually covers six key areas known as the ‘6 P’s’ Product - The service you offer Pricing - What you charge People - Are your employees performing effectively in their roles?

Place - The environment where you deliver your services Processes - How you manage the practice and patient communications Promotion - Raising awareness of you and your practice To successfully stand out from the crowd you need to deliver a great combination of all of these elements. The following are three areas that you can develop within your practice to help you raise your profile and gain prominence in your local area.

1. SEEK FAME This is not national celebrity fame, but fame at a local level. If people don’t know about you and the services that you offer in your local area, you are going to struggle to find the new patients needed to turn your practice into the amazing success story it could be. Bear in mind local fame is not going to come looking for you, you have to make it happen. To get known locally you must go out, into the community, and network with as many people as possible.

By this I do not mean visiting networking clubs where thirty people rush around pressing business cards into each other’s hands whilst asking, “How can we do business?” Nor am I talking about seeking individual patients who may be a parent at your daughter’s school.

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Instead I’m talking about strategic networking, with individuals or organisations that can put you in front of groups of your ideal patients, and not just one or two of them. This obviously requires you to know exactly who your ideal patients are. If you don’t know this, you need to go back to basics and work out who your best patients are. They will most probably be repeat patients; those that are happy with your service and willing to spend money in your clinic on a regular basis. Your best patients are your ideal patients and you want to find more of them. Once you know who they are, you need to figure out where they congregate en masse, and who has the power to put you in front of them. For example, it may be the editor of Yorkshire Life or the owner of a local health centre, or even the manager or captain of a local netball team. It really does depend on who your ideal patients are. These gatekeepers are the people you need to network with. Get to know them, and help them get to know you and the services you offer. Once you have made a meaningful connection with these people in your community, you need to work out how you can help them to help their audience. What real value can you add that, in turn, demonstrates what you can do, and how you can solve any problem their audience may face. For example, you could help them by giving advice on how to look fantastic for the annual club charity ball using simple self-help techniques, or you could share a six-week countdown calendar to help them get ready for their summer holiday. In the eyes of potential patients you immediately gain credibility by being associated with, and introduced by, a person that they already know and have respect for. However, you still need to demonstrate how you can help these potential patients.

Getting in front of these groups of people can take many forms: • A printed article • A face-to-face presentation • A practical demonstration • A joint offer promoted by email • A feature on their website • A guest post on their blog • A video embedded on their website Please note at this point you are helping them, not selling to them.

You have to earn the right to sell to them by building trust and confidence first. So start by demonstrating your expertise and provide them with information or a skill they can get real benefit from – for free. If you can show that you are the best at what you do

Aesthetics | September 2014

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in your area, you will be demonstrating to potential customers why they should choose you for their treatments rather than a competitor.

That is the kind of networking that boosts your local fame quickly and delivers real results in the form of new enquiries and new patients.

2. GET ONLINE Nowadays almost everyone turns to their favourite search engine to help locate a service that they want to access, even if it is just in their local area. So it goes without saying that you need a web presence in order to show up on these search results. There are two ways I would recommend you do this.

Have a website Websites are a fantastic way to showcase your expertise, help people get to know you and give them an easy way to make contact.

Here are a few points you should consider when putting one together; a) Host it yourself – don’t use a third party hosted site. You often don’t get a bespoke domain name, are not in complete control of the content and structure, and often don’t own the content on the site. b) Focus the content on your home page around your ideal patients, and not around you as a practitioner. This is not the place to talk about your qualifications or extensive CPD record. Here is where you should talk about problems that prospective patients can relate to and how (in brief terms) you can help. Also talk about the town/area you are based in so visitors see the local connection and know you are there to help local people. c) Build in a mechanism for capturing people’s email addresses.

Offer something of great value in exchange for their contact details.

This means you can start to communicate with them on a regular basis, and build a relationship that is far more likely to convert into paying patients, rather than potential patients visiting your site and leaving without making a connection with you. Consider a cheat sheet or check list, a “Five things you should know” or “How to prevent…” type document that they can access in exchange for leaving their email address. d) Don’t try to be corporate. Healthcare is all about building trust, and people will relate far more to a site that looks personal and talks

Through the impersonal medium of the internet you have to enable potential patients to make an emotional connection with you and your team .

about “I” and “me”, or “us” and “we”, than one talking in the third person.Even if you have a relatively large practice, try to be personal and help people decide whether they like you and can trust you.

Again here you can incorporate a local spin on the content you write. Talk about local groups you are involved with, events you have attended as a practice, or regional awards you have won. e) Use pictures of you and real people in your practice. Everyone has seen the stock photos hundreds of times before and they do nothing to help build trust. From a local perspective this also increases awareness of who you are in the community. This will all help to build your local fame. As a general rule, think about the overall message your website images portray. For example, a picture of your empty waiting room will not give the impression of a popular clinic.

Claim all of your online business directory listings Hundreds of different online directories collate basic business information from telephone book listings and include them on their website as free business listings. Depending on what search terms are used, and the location of the people searching the internet, these listings often appear high in the search results if there are no other good quality websites that relate to the search terms. If someone in your area searches for any of the keywords relating to your practice, even if they don’t type the town or location name, the search engines know geographically where they are. The search results provided, including these business directory listings, will be tailored to their location. As you will then be found via one or more of these listings you need to invest time in reguarly updating your website’s content. This way, potential patients find you they see

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Developing your service to please your ideal patients means reviewing every ‘touch point’ - that is, every way that they have contact with your business good quality information and know you are the local “go to” clinic for the treatment they want.

Here are some pointers to make the most of business directory listings: a) Find as many of your existing business listings as you can Search the internet for your phone number, your name and your practice name (one at a time) – this usually pulls out most of the directory listings. b) Claim your listings On sites where you find existing listings, you need to claim ownership of them. Look for buttons that talk about claiming your business, or say “Improve this listing” or “Own this business?” Once you click the appropriate link they will usually lead you through the process of populating your listing. c) No listing?

On sites where there is no existing listing for your business there will be an option to register your business or set up a profile. Find this option and begin to build a listing. If you have a LinkedIn profile you can also create and add a company page to the listing. d) Populate your listings It’s important to complete all of the listing options as extensively as possible. Use logos, pictures, videos, social media profile links, descriptive text and key words – whatever options are available.

Most of these sites will offer you a paid upgrade to add further features. In my experience, this option often does not justify the outlay. However if you don’t have a website this may prove worth the investment. e) Keep a record & remember to update It’s vital to keep a record of all of the sites you register on and all of your login details for each site. This means that in the future, if you change your phone number or want to add more details, you can quickly update all of your listings.

To aid with this process I have created a spread sheet to help you to easily keep track of your listings. Access it online at www.jillwoods. com/wp-content/uploads/2014/07/Business-Directory-Tracker.xlsx If you follow these simple steps you will improve the chances of potential local patients finding you online and picking up the phone, emailing you or calling into your clinic.

3. DELIVER QUALITY The next element of your marketing that you need to crack is to deliver an exceptional patient experience. Of all of the things you do within your marketing mix, delivering an amazing patient experience is the one that has the power to really grow your practice in your local area. It’s also the one that requires time, honesty and money to get absolutely right.

But that investment will repay you many times over. From the moment the phone is answered to a prospective patient, through 56

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to a brilliant clinical outcome and the subsequent follow-up call, the whole patient experience has to be the best it can be. If you succeed in delivering this to your patients, your local fame will grow exponentially. Happy patients will tell anyone who will listen that they received excellent customer service, and direct word-of-mouth recommendation is the most effective business promotion activity there is. By being brilliant at what you do, you will create a local buzz around you and your practice.

Ask – don’t guess To start this process you have to find out what is ‘exceptional’ in the eyes of your ideal patients. The simplest way to do this is to ask them. Don’t guess and don’t set out to deliver a service that you would love to receive unless you fall exactly into the profile of your ideal patient. Ask patients about every element of the service you offer, leave no stone unturned. Developing your service to please your ideal patients means reviewing every ‘touch point’ - that is, every way that they have contact with your business, both before and after they become a patient. You need to make sure the words, images and environment you create are consistent and resonate well with them. These include your: • Website • Business card • Shop front • Reception team • Leaflets • Voicemail message • Internal décor • Clinical equipment • Online directory listings • Promotional videos • Products for sale • Emails or letters • Written marketing material • Social media postings • Blog posts • Stories in the local paper • Public speaking events • Conversations If all of these elements resonate with your ideal patient then you will, in their eyes, have created an excellent experience and they will come back for more.

Crucially, they will become your local promotional marketing tool, recommending you to their family and friends. This above anything else will sky rocket your local reputation. People trust people they know, so if a friend or family member gives them a recommendation for a solution to a problem they have, they are much more likely to consider that as a good option. Hopefully, this information has helped you see how you can boost your local marketing – how easily you can ensure more people learn about you, find you, benefit from what you do, and tell other people about you. These three elements in combination, and if executed well, will make sure more and more of your ideal patients reach out and pick up the phone.

Jill Woods trained and worked as a podiatrist for 11 years before changing to follow the nomadic career of her husband. Following a few years of running online businesses, Jill now combines this experience with her love for marketing to provide specialist marketing support for healthcare professionals.

Aesthetics | September 2014

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In Practice Law

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From complaint to litigation: top tips for keeping a cool nerve Liz Bardolph looks into the possibilities for damage limitation with regard to unhappy patients. This article is based on a presentation at the 2014 FACE conference Introduction There has been a rapid increase in the variety of cosmetic treatments available, with the majority of growth occurring in the non-surgical sector. In addition, more media exposure and increased accessibility have resulted in a rise in the number of treatments undertaken. This in turn has increased the potential for iatrogenic harm and poor treatment outcomes. Just because a known complication has occurred it does not necessarily rule out the possibility of a clinical negligence claim. It is easy to be wise after the event, and as Lord Denning remarked, “To condemn as negligence that which was only a misadventure.”1 This article will suggest general principles for complaint handling, along with ways to avoid, or at least minimise, the possibility of complaints happening in the first place. Should the complaint involve lawyers with the possibility of litigation, the duties of an expert witness will be explained, along with what is accepted as good practice.

General principles for complaint handling Most patients want an acceptance of fault, an explanation, and an apology. The House of Commons Constitutional Affairs Committee (2006) felt that the ‘compensation culture’ was a myth. Recently lawyers have seen an increase in claims arising from sub-optimal cosmetic treatments, with most patients wanting corrective treatment.2 All clinics will have their own protocols for dealing with a complaint by telephone, letter, email or face to face. The important thing is to deal with it immediately, as any delay could make the situation more difficult to resolve. Depending on the complaint, it is a matter of judgement as to when to inform your insurance company and product manufacturer. The amount of time spent on looking into the complaint should be proportional to its seriousness. Communication is key, so actively listen to what the complainant is saying, through tone of voice and body language, and ensure you have full understanding of the concerns. Resist the temptation to be defensive and offer excuses. Instead, offer an apology along with an explanation of what you are doing to put things right. Even if the complaint is groundless, the patient should be thanked for giving you the opportunity to look into the matter. As a matter of course we all apologise in our daily lives, often without thinking. Not only does it show intent to do better, but it can reduce hostility and form an important part of reparation.

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It may even prevent litigation by helping resolution at a local level.

“An apology, an offer of treatment or other redress, shall not of itself amount to an admission of negligence or breach of statutory duty.”3 However, take advice from your insurance company before framing your apology, as you do not want to admit liability. After seeing the patient, record the key facts immediately.

The acronym SOAP may help to marshal your thoughts.4 Subjective concerns are those articulated by the patient Objective refers to what you as the clinician can see Assessment means the possible diagnosis on the presenting facts Plan would be how you intend to proceed Looking after the patient in this way can help to resolve the majority of complaints. If there is a threat of legal action, after investigating the complaint, you would be advised to write a witness statement where all the issues are stated as fact using clear language.

Keeping out of trouble Although it is trite to say that no one sets out to harm a patient, steps can be taken to ensure that patients have minimal grounds for complaint. Needless to say, the clinic must be fit for purpose with adherence to health and safety and cleanliness guidelines.

From a clinical perspective, record keeping not only enables others to see what has happened, how the patient has responded, and a future plan of action, but it can also demonstrate adherence to clinic protocols. In the event of a claim, the case notes will be a key component of the evidence, so they must be clear and contemporaneous. When seeing a patient for the first time, it is important to document the results of your assessment leading to a diagnosis. One of the best ways of doing this is to use a diagram so that, for instance, skin tone, loss of volume and asymmetry can be noted. Reasons for treatment need to be recorded, as this could affect the timing or feasibility of treatment. There needs to be dialogue during the consent process so that the material information — i.e.that which is relevant to the patient – can be taken into account when giving information. In some US hospitals the acronym PARQ is written in the notes to denote that the Procedure

Aesthetics | September 2014

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In Practice Law

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and Alternatives –including doing nothing – have been discussed, the Risks have been explained and the patient has had the opportunity to ask Questions.5 A signature on the consent form indicates that a discussion has taken place and that the patient has agreed to treatment. However, this is not evidence of valid consent.

Duties of an Expert Witness Very few cases reach the courts or the professional regulators, as most are settled through negotiation. This is partly because the onus is on the patient to prove negligence, which can be a considerable legal hurdle, and partly because of cost.

The patient has to prove on the balance of probabilities (51%) that the defendant owed a duty of care, the defendant breached that duty causing damage to the claimant, and that the damage was not too remote i.e. there was a linear connection.

If legal action becomes a reality an expert witness is usually instructed by a solicitor. A person can be an expert witness if, “The witness has acquired by study or experience sufficient knowledge of the subject to render his opinion of value in resolving the issue before the court.”6 There are courses available whereby you can qualify to be an accredited expert witness, and be admitted to a voluntary register. The expert’s duty is to advise the court, and this carries a huge responsibility. Apart from their statutory duty to the court, the expert must be impartial to avoid bias and must not act as advocate. The duties of an expert can be found in the Civil Procedure Rules.7 The expert witness will be required to look at all the evidence from both sides and submit a written report.

They need to research the subject, gather and analyse the facts of the case and present their findings as evidence and opinion. She/ he must state all the material facts and if they do not have enough information they must say so with any assumptions being noted.

The expert witness will need access to good quality peerreviewed publications. From this it is important they keep up to date in his/her field of practice. In the event of the expert changing their mind, this must be made known to the instructing solicitor.

Failure to comply with the Civil Procedure Rules may result in little weight being attached to the evidence or it may be inadmissible.

Either way his or her career as an expert may be curtailed.

Until 2011 experts were immune from being sued, but this was overturned by the Supreme Court in Jones v Kaney8, a personal injury claim where due to the expert’s incompetence, the claimant suffered considerable financial loss and proceeded to bring a claim against the expert.

Good practice for experts To carry out duties as an expert witness, working within your professional area of expertise and being objective and unbiased are key requirements. There must be no conflict of interest. It is advisable to use up-to-date references on current legislation, research and updated techniques pertaining to practice, which will be included in your final report. This can only be achieved if you are a practising clinician and have kept abreast of developments through, for instance, attendance at conferences and by reading and networking. Instructions from the solicitor must be followed carefully, as time and money can be wasted in giving unnecessary information, which may be inadmissible. At the outset the instructing solicitor will request a time limit for report submission.

As they will have a deadline it is important that the agreed timetable is adhered to, with any slippage resulting in penalties 60

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Patients seeking redress do not necessarily want financial compensation, but an acceptance of fault and corrective action. being incurred. If new facts come to light and you change your mind, inform the instructing solicitor immediately. As part of negotiating a settlement you may be asked to attend a joint meeting of experts; as part of good practice, careful preparation is required. Finally, in order to fulfil your obligations to the court you must understand and comply with the rules set out in the Civil Procedure Rules Part 35.

Conclusion The range, number and accessibility of cosmetic treatments has risen over the years resulting in an increase in the number of suboptimal treatments and complaints.

Patients seeking redress do not necessarily want financial compensation, but an acceptance of fault and corrective action.

Many of these complaints can be contained by the practitioners themselves if they bear in mind some basic principles. Responding to the complaint immediately will help to take the angst out of it. Communicating with the patient to ensure you understand and acknowledge the concerns are important starting points.

An apology, without admitting liability, can also go a long way to reparation by demonstrating that you care and are prepared to do something about the complaint. Thorough and contemporaneous record keeping, paying particular attention to assessment, diagnosis, and the consent process, provides evidence that you have carried out your duty of care. The case notes, as well as being a patient record, may be used if there is a claim against you.

If lawyers become involved, the instructing solicitor will ask an expert witness to provide an opinion. His/her role is to advise the court, having weighed up the evidence on both sides and reached a conclusion. However, it is important that they are totally unbiased and must not be an advocate. Receiving a complaint is unsettling, but a prompt and diplomatic response will go a long way to resolving it.

Liz Bardolph has been involved in medical aesthetics for over sixteen years and is past president of the British Association of Cosmetic Nurses.

Following her consultancy work in litigation as an accredited Civil Expert Witness, Liz hopes to complete the Masters Postgraduate Degree in Medical Law and Ethics at the end of 2014.

REFERENCES 1. Roe v Minister of Health (1954) 2All ER 131 2. Luckman M., ‘Avoiding litigation: what aesthetic nurses need to know about

handling complaints’, Journal of Aesthetic Nursing 3(6) (2014), p. 296.

3. Compensation Act (2006), section 2.

4. Transcription411, The SOAP note (www.transcription411.com) <www.transcription411.com/soap.htm> 5. Sokol DK, ‘Let’s stop consenting patients’, British Medical Journal, 348

(2014), p. 2192 6. R V Bonython [1984] SASR 45 per King CJ 7. Civil Procedure Rules (2013) Part 35, Practice Directions.

8. Jones v Kaney [2011] UKSC 13

Aesthetics | September 2014

In Practice Business Process

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Vital statistics Gilly Dickons explores the benefits of collecting figures to boost your business Statistics. Does the word fill you with dread or enthusiasm? Personally, I love statistics. These figures can prove extremely interesting, useful and informative for assessing your everyday practice. Every practice owner benefits from having a clear understanding of the data that underpins their business.

As the saying goes: knowledge is power. For a practitioner setting up a new practice, consider starting the way you mean to go on by harvesting valuable data that you can review periodically. This way you can set yourself goals and targets, as well as bench mark performance. For those practitioners that already have a good client base with regular clinic days, it is essential that you are continually building a database to help manage the business as it grows.

If you haven’t already got a system in place to store information, you can start with something as simple as a spreadsheet alongside an online diary (such as those provided by Google or Apple) – you don’t have to adopt a costly webbased solution. However, for those of you who would like everything stored in the same place, there are some great web-based systems out there that are cost effective to subscribe to, and simple to learn how to use. In the life of your business, the earlier you start to use a system to store valuable data, the simpler it will be as this system will grow with you.

A good CRM (Customer Relationship Management) solution or Diary Management system can support many areas of your business including your marketing, consultation notes, stock control, invoicing, and scheduling and appointment reminders.

Before embarking upon installing or subscribing to a system I would advise you to spend some time thinking about what your day-to-day needs will be. Many online systems will offer you a demonstration, with initial support once you begin to use it.

There are some basic things to look out for in your search for the ideal system, for example: • Can you access the diary easily, and clearly, from your phone or tablet?

• Can you upload consultation notes and patient photographs?

• Is there a diverse but simple reporting system?

• Can you have multiple user logins without it costing a fortune?

• Can you run multiple venues, staff or treatment rooms and still navigate the system easily?

• Is it quick to open and to input data?

• Are costs transparent? Ensure there are no hidden extras – you shouldn’t have to spend a fortune to access a good system.

• Is the diary clear with adaptable time slots?

• Is there initial training?

• Can the system send out automated text reminders and possible emails?

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the earlier you start to use a system to store valuable data, the simpler it will be as this system will grow with you.

Once in place the system will help you to produce and study the figures that underpin your business, supporting your planning and development. If this analysis is not a process that you do at least quarterly, it may seem quite intimidating to carry out. To make the process of collecting statistics less daunting, I propose that you focus on the following key performance indicators, starting with your new enquiries:

Number of new enquiries Carefully log every new enquiry. This information needs to include name, phone number, email address, postcode and marketing source. Ask yourself at this stage whether you are capturing every new enquiry. If not, you need to take action.

Number of new enquiries who book Do you handle your calls personally or do you have designated staff who take care of this? If you have a team carrying out this work then ensure that there is

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In Practice Business Process

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an appropriate system available for staff to log information. You need to identify the number of clients that are booking an appointment during the initial enquiry.

The industry gold standard for conversion is 60%, and the average is recognised to be 45%. However, 70-85% is totally achievable and should be the target for your business. Is there potential to increase your conversions by ensuring that you are looking after every new enquiry? What impact would it have on your revenue if you could convert new enquiries to appointments then treatment?

Let’s look at a hypothetical example using 10 botulinum toxin enquiries from potential clients who will spend £900 over three visits a year: 45% conversion rate gives a potential £4,050 60% conversion rate gives a potential £5,400 80% conversion rate gives a potential £7,200 Every 1% improvement in your conversion rate will increase your revenue by £90!

Number of new enquirers who attend consultation You now need to assess the attendance rate of these new clients. If 90% of patients are turning up to their appointments, then the quality of your appointmentmaking process and follow up is good – be this due to correct phone manner and protocol and/or subsequent reminders. Are you getting many no-shows? If so, you could consider charging a deposit or holding credit card details for your appointments. You should also consider why these customers might be making appointments yet failing to attend. If you aren’t sending reminders, could they be forgetting that they booked at all? To boost the number of enquirers who attend consultation, send appointment reminders 24-48 hours before the appointment; a good diary management system will do this on your behalf. Although some customers will inevitably change their mind about the appointment that they have made, if time is set aside in your clinic diary to see a patient and they don’t turn up, this is time that could have been spent with another patient. Therefore it is in your interest to make every effort to ensure that they attend, and keeping track of the numbers of no-shows will help you to monitor this.

Number of clients who go on to treatment It’s time now to consider your conversion of appointment to actual treatment.

This figure should really be running at 80% plus. The 20% margin here allows for clients who are not suitable, or ready, for treatment. Most people who are asked often say that, off the top of their head, their conversion rate is 90%. However be certain of the facts – you may need to revisit your consultation technique in order to secure such a high number. Whilst you have done the hard work in preparing the patient for treatment, these prospective clients may then go into a different practice ready for treatment. Secure the business at the end of your consultation.

Don’t just assume your conversion is high and that you don’t need to look at the exact figures; you may be surprised to learn your exact conversion rate.

Number of returning clients – your retention rate This statistic really has a huge impact on your business. It is really important to operate a solid recall system, reviewing client treatments at the correct interval.

Always try to book the next appointment before the client leaves the clinic.

Review appointments can be a great way to build relationships with new clients so, even if they do not require post-procedural monitoring, it is a good idea to invite patients back in after their initial treatment to check that they are happy with the results. The time spent on review appointments and forward scheduling will be an investment – the recent Galderma IMPACT study1 shows that it is 32 times easier to sell to an existing customer and five times more expensive to recruit a new one. Schedule in time to really assess your client retention as this makes a huge contribution to your success.

Your cost per lead/enquiry Your business will benefit from understanding your cost to generate each new lead as this will help you to plan a marketing budget, ensuring that you do not waste valuable resources. This is a simple but effective calculation: 64

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Advertising Spend / New Enquiries = Cost Per Lead. For example: You had 10 new enquiry calls (leads) over the last month. You spent £100 on advertising. Dividing £100 by 10 we get a cost of £10 per lead. If we assume that you are operating at an industry standard conversion rate of 45%, you have converted 5 of these leads. If you want to increase your monthly sales you need to increase your advertising budget accordingly. In the meantime, it is up to you to establish what is a ‘reasonable’ cost per lead for your practice – there are some forms of advertising that can be very expensive. This analysis will ensure that you can pursue the most cost effective solution, as it will highlight your most successful source of new clients.

Cost of lost leads/enquiries Another way to look at cost per lead and the value of conversions is the cost per ‘lost’ lead/enquiry: A conversion of only 45% (remember this is the average for this sector) instead of a possible 80% could cost your business £3,150 over those 3.5 lost clients for a 12 month treatment programme.

Average spend per treatment Looking at this information will help you to plan and forecast business, giving you a deeper understanding of your business and clients. You can use this information to target marketing campaigns.

Galderma’s IMPACT study highlighted that when someone buys more than one product or service from your clinic they are 10 times more likely to come back to you – does this reflect in your data?

Average frequency of treatment Have you considered how frequently your clients undergo treatment over a 12-month period? Again, this will enable you to forecast and plan ahead.

You will be able to determine when clients may be dropping off your books, when they need reminders, and what their value is to you over the year.

I have briefly covered the most obvious and central figures to planning and growing a successful business. If you can make the time to explore these, either by checking your records or using a great CRM/Diary Management system, you will be able to extract valuable information to support the growth of your practice. This will, without doubt, be time well spent and will ensure that your practice goes from strength to strength.

Gilly Dickons is the founder of Aesthetic Response, a unique, expert enquiry management service to the UK’s aesthetic and cosmetic sector. AR’s team of patient advisors manage calls and diaries on behalf of a variety of practices, using exceptional customer service skills to convert valuable enquiries into consultations.

REFERENCE 1. Galderma IMPACT study (2014)

In Practice In Profile

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“Being at the cutting edge of new technology is wonderful” Since leaving Sydney, Australia 25 years ago, Dr Rita Rakus has become a wellestablished cosmetic doctor and aesthetic trainer in the UK In a 1994 review, a journalist so impressed with Dr Rita Rakus’ subtle approach to lip volumising entitled her the ‘London Lip Queen’, and it has stuck with her ever since. “It’s a great compliment,” says Dr Rakus. “In those days, lips were very artificial.

I specialise in a very subtle lip and try to make patients look slightly more youthful – no one would even know that they’ve had any treatment done.” After qualifying as a medical practitioner in Sydney, Dr Rakus had decided to move to the UK in 1989 to learn more about non-invasive aesthetic procedures. “The aesthetics field was quite advanced here,” she explains. “There were more opportunities in the UK to further my training and development as a practitioner.”

In 2000, Dr Rakus met Dr Patrick Bowler and together they formed the British Association of Cosmetic Doctors (BACD - now known as the BCAM) and, alongside other industry experts, developed an official training programme for aesthetic practitioners. Dr Rakus is still actively involved in training and lecturing, travelling frequently in order to stay up-to-date with emerging technology and techniques. “In the clinic we tend to stay at the cutting edge of technology and really specialise in providing excellent treatment and training,” says Dr Rakus. Based next to Harrods, in Knightsbridge, and with satellite clinics throughout the UK, Dr Rakus sees patients from all over the world.

“Aesthetic medicine is now so broad, and accepted. Around 25% of our patients are male and we see people from all walks of life,” she says. As many more people continue to work until later in life, Dr Rakus believes that a 60-year-old is no longer seen as ‘old’. “These patients are working for longer and want to keep looking fresh and on the ball,” she explains. “They still feel young inside – until they look in the mirror. I 66

can improve problems, such as sun damage, and get patients looking younger.”

Dr Rakus has won both the Ulthera Ultra Premiere Treatment Provider Award and the Premier Pellevé Partner Award. She has treated over 3,000 patients to date, making her the world’s biggest user of PellevéGlideSafe. But the cosmetic doctor says her biggest achievement is being able to make people happy. “My ethos is to try to make at least one person happy every day,” she says.

As a practitioner, Dr Rakus believes that the most important thing to be aware of is the patient’s individual circumstances.

“Whether they’re a working mum or a model, everyone’s got different needs, budgets and situations in life,” she explains. Not everyone wants the plastic look, she claims; some patients just want to feel more confident during their day-to-day life. “People react differently to you, if you feel better about yourself,” says Dr Rakus. “It could just be a little frown line that’s annoying a patient – we can soften that line and cheer them up.”

As a trustee of Hand in Hand, a charity that supports impoverished Indian villages, Dr Rakus is actively involved in raising money to fund schooling, ecology, literacy and citizenship. “My patients come from every field so I always talk to them about the different things they do,” she says. “This gives me the opportunity to get involved in a wide range of charity work.”

Dr Rakus does note that aesthetics can sometimes be a difficult industry to work in. She says, “It takes special skills, but if you’re an artistic person and enjoy correcting problems for people then it’s a great pleasure and can be an extremely satisfying. If you prefer looking through a microscope then aesthetics is not for you.”

For newly qualified practitioners, Dr Rakus advises that travel is the best way to stay at Aesthetics | September 2014

the forefront of the industry. She says, “Go to conferences, spend time with experts and find out what’s going on in other countries – broaden your horizons.” She adds, “But always make sure you enjoy it. If you find that aesthetics isn’t for you then change your specialty.” Reflecting on her career, Dr Rakus comments that the one thing she would have done differently is to have worried less. “You try to help your patients as much as possible but there will always be the odd patient who has a complication. The most important thing to do is to inform your patients of all the complications that could occur – all you can do is be well prepared. A good network of colleagues to help you out is also useful.”

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

I enjoy all aspects of my aesthetic portfolio, but especially love to treat lips.

What technological tool best compliments you as a practitioner?

My radiofrequency, ultrasound and laser machines because they give such good results.

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

To learn how to assess your patients properly – this will enable you to treat them safely.

Do you have an industry pet-hate?

I think it’s important to share knowledge and help each other. Usually that happens, but it’s such a shame when it doesn’t.

What aspects of the industry do you enjoy the most?

I enjoy meeting new doctors and patients when I’m travelling. I also love to see the technological advances – being at the cutting edge of new technology is wonderful.

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In Practice The Last Word

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The last word Mr Dalvi Humzah argues for clarity and unity in aesthetics We work in interesting times. Words are used interchangeably and with imprecise meanings to communicate, and in some cases misdirect, our potential patients. The terms ‘Aesthetic’ and ‘Cosmetic’ are used; the former has been defined as, “Relating to perception by the senses – concerned with beauty or the appreciation of beauty”, the latter may be considered as relating to, “Treatment intended to restore or improve a person’s appearance derived from the art of adorning (beautifying) the body.” The simultaneous use of the two terms has created a sector that in many people’s view is unregulated and lacks cohesion.

Those who offer cosmetic/aesthetic treatments – cosmetic doctors, physicians, nurses, surgeons – refer to themselves as ‘practitioners’. This unclear titling is further confused by the different titles that are used to denote medical specialities. This is particularly prevalent on the surgical side, with terms appended to different titles, e.g. facial aesthetic surgeon, occulo-plastic surgeon, facial plastic surgeon etc. This inconsistent use of titling confuses the public – those who are our patients.

But what is the view of the regulatory bodies?

The Nursing and Midwifery Council (NMC) set professional standards and the Royal College of Nursing (RCN) represents nurses and nursing practice. The General Medical Council (GMC) and the General Dental Council (GDC) also act as regulatory bodies.

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The GMC is involved in the revalidation and professional standards of doctors and medical students. In particular, the GMC maintains a Specialist Register for which entry is obtained through specific faculties and Royal Colleges. Surgeons were initially separated into nine specialties, however this has recently been expanded to 10, to include Vascular Surgery. Within these 10 specialties is the separate specialty of Plastic & Reconstructive Surgery. Within this specialty is the sub-specialty, ‘Aesthetic Surgery’, often called ‘Cosmetic Surgery’, defined by the Royal College of Surgeons (RCS) as “The changing of appearance by choice and not for the treatment of disease.”1 And yet even these current specialties have a tendency to be unclear; for example, the sub-specialty ‘Plastic’ is appended to other specialties, causing further confusion for patients. The GMC and the surgical colleges do not currently recognise aesthetic surgery as a distinct specialty.

It is evident that work needs to be done to promote clarity for the public. The recent investigations by leading figures such as Sir Bruce Keogh have likened regulation within the cosmetic sector to be similar in effect to purchasing a ballpoint pen or a toothbrush.

Interestingly, in his review, the phrase used was ‘Cosmetic Sector’, moving away from the commonly-used phrase, ‘Cosmetic Industry’.

Whilst calling for high quality care and revised methods of informing and empowering Aesthetics | September 2014

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the public, the review’s recommendations called on existing frameworks – the RCS and Health Education England (HEE) – to develop adequate and appropriate qualifications for the aesthetic sector. This will be a difficult process, involving a multitude of stakeholders working in several differing arenas of medical aesthetic practice.

It is high time that aesthetic practice is recognised not as an industry or sector, but as a truly professional specialty. The difficulty in producing a syllabus or qualification is that there is currently no national body that can truly represent the different groups within the aesthetic sector. Many clinical specialties have their own colleges (Royal College of Surgeons, Royal College of Physicians,) or faculties (Faculty of Travel Medicine, Faculty of Podiatry) that have a central role in setting educational and training standards.

Yet for a specialty that has a large public role, attracting increased interest from the Department of Health, there is no move to set up a specific royal college for aesthetics, or at least a multidisciplinary faculty of aesthetics/cosmetic surgery & medicine.

The setting up of such a body should, in my opinion, feature on the priority list of those currently regulating the industry due to the major role that aesthetic medicine has in the current industry — estimated to be in the region of 2.3 billion pounds. The setting up of such a college or faculty would be of benefit to physicians, surgeons, dentists and nurses. With such a faculty as this, there could be a central organisation that has input regarding the standards, educational and academic requirements of the professionals in this specialty. With all the recent interest from the regulatory bodies, both nationally and internationally, as well as interest from the public, the time is now ripe for the ‘aesthetic sector’ to move away from being an ‘industry’ to becoming a fully-recognised specialty in its own right, with its own faculty or college.

Mr Dalvi Humzah, is a consultant plastic, reconstructive and aesthetic surgeon. He is fully registered with the General Medical Council and holds a license to practice medicine; his name appears on their Specialist Register for plastic surgery. This article does not reflect any views of any professional bodies that Mr Humzah is involved with.

REFERENCES 1. The Royal Collage of Surgeons, The Surgical Specialities:

6 – Plastic and Reconstructive (www.rcseng.ac.uk) < http:// www.rcseng.ac.uk/media/media-background-brief ings-and-statistics/the-surgical-specialties-6-2013-plas tic-and-reconstructive>

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z Medical Aesthetic Group Contact: David Gower +44 02380 676733 info@magroup.co.uk www.magroup.co.uk

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Bocouture® 50 Abbreviated Prescribing Information Please refer to the Summary of Product Characteristics (SmPC). 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) 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. 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. Not recommended for use in patients over 65 years or under 18 years. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. 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. 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). 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, eye disorder, 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). General; In rare cases, localised allergic reactions; such as swelling, oedema, erythema, pruritus or

rash, have been reported after treating vertical lines between the eyebrows (glabellar frown lines) and other indications. 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: November 2013.

Full prescribing information and further information is 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 2012 September 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. 1139/BOC/NOV/2013/LD Date of preparation: March 2014

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Allergan, Marlow International, 1st Floor, The Parkway Marlow, Buckinghamshire SL7 1YL, UK Date of Preparation: August 2014 UK/0880/2014