Body Language Issue 65

sept/oct

65 The UK and International Journal of Medical Aesthetics and Anti-Ageing bodylanguage.net

Expression THE LATEST RESEARCH ON USING TOXINS TO TREAT DEPRESSION

GLYCATION I LASER COMPLICATIONS I BRUXISM How antioxidants can help

Reduce risk and avoid adverse events

Treatment approaches

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body language I CONTENTS 3

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contents EDITOR Helen Unsworth 020 7514 5981 helen@face-ltd.com COMMISSIONING EDITOR David Hicks 020 7514 5989 david@face-ltd.com EDITORIAL ASSISTANT Arabella Tanyel 020 7514 5989 arabella@face-ltd.com SALES EXECUTIVE Monty Serutla 020 7514 5976 monty@face-ltd.com ASSISTANT SALES EXECUTIVE Simon Haroutunian 020 7514 5982 simon@face-ltd.com PUBLISHER Raffi Eghiayan 020 7514 5101 raffi@face-ltd.com CONTRIBUTORS Dr Paul Mendlesohn, Emma Davies, Mr Rajiv Grover, Mr Mike Regan, Dr Beatriz Molina, Dr Raj Persaud, Professor Harry Moseley, Professor Bob Khanna, Julien Demaude, Dr Bianka Toebben, Dr Beth Briden, Dr Natalie Blakely, Mandy Luckman, Antonia Mariconda, Dr Rachael Eckel ISSN 1475-665X The Body Language® journal is published six times a year by AYA Productions. All editorial content, unless otherwise stated or agreed to, is © AYA Productions 2014 and cannot be used in any form without prior permission. Printed by Buxton Press Ltd. Enquiries, orders and all other mail should be addressed to Body Language, 2D Wimpole Street, London, England, W1G 0EB. To contact Body Language by telephone, please call us on +44(0)20 7514 5989. Editorial e-mail: editorial@ face-ltd.com Advertising: advertising@face-ltd.com Body Language can be ordered online at www.bodylanguage.net

7 OBSERVATIONS ANALYSES Reports and comments

15 SPECIAL REPORT

England to produce a regulatory framework, Dr Beatriz Molina discusses their current processes and recommendations

THE KEOGH REVIEW: A NEW BENCHMARK

19 PANEL

Kicking off our aesthetic regulations special report, Mr Rajiv Grover looks at some of the recommendations subsequently made in aesthetic medicine after the 2013 Keogh Review, and what they mean for surgical standards in the UK

Our expert panel discuss the consequences and timeframe of EU regulatory developments as well as what they mean for those currently practicing aesthetic medicine

16 SPECIAL REPORT STANDARDS FOR AESTHETIC SERVICES EU Standards, UK regulations and developments in training in the medical aesthetic industry are changing. Mr Mike Regan, Chair of the British Standards Institution Aesthetic Surgery & Non-Surgical Medical Services Committee, gives an overview of what’s currently happening

17 SPECIAL REPORT

GETTING THE GREEN LIGHT

22 PSYCHOLOGY DEPRESSION AND EXPRESSION Can we improve our mood by smiling more or frowning less?

Dr Raj Persaud surveys the latest research into the use of botulinum toxin to treat depression

26 EQUIPMENT LASER COMPLICATIONS Professor Harry Moseley advises how to reduce risk and avoid adverse events with laser treatments, as well as how to deal with them if they arise

NON-SURGICAL REGULATIONS

33 DENTAL

New non-surgical standards are yet to be published for the UK. Working with Health Education

BRUXISM Excessive grinding and clenching of teeth, otherwise known as

4 CONTENTS I body language

editorial panel

37

Dr Jean Carruthers MD, FRCSC, FRC is clinical professor in the department of ophthalmology and visual sciences at the University of British Columbia in Vancouver. With her husband, Dr Alastair Carruthers, she has received the Kligman award from ASCDAS .

Mr Ravi Jandhyala is a member of the Royal College of Surgeons of Glasgow, and a founding member of the UKBTGA. He is also a member of the Faculty of Pharmaceutical Medicine and is an expert in the science behind botulinum toxins for aesthetics.

Professor Syed Haq trained at Harvard Medical School, Massachusetts General Hospital and Tufts University, New England Medical Center. Professor Haq is Director of The London Preventative Medicine Centre, Harley Street.

Professor Andy Pickett has worked on botulinum toxins for over 23 years. Andy has lectured around the world on the products, translating the science into practical understanding for injectors. In 2011 Andy founded Toxin Science Ltd and is head of development at Q-Med.

Anthony Erian FRCS (Erg) FRCS (Ed) is an aesthetic plastic surgeon with more than 30 years’ experience. He is a member of the American Academy of Aesthetic and Restorative Surgery and chairman of the European Academy of Aesthetic Surgery.

Dr Stephen Bassett is medical director of the Aesthetic Training Academy and ShapeCYMRU Cosmetics. He is a Syneron luminary and member of the Merz academy.

He is a barrister, fellow of the Society of Advanced Legal Studies and a legal consultant.

bruxism, can lead to tooth wear, jaw disorders,headaches and hypertrophy of the muscles of mastication. Professor Bob Khanna discusses his preferred treatment approach, using a combination of botulinum toxin and occlusal therapy

37 SKINCARE Elizabeth Raymond Brown, Phd, CRadP, MSRP authored the internationally recognised BTEC qualifications in medical and aesthetic laser/IPL therapies and national occupational standards in light-based therapies.

She is now director of education at LCS Academy Ltd.

Dr Séan Cummings MBBS T(GP), DRCOG, DFFP, MRCGP, LLM is a cosmetic doctor practising in Harley Street. Dr Cummings has more than 20 years’ experience as a practitioner and has a masters degree in medical law.

Dr Cummings works as an expert witness.

Dr Raj Persaud FRCPsych is a consultant psychiatrist who has worked at the Bethlem Royal and Maudsley NHS Hospitals in London from 1994-2008, and as an honorary senior lecturer at the Institute of Psychiatry, University of London.

Dr Bessam Farjo MB ChB BAO LRCP&SI is a fellow International College of Surgeons, founder member British Association of Hair Restoration Surgeons and president of the International Society of Hair Restoration Surgery.

Dr Masud Haq BSc, MRCP, MD is a consultant in diabetes and endocrinology.He is a graduate of Guy’s and St Thomas’s Hospital, and trained at Johns Hopkins in the US and in Melbourne. He has a particular interest in the thyroid and menopause.

Fiona Collins and Marie Duckett are registered nurses and members of the Royal College of Nursing forum for nurses in aesthetic medicine. Their clinic, Fiona and Marie Aesthetics Ltd, is based in Harley Street, London, UK.

RESVERATROL Antioxidants are essential in the body’s fight against the assault of free radicals and consequent ageing. Julien Demaude discusses the latest research into antioxidant formulations for longevity and anti-ageing, with a focus on resveratrol’s effect on oxidative damage

advanced glycation end products

49 PRODUCTS ON THE MARKET The latest medical aesthetic products and services

51 LEGAL CONSENTING AND DATA PROTECTION Keeping patient data safe and taking robust consent data is crucial to protect practice and patients, explain Dr Natalie Blakely and clinical negligence expert Mandy Luckman

57 MARKETING WORKING WITH BEAUTY BLOGGERS

Collagen stimulation, cell regrowth and increased immunity against external damage are all benefits of facial acupuncture and acupressure, writes Dr Bianka Toebben

Currently in the UK, it is estimated there are 750,000 beauty bloggers. Antonia Mariconda explains how medical aesthetic professionals haven’t tapped into the power of beauty bloggers and how they can benefit your business, profile or brand

44 DERMATOLOGY

61 EXPERIENCE

SUGAR AND THE SKIN

RECIPE FOR AESTHETIC SUCCESS

41 ANTI-AGEING FACIAL ACUPUNCTURE

Dr Beth Briden summarises the effects of glycation on the skin, and how antioxidants such as gluconolactone, lactobionic acid and maltobionic acid can help fight the negative effects of

Mix together a successful family, an international education and a wealth of experience, stir well and we have a serving of dermatologist Dr Rachael Eckel

ELEGANT • FULFILLED • MY TIME

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

LOOK HOW YOU FEEL Azzalure Abbreviated Prescribing Information (UK & IRE) site(s) or when the targeted muscle shows excessive weakness or (twitching of muscles around the eyes). Uncommon (≥ 1/1,000 to Presentation: Botulinum toxin type A (Clostridium botulinum toxin A haemagglutinin complex) 10 Speywood units/0.05ml of reconstituted solution (powder for solution for injection). Indications: Temporary improvement in appearance of moderate to severe glabellar lines seen at frown, in adult patients under 65 years, when severity of these lines has an important psychological impact on the patient. Dosage & Administration: Botulinum toxin units are different depending on the medicinal products. Speywood units are specific to this preparation and are not interchangeable with other botulinum toxins. Reconstitute prior to injection. Intramuscular injections should be performed at right angles to the skin using a sterile 29-30 gauge needle. Recommended dose is 50 Speywood units (0.25 ml of reconstituted solution) divided equally into 5 injection sites,: 2 injections into each corrugator muscle and one into the procerus muscle near the nasofrontal angle. (See summary of product characteristics for full technique). Treatment interval should not be more frequent than every three months. Not recommended for use in individuals under 18 years of age. Contraindications: In individuals with hypersensitivity to botulinum toxin A or to any of the excipients.

In the presence of infection at the proposed injection sites, myasthenia gravis, Eaton Lambert Syndrome or Amyotrophic lateral sclerosis.

Special warnings and precautions for use: Use with caution in patients with a risk of, or clinical evidence of, marked defective neuro-muscular transmission, in the presence of inflammation at the proposed injection Date of preparation: March 2013

atrophy . Patients treated with therapeutic doses may experience exaggerated muscle weakness. Not recommended in patients with history of dysphagia, aspiration or with prolonged bleeding time. Seek immediate medical care if swallowing, speech or respiratory difficulties arise. Facial asymmetry, ptosis, excessive dermatochalasis, scarring and any alterations to facial anatomy, as a result of previous surgical interventions should be taken into consideration prior to injection.

Injections at more frequent intervals/higher doses can increase the risk of antibody formation. Avoid administering different botulinum neurotoxins during the course of treatment with Azzalure. To be used for one single patient treatment only during a single session. Interactions: Concomitant treatment with aminoglycosides or other agents interfering with neuromuscular transmission (e.g. curare-like agents) may potentiate effect of botulinum toxin. Pregnancy & Lactation: Not to be used during pregnancy or lactation. Side Effects: Most frequently occurring related reactions are headache and injection site reactions.

Generally treatment/injection technique related reactions occur within first week following injection and are transient and of mild to moderate severity and reversible. Very Common (≥ 1/10): Headache, Injection site reactions (e.g. erythema, oedema, irritation, rash, pruritus, paraesthesia, pain, discomfort, stinging and bruising). Common (≥ 1/100 to < 1/10): Facial paresis (predominantly describes brow paresis), Asthenopia, Ptosis, Eyelid oedema, Lacrimation increase, Dry eye, Muscle twitching

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

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

Adverse events should also be reported to Galderma (UK) Ltd.

AZZ/020/0313

body language I NEWS 7

observations

BONE MARROW DRUG STOPS HAIR LOSS Drug suppresses immune response and promotes hair regrowth A pre-existing bone marrow drug has been used to completely reverse hair loss in three alopecia sufferers, in a study at Columbia University Medical Center in the US. The drug Ruxolitinib, normally used to treat bone marrow disorders, was given to seven women and five men who suffer from alopecia areata and the patchy baldness associated with the condition, with three of these patients experiencing complete regrowth. Some of the researchers’ findings have been published in the American journal Nature Medicine.

The researchers chose the drug following previous research on mice

by Columbia University professor Angela Christiano, a co-leader of the recent study and herself an alopecia sufferer.

The work had shown that immune cells were responsible for destroying hair follicles in alopecia sufferers. Ruxolitinib works by blocking certain enzymes to suppress the immune system.

“It appears to work—not in everyone, but in the majority,” study co-author and director of Columbia’s dermatology clinical research unit Dr Julian Mackay-Wiggan told the New York Times in an interview. “We need a lot more data on the long-term risks in healthy individuals. But it’s certainly very exciting in terms of hair growth.

It was surprising how quickly and impressively the growth occurred.”

Larger trials are now likely, to assess both the effectiveness and safety of the drug, which could have side-effects for the liver and other organs.

STUDY FINDS PLASTIC SURGEONS VALUE TRAINING IN BOTOX PROCEDURES Poll surveys opinion as more nonaesthetic health professionals administer injectables Plastic surgeons consider themselves and dermatologists the best healthcare practitioners when it comes to administering aesthetic injectables such as Botox, according to a US study due to appear in the journal of ISAPS Aesthetic Plastic Surgery.

The study was carried out by doctors from the New York Presbyterian Hospital and Columbia University, also in New York, and involved an eight-question survey that was sent to 26,113 plastic surgeons worldwide.

Of the 882 respondents, 77% believed nurses were not as capable as plastic surgeons in administering Botox, while 81% felt the same for fillers.

The responses echo those of previous patient sur-

veys, suggesting that training is widely held to be the most important factor in the administration of such procedures.

“Since most of the growth in the field of cosmetic injectables is being driven by providers other than plastic surgeons and dermatologists, it appears that further clarification on training requirements and practice guidelines is necessary to ensure a consistent, reproducible and safe experience for the patient,” note the study’s investigating authors Dr Kevin Small, Dr Kathleen M Kelly and Dr Henry M Spinelli.

The study was designed to gather the perspectives of plastic surgeons in light of the growing number of non-aesthetic health professionals who now perform these procedures.

Interestingly, 48% of respondents ranked nurses in other fields as most capable when it came to administering vaccines, followed by plastic surgeons (42%), with just 9% voting nurses of plastic surgeons as best at vaccines.

In terms of the geographical spread of respondents, the majority reside in the US—36.6% were from North America, 29.1% from Europe, 12.9% from South America, 10.1% from Asia, 4.5% from the Middle East, 3.4% from Australia, 1.9% from Africa and 1.6% from Central America.

8 NEWS I body language

events 25-27 September, Aesthetic and AntiAging Medicine Asian Congress, Singapore

STEM CELL THERAPIES NEED REGULATION US study questions “unsubstantiated” claims about efficacy and safety

SEPT

OCT

3-6 SEPTEMBER, LaserInnsbruck 2014, Innsbruck, Austria W: laserinnsbruck.com

3 OCTOBER, BACN Annual Conference & Exhibition, Hilton Metropole, Brighton W: cosmeticnurses.org

4-6 SEPTEMBER, London Breast Meeting, London, UK W: londonbreastmeeting.com

10-14 OCTOBER, Plastic Surgery: The Meeting, Chicago, USA W: plasticsurgery.org

5-7 SEPTEMBER, New Zealand Association of Plastic Surgeons Scientific Meeting 2014, Queenstown, New Zealand W: events4you.co.nz

12 OCTOBER, Second annual Zone Conference, The Langsdown Club, London W: zone-lifestyle.co.uk

7-10 SEPTEMBER, DASIL 3rd Annual Congress, Sun City, South Africa W: thedasil.org 11 SEPTEMBER, RSM Interventional Cosmetics: New and Controversial Treatments 2014, Edinburgh W: rsm.ac.uk 18-21 SEPTEMBER, 1st Euro-Asian Melanoma Congress 2014, Sarajevo, Bosnia W: melanoma.ba 25-26 SEPTEMBER, British Association of Aesthetic Plastic Surgeons 2014 (BAAPS 2014), QEII Conference Centre, London W: meeting.baaps.org.uk 25-27 SEPTEMBER, The Royal Institution: International Conference on Repair, Regeneration and Reconstruction, Mayfair, London W: instituteofsurgery.org 25-27 SEPTEMBER, Aesthetic and AntiAging Medicine Asian Congress, Sands Expo & Convention Center, Marina Bay Sands, Singapore W: euromedicom.com

Clinics around the world are making unsubstantiated claims about the effectiveness and safety of cosmetic stem cell therapies, according to a study in the August edition of the US Journal of Plastic and Reconstructive Surgery.

“Although stem cell therapy remains in its infancy, there are a growing number of cosmetic practitioners that are advertising minimally invasive, stem cell-based rejuvenation procedures,” reports the study, authored by researchers from Stanford University School of Medicine.

“With unsubstantiated claims that these procedures are safer, have equivalent or better outcomes, and have faster recovery periods than conventional procedures, many of these practitioners are emphasizing profit over quality and safety.”

The authors identified 50 clinics using direct-to-consumer marketing by Googling terms such as “stem cell therapy”, “stem cell treatment” or “stem cell facelift”, as would a potential client.

Due to various natural limitations, including these practitioners to sort the cells by flow or magnetic cytometry, the authors judged it likely that the therapies advertised used many other cells in addition to stem cells.

Some clinics were also marketing platelet-rich plasma treatments as stem cell treatments, despite the fact that such plasma does not contain any stem cells. The study also notes that while the use of stem cells in cosmetic medicine increases, approval of its use by the Food and Drug Administration (FDA) remains limited.

“When considering clinical use of stem cells, one must be cognizant of the fact that cell and tissue processing pose a risk of contamination and/or damage to cells,” the study notes.

“Regulation of stem cell therapy is thus essential to ensure patient safety.

For this reason, the growing number of ‘stem cell–based’ cosmetic procedures is worrisome, because of the lack of oversight and dearth of scientific studies or trials to evaluate their efficacy and safety,” the authors conclude.

22-24 OCTOBER, 35th Annual Meeting of the International Society for Dermatologic Surgery, Jerusalem, Israel W: isdsworld.com

NOV

3 NOVEMBER, 3rd National Aesthetic Nursing Conference: Clinical excellence in cosmetic medicine, Cavendish Conference Centre, London W:eventsforce.net 6-9 NOVEMBER, ASDS Annual Meeting 2014, San Diego, USA W: asds.net 7-9 NOVEMBER, American Academy of Aesthetic Medicine 11th Annual Congress, Las Vegas, USA W: aaamed.org 29 NOVEMBER, Wigmore Medical Open Day, Royal Society of Medicine, London W: wigmoremedical.com

Some clinics were marketing platelet-rich plasma treatments as stem cell treatments

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body language I NEWS 11

BOOST FOR SURGICAL MIGRAINE CURE Researchers quantify benefit of treatment for migraines A US study by plastic and reconstructive surgeons has found a surgical eyelid procedure to be effective at treating migraines.

The study, carried out by surgeons and due to be published in the Journal of Plastic and Reconstructive Surgery, found a high success rate in using the technique to decompress the nerves that trigger migraines.

Of the 35 patients who underwent the procedure, 90% reported relief from migraine symptoms (as well as benefitting from a cosmetic eyelid surgery). Migraine headaches were totally eliminated in 51.3% of patients, with a fifth experiencing an 80% reduction of symptoms.

Almost one third of the patients had between 50–80% of their symptoms resolved. All of those who took part suffered from chronic nerve compression migraine headaches.

The procedure, which involves making incisions through the upper eyelid, offers an alternative to the more commonly used endoscopic surgical treatment for migraine. The study’s findings are particularly exciting since many migraine sufferers cannot take advantage of the endoscopic treatment for reasons such as conflicting health issues.

“Surgery is a valid treatment for migraines in certain patients,” notes study co-author Dr Oren Tessler, Assistant Professor of Clinical Surgery at the Louisiana State University School of Medicine in New Orleans.

“We believe that these patients should have ready access to migraine trigger site decompression surgery. Although larger studies are needed, we have shown that we can restore these patients to full and productive lives,” Dr Tessler says.

The researchers also included surgeons from Massachusetts General Hospital and Harvard Medical School.

60

second brief

WORLDWIDE COSMETIC PROCEDURES According to reseach carried out by the International Society of Aesthetic Plastic Surgery (ISAPS), more than 23 million cosmetic surgical and non-surgical procedures were performed worldwide in 2013. For the first time, Brazil has overtaken the United States in the number of surgical procedures performed, and botulinum toxin proved the most popular treatment, taking the top spot for overall cosmetic procedures performed.

Countries that performed the most cosmetic surgical and non-surgical procedures in 2013 include:

UNITED STATES: 3,996,631 (17%)

MEXICO: 884,353 (3.8%)

SPAIN: 447,177 (1.9%)

BRAZIL- 2,141,257 (9.1%)

GERMANY: 654,115 (2.8%)

Top cosmetic surgical procedures performed in 2013:

Top non-surgical procedures performed in 2013:

Breast augmentation—1,773,584 Liposuction—1,614,031 Blepharoplasty—1,379,263 Lipostructure including lipofilling and stem-enhanced lipofilling—1,053,890 Rhinoplasty—954,423

Botulinum toxin—5,145,189 Fillers and resorbables—3,089,686 Laser hair removal—1,440,252 Non-Invasive facial rejuvenation—1,307,300 Chemical Peel, CO2 resurfacing, dermabrasion—773,442

Source: The International Society of Aesthetic Plastic Surgery (ISAPS)

body language I PROMOTION 13

AMEC 2014 The Aesthetic & Anti-Aging Medicine European Congress enters its second year, taking place at the start of the season on the 24th and 25th October in Paris

F

ollowing the success of the 1st Aesthetic & Anti-aging Medicine European Congress (AMEC) launched last year, Euromedicom and Informa Exhibitions are pleased to announce the 2nd edition of the Congress (AMEC 2014) which will take place on the 24th and 25th October, at the Palais des Congrès in Paris.

Under the scientific supervision of the World Society of Interdisciplinary Anti-aging Medicine (WOSIAM) and the Multispeciality European Society for Aesthetic and Anti-aging Medicine (MESAAM), the AMEC 2014 has been developed to meet the European need for a larger global aesthetic and anti-ageing event at the start of the new season. Its scientific program is the result of the close collaboration with different active medical partner associations from Russia, Northern Europe and South East Asia.

Content for all levels of expertise The AMEC 2014 scientific programme places emphasis on highly practical content and is adapted to physicians of all levels of expertise. Several interactive live demonstration sessions will address clinically relevant essentials. Participants can directly and assuredly apply this updated information to their daily clinical practice.

The 2nd Anti-Aging & Beauty Trophy Euromedicom is organising the 2nd Antiaging & Beauty Trophy, awarding the industry. The Trophy will be conferred to companies for their best and most innovative products and technologies of the year.

Keynote speakers include: Aesthetic dermatology: Raj Acquilla (UK), Doris Day (USA), Christine Dierickx (Belgium), Marete Haedersdal (Denmark) Kate Goldie (UK) and more Aesthetic surgery: Mark Codner (USA), Berend Van der Lei (the Netherlands), Steven Hopping (USA) and Olivier Galatoire (France).

Anti-ageing and preventive medicine: Sylvain Mimoun (France), Bernd KleineGunk (Germany), Cem Ekmekcioglu (Austria) and Daryl O’Connor (UK).

In an effort to promote and encourage high-standards of clinical excellence, we will be nominating physicians for their “Best Clinical Cases”. The participants are cordially invited to apply for this competition and participate in the Trophy award ceremony. The evaluation of the best cases will be performed by experts from different countries.

Complete aesthetics management Training and educational sessions, live demonstrations and workshops will be run by a world class faculty of opinion leaders.

More than 150 internationally renowned speakers from academic institutes and private practice will share their expertise.

The 2nd AMEC will also feature advanced educational programmes: • The 2nd European Plastic and Aesthetic Surgery Rendez-Vous, will cover a full day focused on “Eyes and periorbital zone: Rejuvenation and beautification” with live demonstrations transmitted from the operating room.

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body language I SPECIAL REPORT 15

The Keogh Review: a new benchmark Kicking off our aesthetic regulations special report, MR RAJIV GROVER looks at some of the recommendations subsequently made in aesthetic medicine after the 2013 Keogh Review, and what they mean for surgical standards in the UK

T

he Keogh review was the largest of its kind for 30 years. There had been others, but because of the PIP crisis—where more than 45,000 women had defective implants inserted—it became incredibly important for the government to act. Following the review, 46 recommendations were made.

For surgery, the Keogh review recommended that the Royal College of Surgeons set up a committee, which would be responsible for setting standards, instructing different types of surgeons on what they could and couldn’t do, and registering them as trained in cosmetic surgery. They decided that there needed to be an implant register, just as you would have for hip or knee replacements. The PIP crisis showed us that nobody knew what was happening, and having a simple register was thought to be essential—if there was a fault with a particular im-

66 Advertising can glamorise surgery, making it look like a beauty treatment.

People forget that it’s a medical procedure with significant risks 99 plant, you could recall individuals.

They realised that there needed to be greater research and data capture. In fact, Sir Bruce Keogh referred to the cosmetic sector as a “data free zone”. He wanted real, formal research, so that there would be safety data to know which treatments were effective and which were not.

Another issue he felt concerned by was advertising and marketing. Advertising can glamorise surgery, making it look like a beauty treatment. People can forget that it’s a medical procedure with significant risks. All kinds of packages were available

from certain cosmetic surgery clinics, targeting vulnerable individuals with deals such as “divorce, feel good” packages.

These, they thought, should be outlawed.

The PIP crisis highlighted that there were basic elements missing in our current surgical standards. For example, many women thought that a breast implant was for life and it came as a surprise that even a normal, non-defective implant would need to be replaced, on average, every ten to twelve years.

This is simple information that should have been clear, yet patients were led to believe there was lifetime guarantee.

What implant manufacturers actually offer is a lifetime guarantee that an implant isn’t going to rupture.

Recommendations The committee has been divided into three sub committees to put these regulations and standards into place. One is specifically for standards and certification, another is for clinical quality and outcomes, while the last committee is for patient information.

To train in cosmetic surgery, you will first of all get a CCT, or a certificate of completion of training in surgery, which means you are then on the specialist register of the General Medical Council (GMC). That allows you to have the “core standards” in cosmetic surgery.

If you train in plastic surgery, ENT or ophthalmology you get core information about the relevant areas within your anatomical field. But the committee specifically wanted something for those who want to train in cosmetic surgery. Most training in surgery is done via the NHS and, as of now, you will not be there to perform any cosmetic work. Therefore you would get a credential in cosmetic surgery after you have completed your normal training.

Moving forward There will probably be a period of grace, so if you have been performing these treatments for a number of years and have been doing it in a safe, satisfactory way— which of course you would audit as part

of your GMC appraisal—then there may be some grandfathering. You would reach this point without having to obtain specialist training in surgery. For anybody coming into cosmetic work afresh, there will be a line drawn in the sand, so that you have to be on a specialist register.

A pilot study is now in progress for a breast implant register. We are not the only country to have had problems; these issues are worldwide and a few countries are now collaborating. It would be useful for research purposes to have a register where the same data is gathered in different countries.

This method of data capture and this particular pro forma is called the International Collaboration of Breast Device Registry Activities (ICOBRA), developed in Australia and will be used in the Netherlands. It’s the basic template for what we will be using in this country. The MHRA, who regulates implants, has a sub-group called CPRD which is responsible for clinical trials and will be housing the pilot study.

At the British Association of Aesthetic Plastic Surgeons, we have founded, together with the Healing Foundation, a National Institute of Aesthetic Research.

This is based at the Royal College of Surgeons and specifically tries to address the data vacuum which Sir Bruce Keogh mentioned and will raise money to carry out research and audit within this sector.

The schedule for each subgroup on credentialing and standards, quality and outcomes and patient information, has a completion point of early 2016. It may be easier to regulate surgery this way because of the CQC—most surgeons are on the specialists’ register and have to be appraised and revalidated. Much of the regulatory framework requirements are already in existence. It’s not unrealistic to believe that if you were having surgery in the UK in 2016, it may be a different playing field than prior to the PIP crisis.

Mr Rajiv Grover is a Consultant Plastic Surgeon at London’s King Edward VII Hospital and President of British Association of Aesthetic Plastic Surgeons (BAAPS)

16 SPECIAL REPORT I body language

Standards for aesthetic services EU Standards, UK regulations and developments in training in the medical aesthetic industry are changing. MR MIKE REGAN, Chair of the British Standards Institution Aesthetic Surgery & NonSurgical Medical Services Committee, gives an overview of what’s currently happening

T

he British Standards committee reports into Europe on a new European standard on aesthetic services, covering both surgical and non-surgical treatments.

These two standards cover competences—which can be quite an emotive subject—as well as management and communication with patients, facilities, requirements on room type and more.

It looks at each of the individual procedures that can be offered and defines the associated safety levels required, such as potential risks and anaesthesia. There is also a section on quality assurance and a code of ethics on marketing and advertising.

Development The first of the two aesthetic services standards relates to surgery, which has been approved for publication by the European Committee on aesthetic services, developing the work under CEN (European Committee for Standardisation).

CEN is a powerful body that represents all countries in the EU, plus some others in the EEA. Subsequent to the June 2014 announcement by CEN regarding the positive voting result on the surgical standard throughout Europe, two CEN member national committees—not the UK—have lodged an appeal against the result.

This appeal will be considered by the CEN Technical Board and, in the meantime, publication of the surgical standard will be put on hold.

Work on the non-surgical standard is currently being discussed. This is feeding in very well to the Health Education England work on non-surgical training. We’re hoping to publish the non-surgical standard sometime next year.

These standards have been in development for the last four years. Two large Europe-wide public consultations were carried out in 2012 and 2013.

Impact So how does this impact the UK, including from a regulatory point of view? If and when the standards are published by CEN, they will be implemented in the UK as British Standards (i.e. BS ENs) and made available as voluntary best practice documents.

As an appeal has been raised against the surgery standard, we don't yet know what the outcome will be. If the appeal is granted, and CEN decide not to proceed to the next stage of publishing the document as an EN (European Norm/European Standard), then the UK will have to rethink its position.

The non-surgical standard, which is in development, is even

more involved. Each country can request exceptions to what has been agreed in Europe, if the standard conflicts with that country's own national legislation.

In the UK, we’ve been granted exceptions, based on UK legislation, to allow dentists and nurses who are independent prescribers to carry out appropriate non-surgical procedures, within their competence.

We also have an exception to allow non-healthcare professionals, such as particular beauty therapists, to perform noninvasive laser and IPL treatments.

However, we don’t yet have an exception to allow nonhealthcare professionals to administer injectables, as there is no relevant legislation which covers this profession in this matter.

We realise that any forthcoming debate on this will be deeply emotive for the various stakeholders concerned, despite the fact that NHS Medical Director, Sir Bruce Keogh has openly rooted for it to be a possibility.

We still need to look at the remaining input into Europe and we must consider the need for any further exceptions to the European standard, if new legislation is introduced. After this we’ll move into a rolling five year review period.

Mike Regan is a Laser Protection Adviser and Director of Bioptica Laser Aesthetics. He has a background in physics and engineering and has been involved with standards work since 2001.

W: bla-online.co.uk

body language I SPECIAL REPORT 17

how we could move forward with these groups.

Initially we had trouble trying to resolve how we could allow unregulated practitioners to continue. We collaborated and spoke to various people, including non-healthcare professionals, and were surprised to find they weren’t that far off from where we felt the regulations should be moving towards.

Recommendations We are currently at phase one and a big part of the debate was what we were going to call ourselves. We all have different backgrounds, and we were all taught in different types of colleges.

We weren’t sure whether “aesthetic practitioners” or “cosmetic practitioners” was more appropriate. The main consideration was clarity for the public so with this in mind we chose the term “cosmetic”.

We only based these meetings on the key five practices: botulin toxin, dermal fillers, chemical peels, lasers and IPL. It later became obvious that LED had been omitted and should be part of IPL as a group, and hair restoration is becoming very popular too. We had a lot of different working groups in different areas.

The main question was regarding education: what were the foundation qualifications people needed and where did they start? The different levels are a Certificate of Higher Education (Level 5), a Bachelor Degree (Level 6) a Master’s Degree (Level 7), and a Doctorate Degree (Level 8).

You currently must have a Doctorate or Master’s Degree to be able to treat with botulin toxin. Beauty therapists are the only professionals who are not already professionally qualified in a body, so they have to have supervision.

But how will this supervision happen? We want to help these individuals to move forward to those levels, so they can actually progress. Beauty therapists, for example, are not able to perform laser treatments straight away, so they need to do a Level Four certification. This is so they have the foundation module with some core knowledge, skills and competencies and can learn laser treatments and move on to become a specialist in laser.

Non-surgical regulations New non-surgical standards are yet to be published for the UK. Working with Health Education England to produce a regulatory framework, DR BEATRIZ MOLINA discusses their current processes and recommendations

I

n January 2014, my friend and colleague, Emma Davies called me and told me that we had 10 days to get paperwork together for Health Education England, with a view to moving forward with UK non-surgical regulations.

It was a massive task and obviously very daunting. Emma and Andrew Ranking have done an amazing job collaborating with other professionals, so that nurses and doctors could contribute information for the meetings.

We have been differentiating between two groups. One group comprises practitioners who are not currently registered with any regulatory body, such as beauty therapists who are providing injectables but are not regulated.

The second group includes healthcare professionals who are already registered with a regulatory body. We needed to establish

Where we are We don’t yet know how the process will end, and our status is currently “in progress”. For the moment, where lasers are concerned, the minimum educational requirement to practice will be Level Four. We then need to decide what content to include in the Foundation Course. This is difficult because there is a lot to cover. Elements such as how long the course will be, or how many hours need to be spent, have not been finalised. We just have recommendations at the moment.

If you want to see any person as a paying customer and for them to perform any sort of treatment—even “simple” procedures with few complications—it is still slightly invasive. There are a number of psychological implications that we need to consider for these patients.

We’re still putting together a programme for lasers and chemical peels, and setting out what needs to be done for those individuals to be able to perform safely. The non-surgical side is a bit more difficult than the surgical side of these new standards and regulations. Although a lot of progress is being made on the training framework, the Government seems intent on not backing this up with regulation. We hope to have these recommendations finalised and published in 2015.

Dr Beatriz Molina is a member of the British College of Aesthetic Medicine and Director of Medikas, a MediSpa providing beauty and non-surgical treatments.

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body language I PANEL 19

Getting the green light Our expert panel discuss the consequences and timeframe of EU regulatory developments as well as what they mean for those currently practicing aesthetic medicine Dr Beatriz Molina: We’ve been working closely with the GMC for the last few months, discussing this option and whether it is in the pipeline.

We are in talks at the moment and are moving towards getting cosmetic medicine as a speciality for doctors.

Dr Paul Mendlesohn: It’s the same in dentistry, because the General Dental Council, for example, doesn’t consider medical aesthetic treatments as part of dentistry.

They say if you’re a dentist and you’re performing these treatments, you’re not being a dentist.

Nevertheless, you fall under the dental regulations if something goes wrong. It’s quite an unusual situation, and they’ve been changing their stance on it because they don’t know where the dentist’s expertise ends.

Non-surgical treatments are growing so quickly, you can’t get them back in the box. There are too many people offering treatments in too many different ways.

I think the reason that they are not being regulated is that it would be a bit like prohibition—if you regulate it, it’ll go underground.

I see the regulations as a long way off, because it’s impossible to manage. I think self-regulation and self-standards, based on the standards that these experts are developing, are going to be the way forward. We have to create and subscribe to standards. That will differentiate us from the people who don’t.

Q: How will practitioners enter into the non-surgical training programme, and what is in place to enforce people to adhere to it?

Dr Beatriz Molina: At the moment, that’s the problem—there isn’t any enforcement. I think they will suggest that everyone has to go this way and with time it may be that we can say this is a regulatory requirement, but at the moment, that’s not the case.

Emma Davies: I think the government has a view that the existing professional registers—the GMC, the NMC and the GDC—will take a greater role in holding us accountable to our standards.

That goes round full circle. If we’re accountable to our professional regulators, then we are regulated. I’m interested in whether the GMC think that aesthetic medicine could become part of a specialist field of practice, and therefore have its own register.

Emma Davies: It’s very important for consumers. They need to be directed to somebody who’s signing up to a set of standards and being measured against them. Then there are the consumers who don’t care, through ignorance—we have a role to play in educating them.

Q: We see with dentistry and teeth whitening, people are still bleaching teeth when they shouldn’t be. The GDC struggles to enforce it. There have been a few prosecutions, but people

20 PANEL I body language

66 The exceptions for the injectables that we have at the moment are for dentists and nurse independent prescribers 99 generally just carry on. How do you see that it’s going to work?

Dr Paul Mendlesohn: I’m a dentist, and I know with the huge amount of illegal tooth-whitening, there are one or two cases a year, because there are no resources.

It’ll be exactly the same. On the surgical side I am sure it will be enforced, but on the non-surgical side, I think it’s impossible to enforce.

Q: What is the time frame for the non-surgical recommendations?

Mike Regan: It is proving very difficult to get Europe-wide consensus on the nonsurgical draft. In addition to the recent vote on the surgery standard, there was also a vote on how to proceed with the non-surgical draft.

Currently, there’s going to be a need for another Plenary meeting, probably in Austria in the next few months, to decide a way forward.

Unfortunately, we don’t have a sufficient number of participating countries to take the non-surgical draft any further at the moment, but we’re hoping, on the back of the success of the surgery standard, that we will be able to resolve that, with a publication date sometime next year—maybe quarter three. However, in light of the appeals that have been lodged against the surgery standard we may need to rethink the way forward.

Q: Are you suggesting it’s only going to be prescribing nurses who are going to be able to inject?

Mike Regan: The situation is this; as you can imagine everything must be done very formally within Europe and it takes quite a while.

The way it works is a European Standard is issued, and each member state can apply for exceptions—technically known as A-deviations—and we’ve currently been granted the deviations mentioned previously.

It all depends what the UK member

associations of the BSI committee ask for, and also what comes back in the public consultations. Current exceptions for injectables are for dentists and nurse independent prescribers.

Q: Is it just that those groups are able to work autonomously? Or is it that you can’t inject if you’re not a prescribing nurse, a doctor or a dentist?

be “harmonised” with a suitable European directive, and then meeting the standard/EN would be a way of meeting the European law.

Even then, it would be the European law that must be met, not the EN as such, the EN just being “one way” to meet such a law . However, there is in any case currently no relevant European directive in this area.

Q: As an ENT consultant, what is it likely that I will need to do, to continue aesthetic surgery in the future?

Q: So we could potentially ‘not’ adopt it, although we probably will?

Mr Rajiv Grover: You will probably be able to just carry on. You are already on the specialist register, you’re already working in a CQC-registered environment because you have to be for your admitting rights.

You’ll be having an annual appraisal—which is a whole practice appraisal— so even if it’s done in the NHS, you will have your private practice appraised, and you’ll be revalidated by the GMC. If they do come up with the GMC specialist area of cosmetic surgery, then because you are already practicing it and you’re already having your revalidation appraisal, you will probably be given that automatically.

Your trainees will get their CCT when they finish their training. They will probably not have been exposed to as much aesthetic work as you have been. If they want to do a fellowship in facial plastic surgery, allowing them to do eyelid and facelift surgery, they would need to do that in an accredited way, beyond their CCT. For you, I think it’s business as usual. For your trainees, there may be more hurdles. Although, to maintain appraisal and revalidation, we may be required in the future to do more rigorous things, like getting more CPD points.

Mike Regan: According to the CEN rules, if an EN (European Norm/European Standard) is published, all member states of CEN have to adopt it. Thus the UK would have to produce a BS EN, a British Standard European Norm.

We have to publish it. It will comprise 50 pages of guidance from top-level medics throughout the whole of Europe, so it does serve a useful purpose, but it’s not going to be mandatory.

The reason it’s not going to be mandatory is because all standards are in fact voluntary. Some European Standards can

Dr Beatriz Molina: If you think about the non-surgical, it’s similar. We’ve got a lot of colleagues who are doing more invasive procedures, and they’ve been very worried. In conversations with the GMC, I believe what they’re saying is that if you prove your competency and have treated enough cases to prove you are capable, you will continue.

For doctors, it doesn’t matter what your background or speciality is—what they are saying is you have to have enough hands-on training and we do our appraisals and audits we can carry on.

Mike Regan: We may need to firm up on the precise details of particular exceptions. It’s one of the things that Sharon Bennett of BACN—who is the UK lead on future work on the non-surgical draft—will be taking forward on this ongoing debate in Europe with regard to the non-surgical side.

Q: When the The European regulation comes out, does the country adopt it, or does it automatically apply? It doesn’t become law in the country—how does that work?

Mike Regan: The European rules are that once a European Norm is published, then each member state has to adopt it— there’s no question. However these European standards are not mandatory, they’re high-level guidance.

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22 PSYCHOLOGY I body language

Depression expression Can we improve our mood by smiling more or frowning less?

DR RAJ PERSAUD surveys the latest research into the use of botulinum toxin to treat depression

I

work in private practice in Harley Street and take a large number of referrals from aesthetic professionals—often ostensibly due to concerns over offering a procedure to a particular client. Alarm bells have rung, the client may have unrealistic expectations of the outcome or want psychological reassurance that it’s okay to go ahead.

Another kind of client is one that has had many aesthetic procedures and the professional has concerns that they may be suffering from a condition like body dysmorphic disorder (BDD), otherwise known as “imagined ugliness syndrome”. I became interested in the aesthetics field because of these types of referrals.

A new study has been published indicating that botulinum toxins could provide a treatment for de-

pression. This has interesting implications about the way toxins are perceived. If they can be considered as a treatment for depression, then this changes much of the economics around toxins.

I’ll tell you a very old joke: There is a middle-aged woman who has let herself go a little, who hasn’t been looking after herself and, as a result of not being particularly fit, she has a heart attack. She’s rushed to the casualty department, the cardiac surgeons are called down and they work away on her on the operating table. Unfortunately, they lose her and she dies.

However, this is actually a neardeath experience. She finds herself at the pearly gates and she meets God. She says somewhat anxiously to God, “It’s not my time, is it?” and God replies, “No, don’t worry,

relax, you’ve got another 49 years, 8 months, 7 weeks, 6 days, 5 hours to live.”

She’s reassured by this and the surgeons working away on her bring her back. She comes back to life and recovers in the recovery room. She’s somewhat alarmed by this near-death experience and decides that she really must take herself in hand and look after herself.

While she’s in hospital recovering, she books herself in for various cosmetic surgery procedures. She has a tummy tuck, a facelift and even has her hair done. Like a shiny new button, she walks out of the hospital’s main gates a few days later, crosses the main road outside the hospital, is hit by a car and dies instantly.

She now finds herself back at the pearly gates and meets God

body language I PSYCHOLOGY 23

seem much more likely to have an aesthetic procedure.

Most people believe that when you perform a facial expression like a smile, it’s because you are cheerful

again and, somewhat indignantly, she says, “But wait a second, I was here only a short while ago and you said I had another 49 years, 8 months, 7 weeks, what was all that about?” And God says, “I’m really sorry about that. The thing is, I just didn’t recognise you!”

Jokes relate to how laughter may be a treatment for depression. This isn’t because you’ve been cheered up by laughing, but that the facial muscle change that occurs seems to have a profound effect on mood.

Reasons for aesthetic procedures People seem to think it’s obvious that patients go for aesthetic procedures because they want to look better and, as a result of looking better, they feel that many of life’s outcomes will be different for them.

It’s useful to consider why a particular person wants a particular procedure ‘right now’. I find that aesthetic professionals and doctors don’t ask the question enough— why this patient and why now? Very often, people have been struggling with an aspect of their appearance for many years, but decide to visit a doctor ‘right now’ because of what I like to call ‘the transition’. A transition is occurring in their life; a life event that they’ve been psychologically affected by and that’s why they want the procedure right now.

Classically in women, this often occurs around the time of a relationship breakdown. A key moment of transition is when they are interested—for the first time—in having an aesthetic procedure.

Women who are newly divorced, or who are going through a divorce,

Reaction and behaviour Given that patients are often going through this psychological transition, there is even more reason to think psychologically about what’s happening and who will benefit most. Another consideration is, how will improving your appearance make a difference to your life’s outcomes? This is another question aesthetic professionals don’t ask enough. A patient is going to react to an aesthetic procedure they’ve had, and the way they react to it is going to determine the impact that procedure has upon them.

Say someone has suffered from bad acne for many years and as a result, has become somewhat inhibited and socially withdrawn.

They have a procedure, their acne is cured and they look marvellous now. However, if they continue to be socially withdrawn and inhibited, the procedure is unlikely to have much impact on their lives.

Considering how a patient will react to a procedure and how they will behave following treatment, is crucial in determining how much of a positive impact the procedure will have on their lives. The key psychological variable that predicts this impact is one that most aesthetic professionals seem unaware of; a spectrum in the personality dimension that psychologists refer to as internality and externality.

This is answered by a profound question that people rarely ask: “What is it that you think determines your destiny? What is it that you think determines your future?

Is it you, or is it other people?” Internals in this locus of control theory of personality, tend to believe that destiny is in their hands—that if they work hard and make the right decisions, they can end up wherever they want to be. They are in control of their own destiny.

Externals, on the other hand, believe they’re a victim of circumstance and that there’s not much they can do to determine their future. This has some profound implications. Externals are much less likely to go and vote because they don’t believe they can make that much difference. Externals are less likely to believe in the benefits of

24 PSYCHOLOGY I body language

hard work and tend to take shortcuts. They’re more likely to be caught or arrested for cheating or committing fraud.

If you have a patient who is more internal in orientation, they are more likely to positively react to the procedure you’ve done and do something positive about it. If they had been withdrawn and inhibited when you performed the procedure, they’re much more likely to realise they’ve got to bring something to the table to capitalise on the benefits of that treatment.

We should become much more aware of our patients in terms of the internality and externality dimension. Interestingly, doctors and professionals in general—given they’re highly motivated people— tend to be more internal in orientation and seem to assume the rest of the world is as internal as they are.

It isn’t. Most of our patients are going to be a lot more external than we are.

A recent psychological finding showed that people are becoming more external with each generation. A matter analysis was carried out, whereby all the studies done measuring internality and externality since the early 1960s were grouped together. The study showed that younger generations aged between 16 and 21 are getting more external as the years go by.

Your children, you will notice, are perhaps a lot more external than you are. Younger people are more external than older people.

This shift in externality in these modern times has some dramatic implications that aesthetic professionals should be thinking about.

Facial expressions Most people believe that when you perform a facial expression like a smile, it’s because you are cheerful. In other words, expression comes secondarily to the primary emotion. A new study shows that actually, it may be the other way around.

It may be that your expression drives the emotion—looking sad might, in fact, make you feel sad. A lot of psychological research backs up this surprising finding; studies showing that people’s expressions are manipulated without manipulating their mood.

For example, you can get people to smile by asking them to put a pen between their teeth. All the facial muscles involved in putting a pen between your teeth are the same as those involved in smiling, so you can get a subject to smile without cheering them up.

You’re performing an intervention where they smile, or deploy the same muscles involved in smiling.

There’s a great deal of research that indicates, depending on what measure you use, those people seem to cheer up, simply by performing that procedure.

On the other hand, if you get people to furrow their brow, deploying the same muscles on the face that we use when we frown or look sad, those people seem to be more negative in their outlook.

Botox and depression Drawing on that research base, a team of researchers led by Dr Axel Wollmer and Dr Tillmann Kruger at the Universities of Basel and Hanover in Germany, did a very interesting experiment. They performed a study on 30 patients, randomised into 15 receiving the Botox and 15 receiving a saline injection as the control. These patients were profoundly depressed.

They had, on average, a 16-year history of recurrent depression, with each episode of depression lasting an average of 13 months.

Subjects were given one injection of Botox in the glabella region—the researchers were particularly interested in the corrugator supercilii and the procerus muscles, both of which are involved in the glabella region for frowning. One injection, compared to the placebo group, resulted in an alleviation of depressive symptoms at a level of almost 50%, within six weeks of treatment. The finding continued through to the end of the study, which ended at 17 weeks.

If we were giving these patients an anti-depressant, or performing some kind of psychotherapy to get that kind of alleviation of symptoms, it would be rather astonishing. So why is it that a single Botox injection can have such a profound impact on the mood of very depressed people?

There are various theories. One suggests it might have something to

do with the physiology of muscles; the alteration of blood flow around the face, following the theory that when you smile or frown, you’re altering blood flow to the brain. In that way, facial expressions could have an effect on your mood.

Another interesting theory is that when you look in the mirror, and you feel that you look depressed, that may make you depressed as well. You may get into a feedback loop; feeling low, looking into the mirror and seeing yourself not look as great as you’d like to.

The final theory suggests that depression has a very social element. Depressed people are not pleasant to be with, so people withdraw from them. Depressed people end up finding themselves isolated and, as a result, end up being more depressed. If people look more cheerful as a result of the Botox injection, it may have positive social cycle effects.

If Botox could be seen as a reliable treatment for depression, this has some profound implications.

The finding might introduce new clients into considering treatment but also, given that there is still a stigma around aesthetic procedures and vanity, it could counteract that idea if it’s seen as a serious treatment for depression. It could therefore change the economics.

Dr Raj Persaud FRCPsych MSc MPhil is a consultant psychiatrist and Emeritus Visiting Gresham Professor for Public Understanding of Psychiatry.

If you look in the mirror and feel you look depressed, it may make you depressed as well

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26 EQUIPMENT I body language

Laser complications PROFESSOR HARRY MOSELEY advises how to reduce risk and avoid adverse events with laser treatments, as well as how to deal with them if they arise

W

hen we’re dealing with lasers, we have to take potential complications into account, and know how to deal with them if they arise. We can use the ALARA principle—As Low As Reasonably Achievable. This means that the risk should be as low as reasonably achievable. If you can minimise the risk

and it’s not too difficult then that’s the starting point.

I did an analysis of laser accidents a few years ago, and one practitioner using a CO2 laser sustained corneal damage.

He claimed that he had worn the goggles, but an independent examination of the goggles showed no sign of a laser burn.

Therefore, my assumption is that goggles

were not worn and they did not adopt the ALARA principle. They didn’t keep the risk as low as reasonably achievable, because they didn’t wear their goggles.

When things do go wrong, as sometimes they do, a key question is often asked: was the accident reasonably foreseeable? So let’s just say, yes things can go wrong, but was it predictable? That’s a

body language I EQUIPMENT 27

66 Any undesired effect of a laser is considered a complication, such as purpura following dye laser or erythema. Now you might say, “This happens all the time”. It does, but it is still considered a complication.

99 cation. So virtually every time you use a laser, assuming you do something useful, you will also cause some degree of harm.

We have to accept that complications happen and what we have to do is manage them.

key element. Applying this to an analysis of an endoscope accident, the endoscope had been flexed through an acute angle and the fibre broke. Would you say that this was reasonably foreseeable? If you bend a fibre through a tight angle, what do you think is going to happen?

If it’s judged as reasonably foreseeable, one key question has been answered. Of course, when things go wrong it may not be the operator’s fault; the equipment can sometimes let us down. We saw one case concerning a filter that had degraded in an IPL—it had degraded to such an extent that there was an excessive amount of UV and lower wavelength blue light emitted. There was therefore a lot of localised disturbance to the skin.

Any undesired effect of a laser is considered a complication, such as purpura following dye laser or erythema. Now you might say, “This happens all the time”. It does, but it is still considered a compli-

Common complications Hyperpigmentation, which is more common in darker skin types, can last for several months and is more likely in tanned skin. In our clinic, we don’t treat people with tanned skin because the tan will fade. Send them away and bring them back after the tan has faded. It’s an unstable kind of pigmentation and the melanin is in different parts of the epidermis.

Hyperpigmentation can also be caused by excessive cooling. I once treated a patient’s leg veins, had the cold air machine on and suddenly realised I’d “frozen” the skin. You have to be careful when you’re cooling the skin, because you can cause problems by over-cooling. In my case, the effect was quickly noticed and harm was avoided.

Hypopigmentation is also a problem, particularly in darker skins. It’s quite rare but, in our experience, the hypopigmentation does sort itself out—however, it can take several months before things go back to normal.

Apart from scarring, which of course is permanent, most complications aren’t too serious. Some patients can get an allergic reaction to tattoo pigment, which doesn’t just happen when they’re getting the tattoo; it can also happen when you’re removing it with the laser. Releasing the tattoo pigment, particularly with Cinnabar which is a red pigment that contains mercuric sulphide, can cause quite a nasty allergic response.

Purpura generally resolves, but you do have to warn patients in advance. When managing complications, we also have to manage the patient and let them know before we do anything the things that can go wrong. We have a scrapbook that we keep in the clinic, and it shows the good

results and the bad results, so they can see exactly what the risks are.

On several occasions, once I’ve gone through the risks, the patient will decide they don’t want the treatment. We don’t charge for consultation, and we’re happy for them to go away and think about it.

It’s very important that patients don’t feel like they’re being pushed into a decision, because they’ll hold that against you. You need to make sure that they’re absolutely certain themselves that they want the treatment.

Hair removal can also cause problems.

A meta-analysis published in 2009 reviewed 203 studies to work out what can happen and what can’t happen with hair removal. The incidences are quite variable; with the ruby laser, the incidence of hypo- and hyperpigmentation was 3-5% and superficial atrophic scarring was 3% in darker skin types. Most people would consider a 3% risk of scarring to be unacceptably high.

In our experience, hypo- and hyperpigmentation have always been transient, but transient can be up to 18 months. But using the diode laser, our regular laser for hair removal, we have seen very few problems. We do have the usual erythema, and the skin can sometimes look pretty angry for several hours or even a day or two, but we haven’t had any significant problems.

The NdYAG laser is a dangerous beast because you don’t see what’s happening. Anything that you’re doing with the NdYAG laser, whether you are targeting hair or vasculature, tends to happen deep within the skin. It’s a very good laser, especially for darker skins or for leg veins, but you have to use it with care and you have to respect it.

Overall, ruby lasers are less well suited to treating skin types four and above, while the alexandrite, diode and NdYAG are fine for four and five. Skin type six can be treated with the NdYAG laser but use with care.

28 EQUIPMENT I body language

Pulsed dye lasers There have been two large cohort studies in the late 90s on complications with pulsed dye lasers. They showed there can be pigment changes between 1% and 9% of patients, and scarring in less than 1% or up to 5%. A good study from Salisbury looked at adverse effects when treating port wine stains, showing the overall adverse effect incidence was about 1.4% per treatment.

One of the study conclusions noted that the incidence of adverse effects in children was not any higher than that in adults. They also pointed out that lower legs are always a problem, because the skin is fairly thin on the lower leg, over the shin area.

Another published study looked at complications of laser dermatologic surgery. In relation to the dye laser, they found occasional problems with the cryogen spray. Some dye lasers use a cryogen spray to cool the skin, and there were some faults with the spray’s delivery. There were bubbles in the supply line, which meant the skin didn’t get cooled and they had three patients with atrophic scars.

Many of the complications in this paper came from using the NdYAG laser, including persistant scarring and ulceration. The main problem is that you

I don’t see the point of treating freckles—the best thing is to give the patient some sunscreen and advise that they stay out of the sun

don’t see immediately what you’re doing.

Sometimes you may be tempted to give a second or third shot, but don’t do it.

However, another paper published in 2013 looked at complications in treating dark skins. The lowest incidence of adverse events associated with laser hair removal on darker skin types was achieved with a long pulse NdYAG laser. So for treating dark skins, the NdYAG is the most appropriate.

Pigmented lesions So can we treat pigmented lesions safely?

Almost any Q-switched laser or IPL will treat lentigo. Café au lait can be treated, but they do tend to recur and some of them are resistant to treatment. I don’t see the point of treating freckles—the best thing is to give the patient some sunscreen and advise that they stay out of the sun.

We’ve been treating a patient in our clinic with an epidermal naevus for preventive measures. She thought it was getting bigger, so she came to us and asked if there was anything we could do to help. Because the area is heavily pigmented, we started off using the Q-switched NdYAG laser.

Since the practice of laser treatment is not an exact science, I decided to also try the Q-switched KTP laser. We used the Q-switched NdYAG at one end of the le-

66 Be careful with melasma because of the risk of hyperpigmentation, particularly if there is a dermal component to the pigmentation 99 sion, working from the bottom up, and the Q-switched KTP working from the top down. Both areas have improved a lot, and the lesion has flattened and is breaking up. However, the area treated with the Q-switched KTP laser is doing much better than the area being treated with the Q-switched NdYAG laser.

Be careful with melasma because of the risk of hyperpigmentation, particularly if there is a dermal component to the pigmentation. If in doubt, don’t treat. For Becker’s Naevus, we just use the hair removal laser and get rid of the hair because the pigment doesn’t shift very easily.

The only lesion that I would say is easily treated is the Naevus of Ota or Ito, using Q-switched lasers; they work very well in that case.

Hair growth What about changes in hair growth? One complication which is now widely recognised is paradoxical hypertrichosis. In other words, we’re trying to improve the situation by removing hair, and we end up causing increased hair growth. It was first reported in treatments using IPL, with increased growth of fine hair in close proximity to treated areas.

A recent review into paradoxical hypertrichosis showed that incidence is anything between 0.6% and 10%—we don’t know the true value because people aren’t really reporting them. The riskdepends on the skin type; there is greater risk of this in darker skinned patients and those with very fine velous hair.

This paradoxical hair growth can occur when you’re using IPL for other conditions, so it’s not just something to warn about when you’re doing hair removal.

Another study showed that we can see this complication on tattoo removal and port wine stains.

Contributing factors include areas with fine hair or light- Continued on p30

30 EQUIPMENT I body language

er coloured hair, and darker skin types.

The theory is that with this fine hair, the target isn’t quite big enough to be destroyed, but it’s big enough to absorb some of the beam—particularly if the area is near the edge of the beam, the heat seems to stimulate the production of hair.

It can be avoided to a degree. Place cold packs with crushed ice around the treatment area, which reduces the temperature; if there is some stray light, it won’t be enough to stimulate any hair growth. We use this technique in treating ‘at risk’ areas.

Leukotrichia is laser-induced whitening of dark hair, another complication.

We actually change the colour of the hair, because we cause a switch-over from eumelanin production to pheomelanin which is the lighter shade of melanin.

Prevention A 2009 study reported a series of patients who were being treated between the eyebrows to remove the hair. There is no detail about the laser technique but the patients didn’t seem to have protective eyewear but simply closed their eyes. But when you close your eyes, your eyeball rotates in the socket and you actually look upwards.

You may think that your patient has their eyes closed, so you’re perfectly safe.

But remember, if you’re using a YAG laser, or even a diode laser, you’re getting some penetration. The YAG penetrates up to 3 mm, which can be enough for the iris—which is pigmented—to absorb the beam. In this study, the patient’s iris was damaged with adhesion between the front of the lens and the rear of the iris.

The condition had still not resolved three months after the incident.

Another study showed melanoma developing in a tattoo during laser removal.

There is no suggestion in the paper that the laser caused the melanoma; it’s very

When you close your eyes, your eyeball rotates in the socket and you actually look upwards

clear that while they were doing the tattoo removal, they noticed a dubious pigmented area, had it biopsied, found it was a melanoma and had it excised. But if you are treating any area where there may be dubious brown lesions, and within a tattoo it’s not always easy to see what you’re treating, stay well clear and get a biopsy.

An interesting case that was recently reported involved permanent hair removal with a pulsed dye laser. A young male patient who had received 22 sessions of dye laser as a child, for removal of a port wine stain. Although this produced improvement, his clinician felt they couldn’t progress the treatment any further and that they’d reached a plateau, so he was referred to someone else.

That’s when a particular feature was noticed—an area showing permanent hair removal. This was an area in which the port wine stain had been removed. As a result, the laser beam penetrated deeper into the skin and was absorbed by the vascular plexus at the root of the hair shaft, which is probably why they’ve ended up with unexpected permanent hair removal.

Another recent case involved second degree burns within a tattoo following IPL laser hair removal. The practitioner was carrying out hair removal and didn’t

stop when they got to the tattoo. They probably have removed the hair but they’ve also taken away a chunk of the tattoo.

Needless to say, the patient’s not at all happy. Do not go near a tattoo with a hair removal-type device, laser or IPL, otherwise you’re going to end up with quite a mess. Your patient will not be happy and will most likely sue.

Conclusion We have to understand the degree of complexity that we’re dealing with. We often try to simplify things, but find that some situations are more difficult to predict and there are too many variables. We can end up doing the wrong thing or saying the wrong things, possibly with the best of intentions. So complications are not nice but they shouldn’t stop us using lasers. By taking account of potential complications, we can actually treat patients better.

Professor Harry Moseley is Honorary Professor in the Dermatology Department at the University of Dundee and Head of Scientific Services in the Photobiology Unit, Ninewells Hospital & Medical School, Dundee, UK

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body language I DENTAL 33

Bruxism

Excessive grinding and clenching of teeth, otherwise known as bruxism, can lead to tooth wear, jaw disorders,headaches and hypertrophy of the muscles of mastication. PROFESSOR BOB KHANNA discusses his preferred treatment approach, using a combination of botulinum toxin and occlusal therapy

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or at least 10 years, medical professionals from dermatological, surgical and dental backgrounds have been injecting various masticatory muscles to treat bruxism, so it’s imperative that we look at the underlying aetiological factors so as to fully understand this complex condition prior to treatment. The medical background of the treating practitioner is essentially irrelevant as

the patient presents with the same features and hence we need to understand what these are.

Its estimated that at least 40% of us will suffer with bruxism at some point in our life. It involves over zealous clenching and grinding of the teeth ie.a parafunctional activity which is so outside of the norm.

It’s a complex situation and often poorly understood. It has been

related to certain personality types, such as high-achieving go-getters and, of course, stress.

This is not a condition that only occurs later on in life—it can happen in children and can progress firmly into adulthood. We’re all aware of masseteric hypertrophy and how it’s particularly discernible in women, as we often deem this to be more masculine characteristic.

However, research on masseter-

At least 40% of us will suffer with bruxism at some point in our life

34 DENTAL I body language

ic hypertrophy is quite thin on the ground, particularly pertaining to the involvement of botulinum toxin. There has been a distinct lack of dose-related response studies and hence a “one size fits all” approach to date.In my opinion we need to have a dose-related type of response strategy and methodology to be able to treat different types of presentations and variations within bruxism cases.

The masseters are an important part of the masticatory system, but we can’t ignore the temporalis or the medial and lateral pterygoids.

We could also look at the sternocleidomastoid, trapezius and splenius capitis, which are often involved, and even the platysma in excessive bruxism.

Injection complications Back in 2003, I looked at trying to achieve a dose-related protocol for the injection of masseters. I looked at a number of ways of achieving this in a systematic way, being mindful of the complications that can ensue, notably inadvertent injection into adjacent superficial muscles such as the risorius.

This is superficial to the mas-

seter but extends quite far laterally overlying the muscle, so if your injections aren’t deep enough and posterior enough this can lead to smile asymmetry. This is one of the most cited complications following injections of masseters.

Over-exuberant treatment to the masseter can result in ‘jowling’ in patients with excessive and slack skin at the mandibular border.

In such cases we can treat over two or three sessions over an 8 week period and achieve very good results—dramatic results in many cases without exacerbating any pre-existing jowls. In addition we can improve the definition of the cheekbones without physically treating those areas, just by changing the balance of the facial parameters.

If necessary as part of the diagnosis,treatment of the medial and lateral pterygoids can be done extra-orally, if we consider the anatomy.

Underlying cause In 2003, I looked at my referral patients and every single one—as is the case today—had to complete a comprehensive occlusal assessment.

I investigated the underlying aetiology and it was clear to me that the majority of these patients had discernible signs of occlusal disease, and TMJ degeneration or derangement.

This is of course a problem— the danger is that if we adopt the approach of merely ‘putting a plaster on the wound’,then we’re not getting to the underlying cause and diagnosing the problem as a medical practitioner ought to.

This issue is not a new discovery; it was highlighted back in 1901

by Karolyi looking at the role of occlusion and TMJ function. There has since been a disconnect between Dentistry and Medicine and therein lies the problem.

In 1961, Ramford noted that malocclusions and dental inferences are a large etiological factor to bruxism and the pathophysiology of pain. That seems to be the accepted norm now for most teaching within the dental fraternities across the world. This is a serious problem and the key is early intervention.

Bruxism itself is a very complex disorder and seems to be related to genetic susceptibility and autonomic dysfunction with faulty de-

Before and six weeks after treatment to the masticatory muscles using protocols and techniques developed by Prof Bob Khanna

body language I DERMATOLOGY body language I DENTAL 35

This patient exhibited bilateral masseteric hypertrophy with the right side larger than the left.

Also due to her age she had skin excess in the lower mandibular border area, commensurate to the jowl position.

This would have been exacerbated if a careful staged approach had not been taken using toxins.Comprehensive occlusal therapy was also undertaken to address the underlying occlusal aetiology

scending inhibitory pain controls.

If we consider this male patient with unilateral masseter hypertrophy, after carrying out a differential diagnosis to ensure the problem is indeed a muscular one, we need to understand why he has this unilateral masseter hypertrophy.

Examining the occlusion it was found that the patient had a unilateral dental interference in the molar teeth -this is not uncommon.

These are what we call non-working side or working side posterial occlusal interferences .

On lateral excursion, when the mandible is moved to either the right or left, certain teeth are clashing when they ought not to be. In an idealised occlusion, the canines should be the only teeth that actually guide this excursion.

The relevance to muscle hypertrophy is that the occlusal interferences in the posterior teeth lead to excessive and differential contractions of the masticatory muscles— in particular the masseters, therefore inducing hyperactivity and hypertrophy which will eventually lead to oro-facial pain and the continued destruction of teeth and the TMJs.

Therefore if we only treat the muscles with botulinum toxin, we’re not going to solve the underlying problem and aetiology.

Assessment The solution starts with a comprehensive diagnosis and dental assessment, looking at occlusional interferences and temporomandibular joint issues with x-rays, MRIs and CTs. We need to conduct a comprehensive muscle examination with or without EMJ tracing, looking at all the muscles of mastication and then take a comprehensive history.

Most people who clench and grind are aware that they do it or if not their partners certainly do!.It’s not something that goes on without being noticed.

In excessive situations it’s audible, so partners will often say they hear their partner crunching and grinding their teeth in their sleep because it’s often nocturnal.

Failure to carry out a comprehensive assessment will lead to an incomplete diagnosis and therefore complete ignorance and neglect of the underlying aetiology.

We have to avoid continued

TMJ and dental degeneration and the potential for exacerbating these pathophysiologies by just using botulinum toxin.

We wouldn’t treat a diabetic ulcer without treating the underlying cause; the diabetes. We wouldn’t treat a retrosternal chest pain with a little ointment or analgesics without looking deeper at the cause of that particular condition, so why are we doing this with bruxism?

Therefore treatment in my opinion should involve botulinum toxin as an adjunct to occlusal therapy.

Occlusal therapy can range from very specific designs of removable or fixed splints followed by occlusal equilibration treatment (adjustement of tooth surfaces) I’ve developed specific protocols for the treatment to strategically administer btx to the masticatory muscles that are in spasm or hypertrophic,so as to deal with all types of presenting cases.

Professor Bob Khanna is a cosmetic and reconstructive dental surgeon, with clinics in Ascot and Reading.

He also runs the Dr Bob Khanna Training institute for Facial aesthetic training www.drbobkhanna.com

body language I SKINCARE 37

cation to make the link between resveratrol and its beneficial effect on ageing.

Resveratrol Antioxidants are essential in the body’s fight against the assault of free radicals and consequent ageing. JULIEN DEMAUDE discusses the latest research into antioxidant formulations for longevity and anti-ageing, with a focus on resveratrol’s effect on oxidative damage

T

he antioxidant market is expanding, particularly in the US, so we’re constantly looking into the development of new antioxidant formulations and their effect on the skin.

Certain actives do need more research, because we still don’t know their full capability as anti-ageing solutions.

Resveratrol is a well-known antioxidant and we have plenty of natural sources; around 70 plant species, nuts, nut weed and grapes. When we talk about resveratrol, and the communication between resveratrol and resveratrol derivatives, the effect could be very different.

The chemical structure of resveratrol is pretty simple. It’s a polyphenol and we can have a cis-resveratrol and a trans-resveratrol. In 1997, a prominent paper from Dr Chang reported that the topical application of resveratrol could reduce skin tumours by 98% in mice, and since then

there have been many studies across the world, most notably on ageing and longevity.

Using resveratrol, scientists reported that they were able to increase the lifespan of yeast, followed by worms and fruit flies, and then fish. In 2012, scientists from Barcelona determined that resveratrol extended the lifespan in mice and honeybees. Resveratrol has interesting activity in different fields of medicine—neurological, cardiovascular, diabetes, chemotherapy, inflammation and cosmetic medicine.

In 1956, Dr Harman published an article in the Journal of Gerontology entitled, “Ageing: a theory based on free radical and radiation chemistry.” The paper concluded that cellular accumulation of free radical damage by use of biological components, leading to the degradation of body tissues, is the primary cause of cholinergic ageing. It was the first publi-

Ageing When we talk about ageing, we are talking about oxidative damage. We have two sources of reactive oxidative species (ROS). We have extrinsic sources—resveratrol stimulation generating external ROS—and we have an intrinsic sources; produced naturally during synthesis respiration and inflammation.

When we consider an antioxidant strategy, we need to think about multiple strategies. One requires exogenous antioxidants, requiring external supplementation, such as our current cosmeceutical products containing resveratrol, baicalin or vitamin E. The other strategy needs to use endogenous antioxidants, such as those produced in normal serum metabolism to fight ROS production. Enzymes like glutathione, peroxidase, catalase, bedrobinol and antioxidant combinations have greater potential to neutralise the range of ROS emitted along the oxidation pathway.

Dr Harman also published a publication in the 1970s on his free radical theory of ageing, incorporating the role of mitochondrial ROS production in the ageing process.

Mitochondria is one of the primary internal sources of ROS, which are produced when oxygen acts as a final electron acceptor. Dr Harman stated that an accumulation of mitochondrial DNA mutation, caused by ROS production, is the principal determinator of the rate of human ageing.

We can therefore have a vicious cycle of radical damage. We have two sources of ROS production, from environmental stimulation and from internal production, which results in mitochondrial oxidative stress. We then have an increase of mitochondrial DNA mutation, followed by an increase of mitochondrial ROS production and again, a double increase of mitochondrial DNA mutation—it’s a vicious cycle which is very bad for the mitochondria and, therefore, for the cells.

There are plenty of diseases linked to mitochondrial dysfunction. We have neurodegenerative disease, diabetes mellitus and the premature ageing syndrome called lyceum cell syndrome. So mitochondria are key in terms of ROS production. In terms of skin, an inhibition in the mitochondrial oxidative stress level has a detrimental effect on the physiology of skin ageing.

38 SKINCARE I body language

66 Resveratrol protects the keratin side by acting on mitochondria. Resveratrol takes on the properties of intra-cellular affectors protecting against age-related skin cell damage 99 We performed an interesting experiment, injecting mitochondria from older fibroblasts into younger fibroblasts—the combination caused rapid ageing, highlighting the effect of mitochondria into skin cells.

NRF-2 pathway Returning to resveratrol, the active has a classical antioxidant effect, going through a scavenging activity against reactive oxygen species. The antioxidant can reduce mitochondrial ROS production, but it can also promote mitochondrial biogenesis. We also now know that it is able to stimulate a specific pathway; the NRF-2 pathway.

The NRF-2 pathway is the cellular antioxidant defence system, and is actually a small transcription factor—it’s very important to stimulate your own defence system. Resveratrol is able to boost the NRF-2 pathway and through this activation, the resveratrol can split the complex NRF-2 and keep one into the cytoplasm.

The NRF-2 transcription factor then goes into the nucleus, increasing the expression of antioxidant genes stimulating the production of over 200 enzymes dedicated to antioxidation. All of these enzymes and endogenous antioxidants are then able to link the ROS produced by cells. So it’s important to find a new strategy with antioxidants which can stimulate this pathway and quench the ROS pollu-

tion stimulated by environmental factors.

So what about the skin? A few years ago, collaborative research between McGill University in Montreal and L’Oreal showed that resveratrol is able to bind the keratin sides on cells. Resveratrol protects the keratin side by acting on mitochondria. Resveratrol takes on the properties of intra-cellular affectors protecting against age-related skin cell damage.

In another publication in 2013, we showed that in the specific reconstructed AB Skin Model, we were able to stimulate the NRF-2 pathway with resveratrol and increase the production of the glutacyan, one of the most powerful endogenous antioxidants that we have in our skin.

Limitations There are three main limitations with resveratrol. The first is the photo-instability of the active—if you were to put a resveratrol solution close to the window, you would see a change of the colour. That’s a big limitation for us in terms of formulation.

Then the second is its bioability. We know that resveratrol is rapidly metabolised after oral administration, decreasing the plasma concentration and the bioability.

Topical administration seems the best way to overcome the inability of the active to maintain a good concentration.

The last limitation of resveratrol is its solubility. It has poor aqua solubility, and we are currently working on this

limitation with new technology called hydrotropes. This technology is originally from the pharmaceutical field. We use hydrophilic actives, such as vitamin B3 and caffeine, and linking them to the resveratrol which is hydrophobic. This solution will enable the resveratrol to penetrate into the skin with the hydrophilic ingredients.

Study We carried out some interesting research with this combination, putting the formula at 45 degrees Celsius for two months. Results showed we were able to maintain a good concentration of resveratrol using the hydrotrope technology. Following a clinical evaluation with resveratrol hydrotropes, we now have a product containing baicalin and vitamin A. It’s better to have a cocktail than using just one antioxidant.

They study involved a critical evaluation on 55 subjects and evaluated different parameters like radiance, firmness, elasticity, density and smoothness. We saw improvements in firmness, elasticity and density after 12 weeks, which were better than with a resveratrol-only formula. Following ultrasound, we could see that compared to baseline after 12 weeks, the combined formula was able to increase skin density by almost 19 %.

We then went through different kinds of ageing bio-markers and we showed we could increase the quantity and the concentration of collagen three into the dermis. VEGF is a marker of intracellular information of oxidic stress and we were able to decrease the quantity of VEGF in our samples, thereby decreasing the inflammation process.

Dr Julien Demaude is the director of International Predictive Models for Evaluation at L’Oreal

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body language I ANTI-AGEING 41

Facial acupuncture Collagen stimulation, cell regrowth and increased immunity against external damage are all benefits of facial acupuncture and acupressure, writes DR BIANKA TOEBBEN

I

have specialised for more than 20 years in integrative medicine, combining traditional with biological and holistic medicine—I have also practiced aesthetic medicine for 20 years, specialising in anti-ageing and biological hormonal replacement. In my work, I try to integrate different dimensions into the treatment.

An acupuncture point is a bundle of blood vessels and nerves that are perforating the superficial fascia of the skin of the lower and deeper muscles. When inserting a needle into an acupuncture point, there is an immediate effect on circulation and on the nervous system—a reflexology effect, pain or a local sensation, a systemic effect along the meridian and a central effect through increased production of serotonin and dopamine in the central nervous system.

By inserting the needle into the dermis, you reach not only the vessels and the neurological system, but also the extracellular matrix.

This is where you find collagen, elastin, fibroblasts and macrophage. By stimulating the dermis with an acupuncture needle, you also have an effect on the immune system which means better resistance for the skin against external damage.

When a patient comes to my office, I don’t just look at the structure of the face; how many wrinkles the client has or how deep the wrinkles are. In complementary medicine, I also look at these in a different way—certain wrinkles are related to certain organs. The face is a mirror of our inner physical, mental and spiritual condition.

A patient with very pale skin may have too many toxins in the body so I would look not just at the

wrinkles, but also how to improve the immune system from the inside to the outside. A patient with high vascularization, for example, may have venous problems. The shape, structure and landscape of the face provides me with information on how to treat the client in an individual and holistic way.

Technique There are different methods of acupuncture, such as combining Chinese with Japanese techniques.

I use a single technique or a combination of horizontal and vertical, superficial and deep insertion, depending on the results I want to achieve, such as increased production of collagen or proliferation of fibroblasts.

For facial acupuncture, I only use Japanese needles which are very fine and almost painless.

To enhance the cheeks, all needles are directed towards the centre zygomaticus. These points mainly

belong to the digestive organs, such as the stomach meridian, the large and small intestine, the gallbladder and the bladder meridian. As well as Chinese acupuncture, I also add points from Yamamoto Japanese scalp acupuncture.

I always combine techniques, usually treating the frontal, dorsal and both sides for symmetry. I use the Conception Vessel, which has a connection to the Governing Vessel and radiates left and right.

I put most needles in horizontally, towards the zygomaticus to have a lift. I add other important points that also have an effect on organic problems, such as one in the ear for stomach issues. The whole body—inner organs, bones, the spine and the immune and hormonal systems—are represented in the ears. Points from Yamamoto can treat vertical forehead lines that aren’t improved with toxins.

We can combine acupuncture with acupressure or local patches,

There are different methods of acupuncture, such as combining Chinese with Japanese techniques

42 ANTI-AGEING I body language

fewer needles. Depending on what the patient needs, I add specific points for facial or neck enhancement. Acupuncture facial enhancement can be used on its own or alongside other treatments.

We can use infrared imaging to show acupuncture meridians with the help of a moxa cigar stick.

Moxa is a Chinese herb used for putting heat in a meridian that lacks energy. We use the moxa cigar to stimulate the acupuncture points along the meridian. The meridian area then shows on infrared as red light.

But this is not heat; it is a photonic emission of our cells. We cannot see the meridian with the naked eye. While we believed what the Chinese were saying for more than 3000 years, we now have visible proof that the acupuncture meridian exists.

So any acupuncture treatment we do in the face will have an effect on the body. We also have to consider when we use micro-needling that we do sometimes reach superficial acupuncture points.

Depending on what the patient needs, I add specific points for facial or neck enhancement.

as they have an effect on the superficial circulation and also increase the proliferation of collagen in the dermis. They also provide pain relief.

I know where the acupuncture points are located so usually use the “very point” technique—finding the point that is more sensitive and inflamed due to the problem area you’re treating. The needle acts as a guide for detecting the point.

Following the law of symmetry, I tend to use complementary points, means treating both sides of the body; front, back, left, right, head, fingers, toes and the ear. The Governing and Conception Vessels have the advantage that they radiate to both sides so I can treat with

Acupressure Why would we use acupressure instead of acupuncture? First of all, it’s less painful. I plan which points to press and how deep to press. You can use acupressure in combination with acupuncture integrated into one treatment session.

Acupressure can be useful for pain relief. One technique is meridian massage—massaging the meridian points and pressing point after point. It is very easy to teach and therefore to be integrated into your practice.

We can use our fingers or patches, either as a single treatment or in combination with acupuncture.

When I insert a needle inside the muscle, I put a patch on top to give an extra local effect. I can also use small magnetic balls underneath the patch, either in gold or silver, to increase circulation and activation of the meridian or to sedate and calm it down.

Patches used on these lines give a visible reaction after 36 hours.

The line appears shallower and the skin looks firmer and enhanced.

The effect doesn’t last long but if

you have a client who is finding treatment painful, you can use a patch to decrease the pain and, at the same time, superficially enhance the appearance.

Integrated treatment When the client comes to me, I have a good look at them, listen and talk to them to find out what the problem is. When I want to go deeper to get health information from the body, I use computerised hair analysis.

This test can help us find out what is wrong at an organic, structural and chemical level. We can find out about intoxication, heavy metals, deficiencies or a lack of vitamins, minerals or hormones that are important for facial enhancement or production of collagen. We can establish intolerance to some types of food or infections with viruses, fungus or parasites, as well as negative environmental influences.

We can also carry out a blood test, particularly if we want to provide bioidentical hormonal replacement therapy (BHRT).

I tend to use a combination of acupuncture, vitamin infusion, aminoacids, antioxidants and oxygen ozone therapy, a BHRT. I also advise my clients to change their lifestyle. I help them to look at aspects of their lives they can positively change to have an impact on their holistic wellbeing. When necessary I refer them to different therapists for additional treatments like hypnosis or osteopathy.

When enhancing the face, we also need to treat the body. We need to treat from the inside to the outside. Products we use have an effect but when the body keeps on intoxicating, such as continuing to drink too much alcohol or not exercising, treatments can only do so much.

We need to look at ourselves in a holistic way, from the outside to the inside and vice versa—the soul must be happy to have an honest smile.

Dr Bianka Toebben is licenced by the University of Essen/Germany as a Medical Doctor and General Practitioner and she specialises in natural and chiropractic medicine

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44 DERMATOLOGY I body language

and the skin DR BETH BRIDEN summarises the effects of glycation on the skin, and how antioxidants such as gluconolactone, lactobionic acid and maltobionic acid can help fight the negative effects of advanced glycation end products

I

n addition to the effect on our waistlines, research has shown how sugar affects multiple organs in our body and our skin.

Glycation has become the new buzzword in anti-ageing technology. A normal enzyme-related reaction in the body, where sugars are combined with protein, is known as glycosylation. More commonly, reducing sugars, such as glucose, react and bind with the amino group of available proteins, causing an abnormal, non-enzmatic reaction called glycation which can be damaging to the proteins in our skin and other organs.

In our skin, the protein molecule that sugar bind to is collagen; more specifically, it is the lysine molecule in the collagen molecule which causes damaging and permanent cross-links called advanced glycation end products (AGEs).

Glycation was first discovered in 1910 but it wasn’t until the 1980s that it really became widely known.

At that time, the food industry started using glycation to enhance the flavour and colour of foods, revealing its significance. It was discovered that the browning reaction when you bake a pie or cookies turning them brown and crispy,

is due to protein alteration from glycation. When we grill meats, the crusty char is also caused by glycation.

The process is also significant in the skin. When we apply a self-tanner, the active ingredient, dihydroxyacetone—a sugar molecule—undergoes a glycation reaction with the stratum corneum and causes damage to the proteins and, therefore, the brown colouring.

Although, usually confined to the stratum corneum, some of the dihydroxyacetone can penetrate into the skin causing further damage to the dermis.

Research has shown how sugar affects multiple organs in our body and our skin

body language I DERMATOLOGY 45

The glycation process To simplify the process of glycation, a protein binds to a sugar.

Normally, under hot conditions or in the presence of triglycerides, the sugar will open up its structure and grab on to the amino group of these proteins, forming unstable intermediates called Schiff bases.

Schiff bases then react, either by breaking apart and dissolving, or they will go on to form an intermediate product called an Amadori product. Over a period of a few weeks, the Amadori produscts will form additional cross-links forming irreversible bonds resulting in advanced glycation end products.

AGEs are damaging; they can form and accumulate in the skin’s dermis, from normally occurring sugars and proteins and from exogenous ingestion of foods containing AGEs such as burnt steak as well as from excess reducing sugars in the bloodstream. Around 30% of the AGEs and sugars we eat ends up in the skin as AGE products. Smoking and ultraviolet damage can also add to glycation.

Studies on diabetics have shown the concentration of AGE products in the skin are more than double the concentration of non-diabetics.

Studies have also shown that glycation end products accumulate in normal skin with ageing and that there is a five fold increase in AGE concentration in the skin between the ages of 20–85. Glycation mainly effects the long-lasting collagen, such as type I and type IV. Glycation accounts for around 10–20% of ageing changes. We used to think the oxidative stress from ultraviolent light accounted for around 90% of ageing, but

currently UV is thought to contribute between 70–80% of ageing changes in the skin. The remaining 20–30% of ageing changes are due to glycation and the gradual slowdown of cellular reactions and the telomere and thymidine dysfunction.

Impact on the skin The sallow complexion that can occur with ageing is due to the deposition of AGE products in the upper dermis, causing a yellowing of the skin. Some AGE products, such as pentosidine, actually fluoresce under a special light so that you can see the accumulation in the skin.

AGE products also damage the collagen and the elastic fibres, causing wrinkling and sagging of the skin. They also disrupt the cellular communication that occurs in the dermis and the skin. AGE product accumulation can also cause inflammation and trigger the release of a cascade of cytokines and inflammatory proteins such as matrix metalloproteinase (MMP) proteins, causing further degradation of the collagen and the elastic tissues.

The damaged glycated proteins are very stiff, break easily and are actually hard to degrade, so they hang around in the skin for a very long time. The glycation of skin proteins could be compared to the tanning of leather with its stiff nature, There are several ways to inhibit this glycation process, thanks to research in diabetics.

One way to reduce unwanted gylcation is to provide sugar competitors, which can bind up the sugar so it can’t attach to the proteins, such as aspirin or acetyl-

66 To simplify the process,of glycation, a protein binds to a sugar. Normally, under hot conditions or in the presence of triglycerides, the sugar will open up its structure and grab on to the amino group of these proteins, forming unstable intermediates called Schiff bases 99

salicylic acid. The competitors will bind to the lysine and the protein molecule and inhibit the sugar from attaching.

We can provide other protein competitors such as additional amino acids to bind with the sugars like arginine. There is a cream currently on the market that loads amino acids into the skin, so that the sugar will bind to the exogenous amino acids, rather than to the lysine in the proteins of the skin.

There is also a category of compounds that interfere with the Amadori products; the intermediary in AGE formation. Aminoguanidine is the gold standard of inhibiting Amadori product formation. Unfortunately, aminoguanadine caused too many side effects to be helpful in preventing glycation is diabetic patients.

Another way to prevent glycation is with antioxidants that interfere with oxidation—it’s the oxidation reaction that causes the Amadori products to form into AGEs. Vitamins B6 and B12 have been helpful with this. Antioxidants appear to stop the reaction by inhibiting the glyco-oxidation.

Alpha hydroxy acids The second and third generation alpha hydroxy acids called polyhydroxy acids and bionic acids have potent antioxidant properties, as well as inhibiting metal chelation, and lipid peroxidation. They also have many other beneficial effects on the skin. The second generation AHA is the polyhydroxy acid, gluconolactone. This is the lactone derivative of gluconic acid. It has four hydroxyl groups, so it can bind four molecules of water and is therefore more hydrating. It’s still a small molecule, so it can penetrate the skin, but does so more slowly so it doesn’t sting like the typical AHAs. Gluconolactone, a natural component of the body, is formed in the Krebs cycle, and is a potent antioxidant, and has been shown to inhibit MMP (collagenase) and the breakdown of elastic fibres by inhibiting elastase. It’s also a heavy metal chelator and can inhibit the chelation of heavy metals such as iron in the

46 DERMATOLOGY I body language

dermis. Gluconolactone also inhibits lipid peroxidation, which is very important in protecting the mitochondria in the cell membrane. It’s been shown to inhibit malonaldehyde production in the model of lipid peroxidation inhibition and also improves the barrier function.

It also has the anti-ageing effects of stimulating collagen, elastic tissue, epidermal repair and the dermal matrix, the glycosaminoglycans, including hyaluronic acid.

The third generation AHA is a complex polyhydroxyacid called lactobionic acid. Lactobionic acid is composed of galactose, “brain sugar”, and gluconolactone. This results in two lactone rings, with eight molecules to absorb water, so it’s more hygroscopic and moisturising. It forms a gel matrix on the skin that attracts water and improves the barrier function. It’s also a powerful antioxidant. This is the main ingredient in the organ perfusion baths to bathe livers and kidneys when they’re being transported, because it’s non-irritating and is a natural component of the body—a strong antioxidant and strong humectant. It also inhibits MMPs, lipid peroxidation and heavy metal chelation and has stimulatory effects on renewing skin components, such as the epidermis, dermis and collagen elastic tissue.

Malotbionic acid is another bionic acid and is derived from corn sugar. It has the same beneficial effects as lactobionic acid, but in addition it has been shown to inhibits ultraviolet-induced pigmentation. In clinical studies, when B-16 melanocytes are stimulated with MSH (melanocyte stimulating hormone) simulating sunlight induced pigment formation—altobionic acid has been shown to inhibit the production of melanin in a dose-dependent fashion.

The polyhydroxy and bionic acids, gluconolactone, lactobionic acid and Malotbionic acid, has pronounced effects in preserving vital skin structures by preventing heavy metal chelation, lipid peroxidation, MMPs including collagenase and glycation. They help prevent the degradation of collagen and elastic fibres in the dermis and prevent damage to these proteins by inhibiting glycation-induced AGEs.

They are also effective in improving the barrier function of the skin in addition to providing a stimulatory effect by increasing production of the ground substance (hyaluronic acid) in the dermis, and by stimulating collagen and elastic tissue production, they plump and firm the skin.

They also help even out pigmentation in the skin through exfoliation and dispersing pigmentation and by inhibiting UV induced melanin formation. They also decrease a sallow appearance by inhibiting the formation of AGE products in the skin.

Research In one study, a patient with moderate photodamage who had a thickened stratum corneum, a thin atrophic epidermis, without the ridges and some solar elastosis in the dermis was treated with lactobionic acid cream. After an 8% lactobionic (Bionic lotion) was applied to the skin twice daily for 12 weeks, the stratum corneum became thinner, more basket-weave and compact, with a thicker epidermis and a plumping effect with more glycosaminoglycan deposition in the dermal matrix.

This is another study showing the effect of MBA (malatobionic acid) in inhibiting MMP formation, In this study, maltobionic acid, at a very low concentration of 0.1%, effectively inhibited MMP formation as effectively as the standad phentrolamine. NeoStrata uses a much higher concerntration, 8%, in their creams.

Another study at the American Academy of Dermatology meeting in Denver 2014 showed the anti-glycation effects of matobionic acid, lactobionic acid and gluconolactone. In this study, the authors took three different concentrations of these products and combined them with the protein albumin in Petri wells. In half of those, they added glucose for the sugar substrate and water as the negative control. The AGE product can take a while to develop so after 24 days, they looked at the different concentrations. Aminoguanidine was their standard for the negative control of preventing glycation at a 0.5% concentration. Gluconolactone, even at 0.1%, actually ex-

ceeded aminoguanidine, the industry standard. The maltobionic acid and the lactobionic acid were also both effective in inhibiting glycation.

Following on from this, they performed a clinical study measuring the skin with a colorimeter to look at the different colours. They found that all three of those antioxidants decreased the yellowness or sallowness of the skin over 12 weeks.

So in summary, lactobionic acid and the multibionic acid in the second generation gluconolactone significantly reduced non-enzymatic glycation, comparably to the protein inhibitor aminoguanidine.

These products can help preserve the skin’s natural structures and reduce the effects of glycation and ageing on the skin over time.

They can be applied topically or taken internally—but if you’re going to apply to the skin, you have to make sure it will penetrate down to the dermis where these reactions occur.

Glycation and its damaging AGE products can be inhibited with topically applied polyhydrox acid and bionic acid creams, but, it is better controlled by watching our intake of glycated foods and sugars.

Dr Beth Briden is a dermatologist based in Minnesota. She is an adjunct professor of dermatology at the University of Minnesota and a dermatological consultant for NeoStrata

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Consenting and n o i t c e t o r p data

Keeping patient data safe and taking robust consent data is crucial to protect practice and patients, explain DR NATALIE BLAKELY and clinical negligence expert MANDY LUCKMAN

I

nformed consent is a fundamental legal requirement and there are many legal disputes that centre around what was said or what wasn’t said before a procedure.

It’s vital to ensure that as well as being given information about the benefits of the procedure, patients also have the risks involved thoroughly explained. They need to know what the complications are and what downtime should be expected.

Not only are you then managing expectations from the start, you are also thoroughly consenting the patient at the same time. The patient should understand all the information that is given to them.

After a consent form has been discussed with a patient, you then need to ask the patient to review the consent form and ask them to sign it to confirm that they’ve understood it. Even if this is the second or third time that the patient has been seen, you should still consider re-consenting before every procedure.

You should certainly be check-

ing whether anything has changed in the way of health or lifestyle.

Taking the time to do this can save many hours of protracted argument in years to come.

Using consent forms provided by the manufacturer is a good start, but as the practitioner any potential claim would come to you. It’s a good idea to have a look through the form and check to see whether you’re happy with it or whether there’s anything that you feel needs to be mentioned from experience in your practice.

Recently there have been a number of cases of blindness caused after filler injections close to the eye. That’s not currently on any of the manufacturers consent forms for filler, but it is a known possible complication. Patients should be informed about this possibility and it should be included on the consent form or it could be a very significant problem if that unfortunate outcome did arise.

When performing a very minor procedure like removal of a skin tag, many practitioners assume implied consent because the patient is

letting them undertake the procedure. It’s good practice to consent before any procedure, even if it’s straightforward, low risk, or perceived as non-invasive.

Exceptions Although consent can be verbal, a lawyer would always recommend getting it in writing so it can be used as a form of documentary evidence if needed.

There are some fundamental principles about when a patient cannot give informed consent—for example, if they lack capacity. If a patient has a severe case of body dysmorphia, it raises questions as to whether they have got capacity to consent to a particular procedure.

Again, if a patient can evidence that they haven’t been properly informed about the treatment, then there isn’t a consent there necessarily. If the patient is under the influence of alcohol—even if they’ve had a little bit too much wine at lunchtime—then they would be lacking capacity.

You need to be wary about

52 LEGAL I body language

putting pressure on the patient to sign there and then. There are variable circumstances when it may be appropriate, but rushing a patient into signing a consent form is not a good idea.

Consent recommendations It’s not a legal requirement to sign a consent form, but the General Medical Council (GMC) have produced guidelines that strongly recommend that any medical records are properly drafted, accurate, legible and contemporaneous.

The records need to detail the information that’s been shared, the decisions made and the actions agreed, together with who’s making those decisions. It’s worth both the practitioner and the patient signing the consent form.

The GMC does recommend that you also time and date the records, in case a claim is brought some years down the line, but it’s not a legal requirement. If you have recorded as much detail as possible about what was discussed and when it was discussed, then it makes it far easier to produce that documentary chain of evidence.

There’s currently very little regulation in place around this, but it is advisable that if you delegate the consent process to a junior, that the person getting consent is technically able to carry out that procedure.

This means they’re fully aware of what’s involved, they can explain the risks and they can make sure that the patient understands what’s involved.

Take patients through the consent form and don’t just give them a piece of paper to sign. Then you can say with confidence that time has been taken to thoroughly discuss the risks, and that the patient fully understands the procedure.

If you give a detailed consultation and consent and then cause a necrosis when doing a filler, it doesn’t mean you definitely wouldn’t end up in court, but if you’re able to evidence that good, informed consent has taken place, then it is less likely.

Using and storing data With all the tablet systems around for keeping medical records, there’s a lot of concern about whether or

not a digital signature is valid, especially when it comes to consent.

In the medical sphere, there’s very little case law around this particular issue, which is perhaps not that surprising. The Electronic Communications Act is the best piece of legislation to refer to, and that does recognise the legal validity of an e-signature in the UK. It also confirms the requirements of the Data Protection Act, which is that confidential information needs to be stored in a safe and secure environment. For example, if it’s going to be stored electronically, it has to be done with password protection or encryption.

There is a question of who ‘owns’ patient data, particularly for people who have mobile businesses and perform treatments in other people’s premises. Somebody recently said they’d had a dispute with the clinic owner, who then decided to go with a different provider for their toxins and fillers. They kept all of the consent forms and all of the medical records. That practitioner wanted to know who actually owned the medical records.

It’s a complicated situation, but the patient actually owns the information. The clinic and the practitioner have a responsibility to make sure that that information is stored and it’s stored confidentially, so that if a patient ever requests a copy of those records pursuant to the Data Protection Act, they can be provided within the 40 day period that’s stipulated.

It’s important that we have access to those medical records to provide the best possible care. The piece of legislation that we need to be familiar with is the Data Protection Act 1998, which controls how the information is used and how it’s stored.

The information must be kept safe and secure, and clearly medical records, particularly photographs, are extremely sensitive. Storing data like that on phones which can be easily lost or stolen isn’t advisable at all. There are other methods of storage which are far more secure.

Another thing that can happen is accidentally syncing private information from an iPad to a personal Cloud. Somebody was tell-

66 The convergence of social media and the medical aesthetic industry is argueably stronger than ever before 99 ing me they came in to find their young son looking at medical photographs from their clinic.

Sometimes technology doesn’t work in our favour so we need to be more careful. As we get busier, our clinics are getting busier, we end up being overrun by paperwork and it’s not always possible to store everything on site. It’s our responsibility to make sure that there are no breaches of data protection. If outsourcing archiving you need to use an appropriate storage facility.

A practitioner recently told me she was driving and had medical records in the boot of her car. The boot flew open and the records flew out. Fortunately they were handed back to her without any problem, but that lady would have been in breach of data protection.

The Department of Health stipulates a maximum period of NHS record retention of 30 years.

The NHS Code of Practice is eight years for adults, 25 years for children.

Practitioners need to remember it can be quite difficult to defend any potential litigation if the contemporaneous medical records can’t be produced. If a grumble or complaint is received, or if there was an adverse outcome, then those records in particular should be retained.

Claimants have a period of time in which to bring a claim, which is three years from the date of the negligent treatment. If there’s a later date of knowledge it will start to run from that period of time, assuming they’ve got capacity. That should give a general feel for how long the documents should be kept.

Dr Natalie Blakely is Medical Director of The Light Touch Clinic in Weybridge and Founder of Consentz, Electronic Health record app. Mandy Luckman is a Partner specialising in Medical Law at Irwin Mitchell.

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54 DIRECTORY I body language

RECRUITMENT

Aesthetic Doctor

classified Body Language Classified offers flexible advertising space for medical aesthetic professionals.

Required

A full time vacancy has arisen for an Aesthetic Doctor at our client’s London clinic. The vacancy is for an established and very busy clinic in Central London, however the clinic is fast expanding and requires doctors around the United Kingdom as well.

To enquire about placing an advert in print and online, call 020 7514 5976 or visit bodylanguage.net

The successful applicant will be fully trained in Botulinum Toxins and Dermal Fillers. Experience in other aesthetic treatments would be an advantage. Full GMC registration with license to practice necessary.

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The UK and International Journal of Medical Aesthetics and Anti-Ageing

The UK and International Journal of Medical Aesthetics and Anti-Ageing

The UK and International Journal of Medical Aesthetics and Anti-Ageing

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bodylanguage.net

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How to apply

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THE LATEST RESEARCH ON USING TOXINS TO TREAT DEPRESSION

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Expression

volume 16 issue 5 number 65

Reduce risk and avoid adverse events

Expression

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volume 16 issue 5 number 65

GLYCATION I LASER COMPLICATIONS I BRUXISM How antioxidants can help

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Expression THE LATEST RESEARCH ON USING TOXINS TO TREAT DEPRESSION

To apply for this position or for more information please forward your CV to :

THE LATEST RESEARCH ON USING TOXINS TO TREAT DEPRESSION

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We also provide follow up support, so if you do have any questions or are unsure of anything we are there to help. You will also have access to our student page, which contains consultation forms, marketing material and suppliers information.

Our training is completely independent of all suppliers, we won’t give you sales pitch or a spiel.

For more information or to book contact Advance on info@advanceclinictrainingandconsultancy.com UK: 0845 261 3714 / +44 (0) 7885 215025 IRE: +353 (0) 860640595

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body language I EDUCATION 55

training TOXINS AND FILLERS 4 September, Advanced Toxins and Fillers, Wigmore Medical, London W: wigmoremedical.com 6 September, Botox & Dermal Fillers Advanced, The Paddocks Clinic, Buckinghamshire W: cosmeticcourses.co.uk 18-19 September, Introduction to Toxins and Fillers, Wigmore Medical, London W: wigmoremedical.com

Beauty Training, London W: advancebeautytraining.com

20 September, Botox & Dermal Fillers Foundation, The Paddocks Clinic, Buckinghamshire W: cosmeticcourses.co.uk

8 September, IISHCA The Physiology and Treatment of Acne, Hagley training centre, Birmingham W: sallydurant.com

24 September, Botulinum Toxin Level 1, The DrBK Training Institute, Reading W: drbobkhanna.com 26 September, Dermal Fillers Level 1, The DrBK Training Institute, Reading W: drbobkhanna.com 27 September, Botox & Dermal Fillers Foundation, Birmingham W: cosmeticcourses.co.uk 7 October, Botulinum Toxin Level 2, The DrBK Training Institute, Reading W: drbobkhanna.com 11 October, Botox & Dermal Fillers Foundation, The Paddocks Clinic, Buckinghamshire W: cosmeticcourses.co.uk 19 October, Advanced Toxins and Fillers, Wigmore Medical, London W: wigmoremedical.com 26 October, Botox & Dermal Fillers Foundation, Manchester W: cosmeticcourses.co.uk

OTHER INJECTABLES 8 September, PRP, Wigmore Medical, London W: wigmoremedical.com 16 September, Sculptra, Wigmore Medical, London W: wigmoremedical.com 26 September, PRP Training, The Paddocks Clinic, Buckinghamshire W: cosmeticcourses.co.uk 6 October, PRP, Wigmore Medical, London W: wigmoremedical.com 6 October, Microsclerotherapy Training, The Paddocks Clinic, Buckinghamshire W: cosmeticcourses.co.uk 18 October, Microsclerotherapy, Wigmore Medical, London W: wigmoremedical.com 20 Oct 20, PRP Training, The Paddocks Clinic, Buckinghamshire W: cosmeticcourses.co.uk

SKINCARE 1-3 September, Basic, Intermediate and Advanced ZO training, Wigmore Medical, London W: wigmoremedical.com 4 September, Level 4 Chemical Peeling, Hagley training centre, Birmingham W: sallydurant.com 7-9 September, Advanced skin course, Advance

25 September, Microneedling Training, Eden Aesthetics, Liverpool W: edenaesthetics.com/events.php 25 September, Advanced peel training, Skinceuticals Training Centre of Excellence, London W: skinceuticals.com

10 September, Microdermabrasion, Academy of Advanced Aesthetics, Cambridgeshire W: academyofadvancedaesthetics.com

25 September, Epionce Skincare and Peel Training, Eden Aesthetics, London W: edenaesthetics.com/events.php

11 September, Agera Skincare and Peel Training, Eden Aesthetics, London W: edenaesthetics.com

26 September, IISHCA The Physiology of Skin Ageing and Regeneration, Hagley training centre, Birmingham W: sallydurant.com

11-12 September, Level 4 Non-Surgical; Blemish Removal, Hagley training centre, Birmingham W: sallydurant.com 15 September, IISHCA Photoageing and Pigmentation Irregularities of the Skin, Hagley training centre, Birmingham W: sallydurant.com

26 September, Dermaroller Training, The Paddocks Clinic, Buckinghamshire W: cosmeticcourses.co.uk 28 September, Taking skin care to another level, Wolverhampton (Venue TBC) W: sallydurant.com

17 September, Skincare & Peels, Wigmore Medical, London W: wigmoremedical.com

29 September, IISHCA - Nutrition and the Skin, Hagley training centre, Birmingham W: sallydurant.com

17 September, Microdermabrasion Training, Eden Aesthetics, Essex W: edenaesthetics.com/events.php 18 September, Advanced peel training, Skinceuticals Training Centre, Birmingham W: skinceuticals.com

29-30 September, SkinSynergy Seminar, AesthetiCare Training, Leeds W: aestheticare.co.uk

19 September, Level 4 Dermal Roller, Hagley training centre, Birmingham W: sallydurant.com 21-23 September, Advanced skin course, Advance Beauty Training, Dublin W: advancebeautytraining.com 22 September, IISHCA - Understanding the Hypersensitive Skin and Rosacea, Hagley training centre, Birmingham W: sallydurant.com 22 September, Medik8 Dermal Roller, Wigmore Medical, London W: wigmoremedical.com 22 September, Agera Skincare and Peel Training, Eden Aesthetics, Essex W: edenaesthetics.com/events.php 22 September, Agera Skincare and Peel Training, Eden Aesthetics, Bristol W: edenaesthetics.com/events.php 22-23 September, SkinSynergy Seminar, AesthetiCare Training, London W: aestheticare.co.uk 23 September, Epionce Skincare and Peel Training, Eden Aesthetics, Essex W: edenaesthetics.com/events.php 23 September, Epionce Skincare and Peel Training, Eden Aesthetics, Bristol W: edenaesthetics.com/events.php 24 September, glĹ?Therapeutics, Wigmore Medical, London W: wigmoremedical.com

30 September, Agera Skincare and Peel Training, Eden Aesthetics, Glasgow W: edenaesthetics.com/events.php 1 October, Epionce Skincare and Peel Training, Eden Aesthetics, Glasgow W: edenaesthetics.com/events.php 1-2 October, Basic and Intermediate ZO training, Wigmore Medical, London W: wigmoremedical.com 3 October, IISHCA Advanced Consultation and Skin Assessment Workshop, Hagley training centre, Birmingham W: sallydurant.com

10 October, Chemical Peel Training Only, The Paddocks Clinic, Buckinghamshire W: cosmeticcourses.co.uk 10 October, Chemical Peel Training & Starter Kit, The Paddocks Clinic, Buckinghamshire W: cosmeticcourses.co.uk 12 October, Taking skin care to another level, Manchester (Venue TBC) W: sallydurant.com 13 October, Epionce Skincare and Peel Training, Eden Aesthetics, Essex W: edenaesthetics.com/events.php 14 October, Microdermabrasion (Face & Body), Academy of Advanced Aesthetics, Cambridgeshire W: academyofadvancedaesthetics.com 14 October, Agera Skincare and Peel Training, Eden Aesthetics, Essex W: edenaesthetics.com/events.php 20 October, Medik8 Dermal Roller, Wigmore Medical, London W: wigmoremedical.com 20-21 October, SkinSynergy Seminar, AesthetiCare Training, Manchester W: aestheticare.co.uk 21 October, glĹ?Minerals, Wigmore Medical, London W: wigmoremedical.com 21 October, Level 4 Dermal Roller, Hagley training centre, Birmingham W: sallydurant.com 22 October, Skincare & Peels, Wigmore Medical, London W: wigmoremedical.com 22-23 October, Level 4 Non-Surgical Blemish Removal, Hagley training centre, Birmingham W: sallydurant.com

5 October, Taking skin care to another level, Birmingham (Venue TBC) W: sallydurant.com

23 October, Microdermabrasion Training, Eden Aesthetics, Liverpool W: edenaesthetics.com/events.php

7 October, Level 4 Chemical Peeling, Hagley training centre, Birmingham W: sallydurant.com

23 October, Epionce Skincare and Peel Training, Eden Aesthetics, London W: edenaesthetics.com/events.php

7 October, Epionce Skincare and Peel Training, Eden Aesthetics, Warrington W: edenaesthetics.com/events.php

28 October, IISHCA - Working with Cosmeceuticals, Hagley training centre, Birmingham W: sallydurant.com

8 October, Agera Skincare and Peel Training, Eden Aesthetics, Warrington W: edenaesthetics.com/events.php

28 October, Microdermabrasion Training, Eden Aesthetics, Bristol W: edenaesthetics.com/events.php

9 October, IISHCA - Hormonal Influences on the Skin, Hagley training centre, Birmingham W: sallydurant.com

30 October, Intermediate peel training, Skinceuticals Training Centre of Excellence, London W: skinceuticals.com

9 October, Microdermabrasion Training, Eden Aesthetics, London W: edenaesthetics.com/events.php

30 October, Dermaroller Training, The Paddocks Clinic, Buckinghamshire W: cosmeticcourses.co.uk

9 October, Dermaroller Training, The Paddocks Clinic, Buckinghamshire W: cosmeticcourses.co.uk

For a complete list of aesthetic course dates, visit bodylanguage.net

www.wigmoremedical.com I 020 7491 0150 | Tel 0207.514.5975 Stand 68 Benjamin Britten Lounge | www.wigmoremedical.com

body language I MARKETING 57

Working with beauty bloggers Currently in the UK, it is estimated there are 750,000 beauty bloggers. ANTONIA MARICONDA explains how medical aesthetic professionals haven’t tapped into the power of beauty bloggers and how they can benefit your business, profile or brand

B

eauty bloggers use a blog to communicate their thoughts and opinions about products, brands and even people who work in the aesthetics industry. They often review the latest products and update their blogs, typically twice a week or more. Some prolific beauty bloggers update their blogs more than three times a day.

Frequently, beauty bloggers are passionate about beauty in general. Sometimes they have niche areas in blogging as well. For example, my niche area is anti-ageing, simply because it interests me. I focus on coaching, educating and empowering the consumer to make sensible choices.

Mutually beneficial relationships develop between

beauty bloggers and brands.

The blogger receives free products and the brand receives free advertising. Prominent beauty bloggers are invited to exclusive events and launches and collaborate with brands that host those events.

There are also beauty vloggers. A vlogger is the same as a beauty blogger, only their medium is video. Instead of communicating reviews and thoughts on a blog, vloggers video their opinions and share on YouTube.

Social media Social media is vital to bloggers to promote their blogs and grow their following.

I am often asked who the top beauty bloggers are. There are different sources that rank

the criteria of the top beauty bloggers, and if you perform a search you’ll never get the same top 10. Cision have compiled a list of the UK’s top 10 beauty bloggers and their blog-ranking methodology takes into consideration the social sharing of the article, the topic-related content, and the post frequency. They rank Jane Cunningham, known as British Beauty Blogger, as the UK’s top beauty blogger, and she has around 36,000 Twitter followers. Bearing in mind how companies rank their bloggers, there are others out there that have a higher number of Twitter followers.

Popular blog Vivianna Does Makeup, run by Anna Gardner, for example has around

58 MARKETING I body language

54,000 Twitter followers.

My blog has become popular because I’ve worked at growing my Twitter presence. People won’t read your blog unless they know that you’re there, and the way to have people read your blog is to grow your following. To do this, social media is key—and it’s hard work. I’m constantly tweeting. I use automated software too, but once every 15 to 20 minutes I tweet, and I have gained around 40,000 followers.

Content Having built up a substantial following, top beauty bloggers persevere by producing good quality content. They blog at regular intervals and the blogs are easy to navigate, with userfriendly wording. Attention is paid to layout and design, with posts supported by great images and also video.

Good bloggers are knowledgeable and are considered trusted sources of information. Their content is engaging and clear, and they inspire readers to take action. A good beauty blogger will present the reader with the truth, and inject some personality into their posts.

You can use sites like Bloglovin to find relevant blogs for your company. Do your research and find four or five bloggers that you think will fit your product, brand, clinic or treatment.

Reach Bloggers are extremely influential. They are essentially mini magazines, and some bloggers have a bigger following than published magazines.

Jane Cunningham described blogging as the gift that the beauty industry was waiting for. And this is in relation to the enormous amount of influence that bloggers have.

The value of bloggers is being realised by brands who see collaboration as a chance to tap into their audiences.

DeVries Public Relations

conducted a survey that shows that bloggers are very influential resources for women who purchase beauty and personal care products. In response to the question, “which resource is the most helpful to provide beauty product advice”, 61% replied, a familiar blogger.

Some said store website and others, social networks.

Blogs are 2.5 times more likely to drive beauty product purchases than magazines.

Visibility The enormous reach that bloggers have can drive up sales of featured products. They can be invaluable in helping you to promote products and services. They can reach large and relevant audiences and offer the opportunity for commercial relationships that can be very lucrative for you, as a brand. They can get the word out about beauty products that normally you wouldn’t see in magazines or on TV, and can provide the coverage and scope of publicity that perhaps your average magazine or TV channel can’t.

Beauty bloggers can also provide copious amounts of customer feedback which is vital, and may not otherwise be possible through traditional forms of market research.

It’s all about visibility, that which you create yourselves as brands, and that which beauty bloggers can offer you. Remember, everywhere on the internet that you have content, that talks about your brand, the better your search engine optimisation. The better your search engine optimisation, the more people buy your brand or try your product or come to your clinic and try your treatment.

Building relationships I get an average of 150 to 200 interactions a day on Twitter and most of those are requests for me to try products and treatments. Due to the sheer volume, unless something is particularly interesting, I can’t

respond. Don’t tweet a beauty blogger to say “Hi, will you try my cream? It’s the best cellulite cream on the whole planet, you’ll love it!” They’ll ignore you. Instead, try something like, “Did you know that 87% of women suffer from cellulite?

We’ve found an alternative product that might provide a viable solution.” A statistic or a fact is interesting. If you really want to grab attention, send a before and after picture with just one strap line.

Remember that even if there’s commercial interest, you cannot expect bloggers to speak falsely about your product or treatment being the best if they don’t believe it is.

Reputation is more important than remuneration. If I genuinely believe in what you do and it’s brilliant, I will write about it for free. If there’s a commercial agreement there, I will be as biased as I can be.

Exclusivity is important. If a product is out there already, beauty bloggers will be less interested. If something is new and fresh, approach beauty bloggers about it.

Build a relationship by pitching something unique, quirky and completely out of the ordinary—that’s how you’ll capture the attention of a beauty blogger. Attend meetings or launches where influential beauty bloggers will be and approach them personally.

It’s imperative to treat bloggers with respect and project a positive image of your brand.

One product featured on an influential blog can propel your brand, your name, or who you are as a person.

Always explain yourself.

When you engage with bloggers, tell them who you are, your background and why you’ve reached out to them.

Creating a relationship is what gathers you a circle of potentially powerful bloggers.

If you approach with an aggressive sales stance, you’ll be ignored. Gain initial interest, then take that interest and

build a genuine and comfortable relationship.

Invite bloggers to well thought out events—tea at Claridges or champagne and cocktails at an exclusive bar.

The invitations I say yes to are always quirky, fun and different. Also give your favourite pool of beauty bloggers an exclusive scoop.

Build trustworthy, genuine relationships and maintain them and bloggers will be loyal to your service, your brand and your product—beauty bloggers are a powerful force.

Antonia Mariconda is an award winning beauty blogger and author and writer and hosts and runs ‘Blogging for Success’ workshops W: thecosmediccoach.com; Twitter: @CosmedicCoach

“Blogs provide real reviews and experiences that bypass marketing speak and glossy brochures. Reading about other’s experiences of aesthetic treatments takes the mystery out of the experience and helps them to make an informed decision on whether any kind of aesthetic treatments are right for them. It’s always helpful for potential consumers to have aesthetician recommendations, so don’t be afraid to approach bloggers, but do expect an open and honest review.”

Jane Cunningham is author of britishbeautyblogger.com, the UK’s foremost beauty blog and thebeautyplus.com.

She has worked for over a decade in the beauty industry as a beauty writer and social media consultant

World Class International Faculty Includes: Dr Patrick Tonnard, Dr Patrick Trevidic, Dr Foad Nahai, Dr Raj Acquilla, Dr Raina Zarb Adami, Mr Jonathan Britto, Mr Alex D. Karidis, Miss Joy Odili and Dr Raffaele Rauso Surgical and Non-Surgical Conferences Surgical & Non-Surgical Technology Workshops Preview the latest tools and technology Live Demonstration Theatre Non-Surgical technology and techniques in action Dental Aesthetics Workshop An ideal taster for those looking to introduce additional cosmetic services to their dental practice Injectables Masterclass with AoAE Demos of Fillers, Toxins and Peels Allergan Medical Institute Free to attend Live injecting by Allergan experts Regulation & Advances Workshop From Keogh to Google Plus tomorrowâ&#x20AC;&#x2122;s world skin grafting this workshop session offers and exciting glimpse and the past, present and future NEW Dermatology Lab The science behind skin and skincare Great Live Debate Theatre Controversy, opinions and insights aired The Business Hub Advice to improve business outcomes Verifiable CPD Content Aesthetic & Dental Practice Management Networking Drinks Reception The key industry social Major Scale Event 200 exhibitors and 4,000 attendees

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Official Charity:

WIGMORE MEDICAL TRAINING YOUR COMPLETE TRAINING EXPERIENCE  For over a decade, Wigmore Medical have been running competitively priced courses, including all the latest trends, products and techniques to ensure top quality training.  Whether you are a newcomer to the medical aesthetic industry or an established practitioner, we feel there is always a training course or two that we can offer you.  Wigmore Medical offer an extensive range of training courses to choose from, including toxins, fillers, chemical peels, Sculptra, Dermal Roller, platelet rich plasma and microsclerotherapy.  All our hands-on training courses are run to a maximum class size of five delegates to ensure a quality learning environment. Unlike some training providers, we do not overfill the training room with delegates.  Our training is doctor-led, medically-based and independent. Our courses focus on the skills you desire and all our trainers are extremely reputable within their field of expertise.  The dedicated team has always taken pride in looking after all of its clients, with the added personal touch where needed.  Please see below for our upcoming course dates and call us now to register your interest and benefit from our professional training and continuous support.

W: WIGMOREMEDICAL.COM/EVENTS I

TRAINING

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* Only available to doctors, dentists and medical nurses with a valid registration number from their respective governing body.

All courses in London unless specified.

E: TRAINING@WIGMOREMEDICAL.COM

I T: +44(0)20 7514 5979

SEPTEMBER

OCTOBER

NOVEMBER

DECEMBER

1 ZO Medical Basic 2 ZO Medical Interm.

3 ZO Medical Adv. 4 Advanced Toxins* (am) 4 Advanced Fillers-LF* (pm) 5 Mini-Thread Lift* 8 Dracula PRP* 9 ZO Medical Basic (Dublin) 10 ZO Medical Interm. (Dublin) 11 ZO Medical Adv. (Dublin) 16 Sculptra* 17 Skincare & Peels 18 Intro to Toxins* 19 Intro to Fillers* 21 Microsclerotherapy* 22 Medik8 Dermal Roller (pm) 24 glōTherapeutics

1 ZO Medical Basic 2 ZO Medical Interm.

3 Mini-Thread Lift* 6 Dracula PRP* 9 Advanced Fillers-TT* (pm) 9 Advanced Fillers-F* (pm) 14 Sculptra* 17 Angel PRP* 18 Microsclerotherapy* 19 Advanced Fillers-LF* (am) 19 Advanced Toxins* (pm) 20 Medik8 Dermal Roller (pm) 21 glōMinerals 22 Skincare & Peels 23 Intro to Toxins* 24 Intro to Fillers* 28 ZO Medical Basic (Dublin) 29 ZO Medical Interm. (Dublin) 29 CPR & Anaphylaxis Update 30 Sculptra* 31 Mini-Thread Lift*

4 ZO Medical Basic 5 ZO Medical Interm.

6 Advanced Fillers-TT* (am) 6 Advanced Toxins-CH* (pm) 9 Dracula PRP* 12 Advanced glōTherapeutics 14 Angel PRP* 15 Microsclerotherapy* 16 Mini-Thread Lift* 19 Skincare & Peels 20 Intro to Toxins* 21 Intro to Fillers* 25 ZO Medical Basic (Dublin) 26 ZO Medical Interm. (Dublin) 26 Medik8 Dermal Roller (pm) 27 ZO Medical Adv. (Dublin) 27 Mini-Thread Lift* 28 CPR & Anaphylaxis Update

1 ZO Medical Basic 2 ZO Medical Interm.

8 Dracula PRP* 10 Skincare & Peels 11 Intro to Toxins* 12 Intro to Fillers* 13 Microsclerotherapy* 14 Mini-Thread Lift* 15 Medik8 Dermal Roller (pm) 16 glōMinerals

FOLLOW @WIGMORETRAINING ON TWITTER FOR THE LATEST UPDATES AND COURSE INFORMATION

Advanced Fillers sessions breakdown: CH = Cheeks/mid-face F = Forehead LF = Lower face TT = Tear troughs

body language I EXPERIENCE 61

Recipe for aesthetic success Mix together a successful family, an international education and a wealth of experience, stir well and we have a serving of dermatologist DR RACHAEL ECKEL

Ingredients 1 commercial airline pilot for travel 1 professional opera singer for performance 1 professor of radiology for medicine 1 cosmetologist for beauty Preparation Mix ingredients together in one multi-ethnic Caribbean island for 17 years. Allow to marinate with an elite international education, before seasoning with a topical agent skincare guru. Lay on a base of precision for zest and opulence.

Bake on a high heat for 30 years.

Presentation One precisionist cosmetic dermatologist with a gusto for topical agents and remedying ethnic skin, who loves to travel and perform—served!

T

hinking back, the person who I became is quite predictable given the familial ‘ingredients’.

My father was a polished pilot with an insatiable zeal for travel and learning about new cultures.

During the zenith of the commercial airline business, he was one of only two Caribbean pilots chosen to work for the glamorised PanAm. Due to his talent and proficiency as an airman, my father was nominated to provide air support in the war, and later became ceremonially decorated for his exceptionally heroic efforts.

An alluring opera singer with a long and distinguished career, my

mother was renowned for her ability to captivate and connect with any audience.

For her loyal and devoted service to the artistic sector of our country, Trinidad, the President awarded her the Hummingbird Gold Medal of Honour.

My brother, an accomplished Professor of Radiology at the University of California, Los Angeles (UCLA), is acclaimed for his refined skill in breast intervention.

With a unique approach to skincare and frontline experience in the beauty industry, my sister has been named a ‘superfacialist’ cosmetologist.

In the French colloquial word, I was a lagniappe; a “little something extra” that arrived 20 years after my siblings. As my brother and sister were so much older, growing up was like having two pairs of influencing parents.

An integral part of our daily family life was music and performance. We were the Trinidadian von Trapps, if you will.

From a young age, I was encouraged by my mother to sing and play instruments. I partook in many national musical contests garnering several first place trophies.

With a background of high achievers, I knew then that I too enjoyed competition and being on stage entertaining an audience.

My fascination with my big brother’s medical tales, coupled with my enthusiasm for human biology, motivated me to apply to medical school in Ireland.

My first interview was conducted at the age of 16, and I was accepted to enter the prestigious program. The Royal College of Surgeons offered an exceptional curriculum.

Research was highly encouraged from an early stage, and I was awarded two state research grants for projects, which I completed in

the Anatomy and Biochemistry departments.

Medical school was indeed demanding at times, but as my older brother taught me ‘slow and steady wins the race’.

With this value in mind, I paced myself, and went on to win six first place medals for outstanding academic achievements.

I began my postgraduate dermatology training at the eminent St. Bartholomews and the London School of Medicine, where I received a distinction in my thesis on leprosy and its history in the Caribbean. But dermatology is a vast subject with many conditions to be familiar with; in order to become

Rachael Eckel’s mother, an opera singer

62 EXPERIENCE I body language

Rachael Eckel’s father, a pilot

The whole Eckel family together

an expert one must narrow their training focus.

Although a relatively novel field, I chose cosmetic dermatology as my subspecialty. My sister’s ability to inspire confidence through simple beautification techniques was a motivating force. This artistic discipline also allowed me to capitalize on my high manual dexterity and creative disposition.

In 2012 I gained my American

Board Certification in aesthetic medicine, and placed first in my graduating year.

I was nominated by the President onto this academy’s Faculty, to teach and examine physicians worldwide in skincare and cosmetic medicine advances.

I remain the youngest doctor to ever achieve such esteemed membership.

Coming from the Caribbean, I have an appreciation for the beauty of ethnic skin and a proclivity towards treating it. However, this is a notoriously onerous category for dermatologists to remedy.

To refine my skillset, I decided to personally train under Dr Zein Obagi; the world authority in managing darker skin types for over thirty years.

During my time with him in Beverly Hills, I also discovered my avidity for topical skincare agents, a domain which Dr. Obagi has pioneered for decades.

Today I remain actively involved in scientific audit, research, journal publications and physician education. I continue to be closely mentored by Dr Obagi, who personally nominated me to lead his venerable ZO Skin Health International Faculty Board.

I lecture extensively worldwide and provide master class training with a principal interest in topical

skincare agents and chemical peels.

In the past two months I was afforded the opportunity to visit Russia, Dubai, Monaco, Paris, Germany, Norway and Sweden.

This hectic travel schedule performing globally in front of large audiences was somewhat foreseeable given my father’s history in aviation and my mother’s career on stage.

This international experience as an educator also gives me valuable insight into the field of aesthetic medicine. I am regularly exposed to varying cultures with diverse cosmetic needs, procedures and disease treatments.

Teaching also forces me to stay scientifically current, so that I am equipped to respond to questions factually. This means that my educational programs and clinical practice are grounded in the latest science.

A student once commented how far reaching teaching can be: as a Physician in an office, I can only affect the lives of the community I serve, but as a teacher to Doctors, I can ‘transform a world’.

Those close to me have often quipped that I never seem to ‘switch off’. I would argue instead that I am one of the lucky who has the ability to remain ‘switched on’.

It is this very characteristic that underpins my precision and all of my achievements; it was with me when I won my first trophy for singing at aged 8 and more recently when Dr Obagi gifted me the opportunity to edit his latest book.

It fosters my voracious desire to improve my scientific knowledge and nurtures my imagination to advance the field of cosmetic dermatology.

When you carefully knead together the correct balance of familial influences, a zesty island, a master mentor, and a tireless drive, you get yourself a 5 foot 10 inch serving of Dr Rachael Eckel.

Dr Rachael Eckel is a Cosmetic Dermatologist and Key Opinion Leader

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BEL092/0314/FS Date of preparation: April 2014