april
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CLINICAL ASSESSMENT
A PATIENT CENTERED APPROACH TO TREATMENT AND MANAGING PERSONALITY TYPES
FACE 2015
BUSINESS MODELS
INJECTABLES
Pre-conference agendas announced plus exhibition update
How to convert prospects into customers and tips for a successful practice
Avoid complications and manage patient expectations
The UK and International Journal of Medical Aesthetics and Anti-Ageing bodylanguage.net
novacutis
body language I CONTENTS 3
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contents EDITOR Helen Unsworth 020 7514 5989 helen@face-ltd.com
07 NEWS
ASSISTANT EDITOR Lousie Renwick 020 7514 5989 louise@face-ltd.com
14 DERMATOLOGY
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 PUBLISHER Raffi Eghiayan 020 7514 5101 raffi@face-ltd.com CONTRIBUTORS Dr Beth Briden, Kimberley Taylor, Chiza Westcarr, Dr Mark Tager, Mr Christopher Inglefield, Marie Duckett, Dr Diane Duncan, Barbara Freytag, Dr Raj Persaud, Prof Adrian Furnham, Dr James Willis 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 2015 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
OBSERVATIONS Reports and comments
don’s Westminster on June 4th to 7th, FACE 2015 will host a world renowned speaker panel, delivering a complete educational programme
HYPERPIGMENTATION Dr Beth Briden looks at the causes of hyperpigmentation in darker skin types and how chemical peeling can be combined with other treatments to improve the appearance of the skin
29 PRE-CONFERENCE ADVANCED MASTERCLASS
19 PRACTICE
FACE 2015 will be hosting an advanced masterclass with Dr Ali Pirayesh as the Scientific Director on “Essential anatomy and techniques for aesthetic procedures”
ASSESSMENT IN CLINICAL PRACTICE
30 INJECTABLE AGENDA
Kimberley Taylor considers a patient centred approach to clinical assessment and offers advice on how to deal with different personality types and management for effective outcomes
23 SKINCARE
The core of FACE Conference, this agenda brings you up to date with the latest treatments and techniques using toxins, fillers, PRP, mesotherapy and fat transfer
31 BODY AGENDA
Chiza Westcarr looks at managing post-inflammatory hyperpigmentation risks in ethnic skin
For the first time, FACE will host the BODY Conference with a full agenda featuring non-surgical treatments to target all indications within this evolving sector
CONFERENCE
32 SKIN AGENDA
28 FACE 2015
Skincare is at the centre of the medical aesthetic industry—
DAMAGE LIMITATION
Held at the QEII Centre in Lon-
4 CONTENTS I body language
editorial panel
topical products and combined approaches to treatment are explored in depth
33 BUSINESS AGENDA 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.
Marketing your practice is vital to secure success in a competitive industry. Our expert panel will guide you through, from social media to website development and PR
34 AESTHETICIANS AGENDA This agenda explores the latest advanced treatments for non-medically trained practitioners, providing a unique forum for therapists
35 HAIR AGENDA Androgenic alopecia and hair loss are common indications—learn about the latest treatments and techniques for effective restoration
36 THE EXHIBITION With over 80 exhibitors, a packed agenda of exhibitor workshops spanning three days and a choice of comprehensive exhibitor symposiums, FACE 2015 offers delegates every opportunity to explore the latest medical aesthetic products and services
39 BUSINESS BUSINESS MODELS Dr Mark Tager shares his tips for a successful practice: how to convert prospects into customers and develop a strong brand
43 MEDICAL AESTHETICS DEALING WITH INJECTABLE COMPLICATIONS Mr Christopher Inglefield outlines the motivations and aims for creating guidelines and Marie Duckett offers her advice on the vital role of managing patient expectations in order to avoid complications
48 PRODUCTS 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.
ON THE MARKET The latest anti-ageing and medical aesthetic products and services
51 EQUIPMENT COMBINATION TREATMENTS
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.
Why use fractional radio frequency when lasers give such great results? Dr Diane Duncan says the answer is simple: fractional RF can do things that laser cannot
54 EDUCATION 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.
TRAINING DATES A comprehensive course calendar for the industry
55 EDUCATION INADEQUATE TRAINING
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.
Barbara Freytag discusses the impact of the rapid expansion of the aesthetics industry, and highlights how education is a vital part of regulation
57 PSYCHOLOGY 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.
EYE CANDY
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.
61 INJECTABLES
Dr Raj Persaud and Prof Adrian Furnham examine the latest psychological research on attraction and infidelity—can ‘eye candy’ always be resisted?
USING TOXINS THERAPEUTICALLY Dr James Willis examines how facial aesthetic practitioners can provide therapeutic use of botulinum toxin to benefit patients
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body language I NEWS 7
observations
SUN DAMAGES CONTINUES AFTER DARK Much of the damage that UV radiation does to skin occurs hours after sun exposure, a team of Yale-led researchers have concluded in a recent study Douglas E. Brash, clinical professor of therapeutic radiology and dermatology at Yale School of Medicine and his co-authors first exposed mouse and human melanocyte cells to radiation from a UV lamp. The radiation caused a type of DNA damage known as a cyclobutane dimer (CPD), in which two DNA “letters” attach and bend the DNA, preventing the information it contains from being read correctly. To the researchers’ surprise, the melanocytes not only generated CPDs immediately, but continued to do so hours after UV exposure ended. Cells without melanin generated CPDs only during the UV exposure. This finding, pulished in Science Journal, showed that melanin had both carcinogenic and protective effects. “If you look inside adult skin, melanin does protect against CPDs. It does act as a shield,” said Brash, also a member of Yale Cancer Center. “But it is doing both good and bad things.” When testing the extent of damage that occurred after sun exposure they found that half of the CPDs in melanocytes were “dark CPDs”—CPDs created in the dark. Attempting to explain the results, Sanjay Premi, associate re-
search scientist in the Brash laboratory, discovered that the UV light activated two enzymes that combined to “excite” an electron in melanin. The energy generated from this process—known as chemiexcitation, a process previously been seen only in lower plants and animals—was transferred to DNA in the dark, creating the same DNA damage that sunlight caused in daytime. Although the carcinogenic effect of melanin is disconcerting, the researchers found that vitamin E offered a potential way of com-
bating the effect, since it both acted as an antioxidant - having the ability to suppress reactive oxygen— and blocked the energy transfer involving excited electrons that disrupted DNA. “One benefit of dark photochemistrys slow course is that it allows intervention,” says the study. “Screening... offers the prospect of developing ‘eveningafter’ sunscreens that could potentially prevent the carcinogenic processes occurring in the skin hours after sunlight exposure ends.”
TOXINS TREAT FACIAL PARALYSIS A safe procedure to improve the smiles of children by restoring lip symmetry in those with facial paralysis Often used as a treatment to achieve facial symmetry in adults after facial paralysis, botulinum toxin A can effectively weaken the strong muscles on the non-paralysed side of the face—but little investigation has been carried out into its use in children. Dr Siba Haykal, of the University of Toronto and his team reviewed medical records and identified 18 children with facial paralysis treated with botulinum toxin A injections between 2004 and 2012. Using facial analysis software they measured lower lip symmetry in patients’ smiling photographs before and after treatment with botulinum toxin A. No complications were observed in patients and facial symmetry improved.
8 NEWS I body language
events 9-11 APRIL, Annual Conference of the Association of Cutaneous Surgeons of india (ACSI) - ACSICON 2015, Kolkata, India W: acsicon2015.com 10-12 APRIL, IMCAS China 2015, Shanghai, China W: imcas.com 16-18 APRIL, 4th World Congress of Dermoscopy and Skin Imaging (IDS), Vienna, Austria W: dermoscopy-congress2015.com 17-21 APRIL, Congresso Brasileiro de Cirurgia Dermatologica, Bahia, Brazil W: sbd.org.br 22-26 APRIL, Annual Conference of the American Society for Laser Medicine & Surgery (ASLMS), Kissimmee, Florida, USA W: aslms.org 20 APRIL – 2 MAY, Cosmetex 2015, Melbourne, Australia W: cosmetex.org 25-26 APRIL, Aesthetic Medicine Live, London, UK W: aestheticmed.co.uk 1-3 MAY, Middle East Congress on Rhinology and Facial Plastic Surgery (MERC), Tehran, Iran W: merc2015.com 6-9 MAY, Annual Meeting of the Society for Investigative Dermatology, Atlanta, Georgia, USA W: sidnet.org
UBIQUINONE MAY NOT ACT AS PREVIOUSLY BELIEVED Popular dietary supplement may offer no anti-ageing benefits Ubiquinone—also known as Coenzyme Q10—is a dietary supplement often used to reduce the effects of ageing. However, a new study lead by Professor Siegfried Hekimi, at McGill University, Canada and recently published in the journal Nature Communications suggests the supplement may offer no such benefits. Ubiquinone, a naturally occurring fatlike substance present in all cells in the body, is used by mitochondria to convert energy from nutrients and oxygen into energy that cells can use. Past research also suggests ubiquinone is also an antioxidant with the ability to reduce damage caused by free radicals which contribute to ageing. Hailed by many as a dietary supplement that can slow ageing with its antioxidant properties, some studies suggesting also suggest it can improve skin roughness and wrinkles. But according to the results of this latest study, ubiquinone may have no anti-ageing
benefits at all. In experiments with mice, in which ubiquinone was erased completely, before restored to normal levels, the study showed that lack of ubiquinone caused illness and early death, since its presence is essential for mitochondria in the cells to convert energy. Despite deficiency of ubiquinone causing early death, no increased cell damage was recorded, suggesting that ubiquinone does not play a role in ageing and is unlikely to have antioxidant properties. Commenting on these results, Prof. Hekimi said, “Our findings show that one of the major anti-ageing antioxidant supplements used by people can’t possibly act as previously believed.” “Dietary supplements cost a lot of money to patients throughout the world—money that would be better spent on healthy food. What’s more, the hope for a quick fix makes people less motivated to undertake appropriate lifestyle changes.”
8-9 MAY, Annual Conference of the Association of Scottish Aesthetic Practitioners (ASAP), Glasgow, Scotland W: imcas.com/en/worldwide-agenda 12-15 MAY, Skin Care 2015, Montreal, Canada W: spsscs.org 14-19 MAY, Annual Meeting of the American Society for Aesthetic Plastic Surgery (ASAPS), Montreal, Canada W: surgery.org 22-24 MAY, SOFCEP Congress, Tours, France W: congres-sofcep.org 2-6 JUNE, Annual Meeting of the Canadian Society of Plastic Surgeons (CSPS), Victoria, Canada W: plasticsurgery.ca 4-6 JUNE, ISAPS Symposium, Nice, France W: isaps.org 4-6 JUNE, Congrès Annuel de la Société Française des Chirurgiens Esthétiques Plasticiens (SOFCEP), Nice, France W: chirurgiens-esthetiques-plasticiens. com 4-7 JUNE, FACE 2015, London, UK W: faceconference.com 4-7 JUNE, Non Surgical Symposium of the Australasian Society of Aesthetic Plastic Surgery (ASAPS), Melbourne, Australia W: asapsevents.org 7-11 JUNE, Annual Meeting of the Southeastern Society of Plastic and Reconstructive Surgeons (SESPRS), Amelia Island Plantation, USA W: sesprs.org Send events to arabella@face-ltd.com
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body language I NEWS 11
60
second brief
MARKET LIFTERS 15.6 million cosmetic procedures including both minimally-invasive and surgical were performed in the USA in 2014—an increase of 3%
TOP 5 MINIMALLY-INVASIVE PROCEDURES + 6% from 2013 to 2014 BOTULINUM TOXIN TYPE A 6.7 MILLION PROCEDURES + 3% from 2013 to 2014 SOFT TISSUE FILLERS 2.3 MILLION PROCEDURES + 7% from 2013 to 2014 CHEMICAL PEELS 1.2 MILLION PROCEDURES + 3% from 2013 to 2014 LASER HAIR REMOVAL 1.1 MILLION PROCEDURES
MICRODERMABRASION 881, 905 PROCEDURES - 9% from 2013 to 2014
TOP 5 SURGICAL PROCEDURES BREAST AUGMENTATION 286, 254 PROCEDURES - 1% from 2013 to 2014 NOSE RESHAPING 217, 124 PROCEDURES - 2% from 2013 to 2014 + 5% from 2013 to 2014 LIPOSUCTION 210, 552 PROCEDURES
EYELID SURGERY 206, 509 PROCEDURES - 4% from 2013 to 2014 FACELIFT 128, 266 PROCEDURES - 4% from 2013 to 2014 Men having plastic surgery continues to rise with 26,175 male breast reduction procedures were carried out in 2014—a 29 % increase since 2000, and 1054 pectoral implants procedures were carried out—a 208% increase from 2013 to 2014. Source: The American Society of Plastic Surgeons (ASPS) annual plastic surgery procedural statistics
OBESITY RELATED TO BRAIN’S OPIOID SYSTEM Researchers at Aalto University and the University of Turku have found obesity is associated with altered opioid neurotransmission in the brain Research published in The Journal of Neuroscience, found that obesity is associated with changes to functioning of the brain’s opioid system, which is intimately involved in generating pleasurable sensations. Obese people were found to have a lowered number of opioid receptors in the brain, however, no changes were observed in the dopamine neurotransmitter system, which regulates motivational aspects of eating. Professor Lauri Nummenmaa and researcher Henry Karlsson, who measured availability of mu-opioid and type 2 dopamine receptors in normal-weight and obese individuals’ brains using positron emission tomography at the Turku PET Centre believe it is possible that the lack of brain’s opioid receptors predisposes the obese individuals to overeating to compensate decreased hedonic responses in this system. The findings illustrate the mechanisms involved in overeating, and provide new insight into behavioural and pharmacological treatment and prevention of obesity. However, it is not yet clear whether the altered brain neurochemistry is a cause or consequence of obesity.
12 NEWS I body language
GOOGLE GLASS IN PLASTIC SURGERY? First plastic surgery procedure performed using Google Glass
Use and outcomes evaluated New insights into the use and outcomes of gluteoplasty and labiaplasty—two of the fastest-growing plastic surgery procedures—were presented in the March issue of Plastic and Reconstructive Surgery, the official medical journal of the American Society of Plastic Surgeons (ASPS). Fernando Serra, MD, and colleagues of Pedro Ernesto University Hospital, Rio de Janeiro, Brazil, evaluated changes in the gluteus muscle in women undergoing placement of silicone implants to improve buttock shape and found volume of the gluteus muscle reduced by about 6% post implant, although there was no associated change in muscle strength. Atrophy may be at least partly related to ‘intrinsic compression’ of the muscle by the implants. Evidence showed that muscle volume began to be regained after three months—possibly after return to exercise and activity after recovery from the implant procedure. At follow-up, the women were closer to the ‘ideal’ waisthip ratio of 0.70, suggesting that implant gluteal augmentation meets the goal of providing a more shapely figure, with relatively minor, potentially reversible muscle atrophy. Vaginal labiaplasty, like gluteal augmentation, is a technique that more women are interested in and discussing with plastic surgeon. ASPS Member Surgeon Ashit Patel, MB, ChB, of Albany (NY) Medical Center and colleagues analysed research on the outcomes of vaginal labiaplasty in a review of 19 articles. They identified nearly 1,950 women undergoing labiaplasty for aesthetic and/or functional reasons and found wide variation in surgical management—the plastic surgeons in the studies used seven different labiaplasty techniques in total with good results. Patient satisfaction rates ranged from 94 to 100 percent, and complication rates were acceptably low. Dr Patel et al propose a simple classification technique to aid in comparing the results of future clinical trials—looking at not just in the type of surgery, but also in anesthesia, wound closure, and postoperative care. They believe that this could be a useful first step toward matching patients to the surgical technique that’s most appropriate for them.
video viewers as well as for the surgeon. Glass has many potential uses, in training, rapid accessing and viewing of medical records, and even reducing the spread of infection by removing the need to handle pens, paper and computers. Dr Rosenfield notes that live recordings also have unique value for self-evaluation by the surgeon. In the future, Glass technology many enable surgeons to receive remote consultations and even ‘virtual assistance”’during actual procedures. Although many challenges remain, the they remain positive about the potential uses Google Glass in surgery. Also noting that “logistical, ethical, and hospital legislative issues” will need to be tackled before Glass can be fully integrated in everyday clinical care. Doctors Davis and Rosenfield commented, “The future of Glass in surgery is very promising and has the potential to make an empowering impact upon the contemporary plastic surgeon not only as a teaching tool for the observer, but for the surgeons themselves.”
HATTANAS KUMCHAI / SHUTTERSTOCK.COM
NEW RESEARCH INTO GLUTEOPLASTY AND LABIAPLASTY SURGERY
Google’s ‘Glass’—a handsfree, computerised eyewear that can present information to the wearer and enable recording and sharing of video, has a wide range of possible applications in plastic surgery according to a special paper in Plastic and Reconstructive Surgery. Christopher R. Davis, MD, and ASPS Member Surgeon Lorne K. Rosenfield, MD, of Stanford University, reported on the first plastic surgery procedure performed using Glass. noting how it could enhance surgical training, medical documentation, and patient safety. “Google Glass is an exciting technology, attracting global interest from multiple industries, professions, and individuals” they note. With the ability to control the device hands-free using voice commands, touch, or head position, Glass is a natural technological addition to the operating room. In their review, the pair identify surgical procedures performed using Google Glass from multiple specialties. They also present Dr Rosenfield’s experience in performing the first plastic surgery procedure with Glass—blepharoplasty, performed in combination with a facelift procedure. Challenges for future refinement, including the limited resolution of the video camera, technical difficulties in streaming, and the need for the surgeon to keep the head in a fixed position. In subsequent procedures, Dr Rosenfield fashioned a headmounted extra-wide LED light to improve clarity for
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14 DERMATOLOGY I body language
Hyperpigmentation DR BETH BRIDEN looks at the causes of hyperpigmentation in darker skin types and how chemical peeling can be combined with other treatments including laser to improve the appearance of the skin
O
ver a third of all dermatologic complaints each year are related to dispigmentation. Darker skinned individuals, especially skin types 4, 5 and 6 are affected with much greater frequency but even types 1, 2 and 3 have problems with uneven pigmentation. People with very fair type 1 skin—the red-haired freckle faced—are often just unhappy with their freckles as they are often called age spots. Darker skin types are at greater risk of hyperpigmentation as any irritation or injury to the skin, whether it be a pimple, a scrape, heat from a laser, can cause the cells to extravasate their pigment, leaving dark, blotchy patches (post inflammatory pigmentation). Melasma is another common cause of hyperpigmentation that can occur in all skin types and is one of the most common causes of hyperpigmentation and most difficult to treat. The melanin production pathway Melanin production can be stimulated by a number of factors including UV light, hormone (estrogen, prednisone, melanocyte stimulating hormone) and inflammation. Inflammatory responses in the skin stimulate melanin production by activation of cytokines. Any type of irritation or trauma to the skin can produce the inflammatory response to activate the melanin production pathway. In the production of melanin inflammatory cytokines, UV light, and hormones act to stimulate the conversion of the amino acid, tyrosine, into dopa, the initial step in melanin production. Subsequently, dopa is then converted into dopaquinone—a precursor of melanin. The dopaquinone is then converted into the pigments, eumelanin and pheomelanin, which are then ‘packaged’ into the melanosomes within the melanocytes and then delivered to the keratinocytes from the melanocytes. Thus, there are a number of steps in the process of melanin production where we can try to inhibit or reduce melanin production and resulting hyperpigmentation.
Brighter skin tone: Before treatment and after 16 weeks
Cause The first step in treating patients with hyperpigmentation is to determine the cause of discoloration. You need to determine if the discolouration is actually due to melanin and not some substance such hemosiderin, blood, or a medication that has been deposited in the skin such as minocycline or amiodarone. It is important to begin with a complete skin exam and medical history to determine if there are any medications or any systemic disease contributing to their dyspigmentation. Certain medications, commonly antibiotics and anti-hypertensives, can induce photosensitivity or a phototoxic reaction when exposed to sunlight. Complete sun protection is of utmost importance in these patients. Hormonal imbalances such as polycystic ovarian disease, or exogenous sources of hormones such as steroids, OCP’s, or estrogen can also be causes that need to be addressed. Inflammation in the skin also needs to be treated as inflammation can stimulate melanin production and also lead to post inflammatory hyperpigmentation. Therefore, eczema or seborrheic dermatitis and rosacea should be treated and irritating skin care products should be eliminated as part of your treatment for dyspigmentation. Once we have determined the cause and eliminated inciting factory if possible, we need to try to decrease melanin production from the melanocytes. We are able to inhibit melanin synthesis with various topical pigment lightening agents. There are many lightening agents to choose from including: hydroquinone, kojic acid, arbutin, ascorbic acid, niacinamide, polyphenols, soy proteins, azelaic acid, N-acetyl glucosamine, licorice extract to name a few. I like start patients on a skin care regime containing pigment lightening agents and polyhydroxy acids to improve the barrier function of the skin, decrease overall pigment in the skin and to decrease inflammation in the skin for at least a month before
Cross-polarized photography was used to enhance melanin imaging
body language I DERMATOLOGY 15
any cosmetic procedures are performed. This is to help reduce the risk of developing post inflammatory hyperpigmentation. Pigment lightening ingredients should be used with exfoliating agents if tolerated to help disperse pigment and help remove melanin that has been extravasated from the cells. Exfoliating agents such as retinoids, glycolic acid, and salicylic acid can be combined with the pigment lightening agents in low concentrations to enhance the lightening process. Care must also be taken with prescribing a skin care regime or topical bleaching agents as to avoid irritation or excessive dryness which can result inadditional hyperpigmentation. Retinoids can be an effective pigment dispersing/exfoliating agent but, can be irritating with their propensity for inducing a retinoid dermatitis. Procedures such as chemical peels. microdermabrasion, microneedling and lasers can be used after the skin has been prepared with a skin care regime with caution if topical pigment lightening agents fail. Darker skin types contain more melanin and when injured release more pigment into the epidermis and the dermis so it is important to try to decrease the melanin in the skin before any procedures. Sun avoidance and sunblock application daily must be stressed to reduce the risk of re-hyperpigmentation. Process Determining the level of pigmentation in the skin is important for treatment expectations. A UV-A Wood’s lamp can be used to try to determine if the pigmentation is epidermal or dermal. Epidermal pigmentation will be easier to treat and will “light up” or glow under the Wood’s light versus pigment that is located deeper in the dermal layer. Dermal pigment will not ‘light up’ or be accentuated under the Wood’s light. Deeper dermal pigmentation will be more difficult to remove. Treatment expectations should also be addressed and that there is no ‘quick cure’ and will require multiple treatments. Minimally invasive procedures must be recommended as any significant injury to the skin may result in additional hyperpigmentation. After prepping the skin with the topical regime, minimally invasive procedures such as superficial chemical peels, microdermabrasion, and microneedling may be considered. It is important to start with a lower strength of chemical peel to see how the skin tolerates them, so as not to induce significant injury to the skin. Alpha hydroxyl acid peels including glycolic, citric, and mandelic acid are excellent peels to use as they can be combined and neutralised, unlike other peels such as TCA which cannot be neutralised.
Brighter skin tone: before and 16 weeks after treatment
66 Determining the level of pigmentation in the skin is important for treatment expectations 99 Treatment Treatment begins with protecting skin from sun exposure using a broad-spectrum sunscreen, clothing or simply avoiding sun exposure. Pigment lightening agents should be used as the first line treatment to reduce the pigment in the skin. Pigment lightening agents can inhibit the melanin formation pathway at multiple steps. Sites to disrupt melanin production include: 1) blocking the enzyme tyrosinase, and thus, the formation of tyrosinaserelated protein, 2) the conversion from dopaquinone to melanin and 3) inhibit the packaging of the melanin granules, and 4) exfoliation to try to shed the melanin and enhance cell turnover. There are many pigment-lightening agents available. Hydroquinone has been banned in Europe and the UK due to its potential for open ulcers and toxicity and kojic acid is in the process of being banned because of the potential for carcinogenicity. Arbutin has also been banned due to its ability to release hydroquinone. Newer lightening agent including ascorbic acid, N-acetyl glucosamine,and other botanicals along with a turmeric derivative and chlorogenic acid from the green coffee bean. A new combination product which contains these alternative regimens looks promising for long term use for lightening the skin. A new pigment lightening product, Enlighten, contains 12 different pigment lightening agents including SabiWhite – a product derived from turmeric, a natural herb that has been used for skin lightening dating back several thousand years. It is non-toxic and its main ingredient, tetrahydrocurcumin (THC)0.25% has been shown to be as effective as 4% hydroquinone, without the toxicity in a recent study. The study compared 0.25% THC against 4% hydroquinone over a four-week period with twice daily application. The study was done using a Mexameter to measure the pigment in the skin as a numerical value. The results showed the THC to be as effective at the hydroquinone at a very low concentration. I would look for THC to become more widely used as a non-toxic lightening agent. Chlorogenic acid is another new ingredient that had been
Treatment of acne/post-inflammatory hyperpigmentation
16 DERMATOLOGY I body language
DR BRIDEN’S RECOMMENDATIONS FOR LONG-TERM MAINTENANCE: “In the past I’ve used alpha hydroxyl acids and the retinoids if they’re tolerated. If they have sensitive skin, I will use Enlighten, with it’s 12 pigment-lightening ingredients that attack all aspects of pigment formation. It’s very mild, nontoxic and does not contain hydroquinone, arbutin or kojic acid. It has the turmeric derivative, THC, along with retinol and some of the milder AHAs and it’s been very good for long-term pigment lightening and control.” “Enlighten has been out for several years now and their longterm studies have been good and problem free. It does not provide a dramatic, immediate, lightening effect, but over time provides a very nice improvement. It can be used on all skin types but was designed for daily use on Asian skin, South American skin and the darker skin where they have problems with pigmentation year round.”
found to help inhibit pigmentation. It is derived from polyphenol in the green beans of coffee. It is a significant source of caffeic acid and quinic acid. Caffeic acid is slightly more effective and has been shown to markedly inhibit ultraviolet-induced pigmentation. In studies using cell cultures, melanocyte-stimulating hormone (MSH) was added to plain and caffeic acid treated cultures to simulate ultraviolet induced melanogenesis. Caffeic acid treated cell cultures inhibited the MSH induced melanogenesis. Caffeic acid has been shown to be a more potent melanin inhibitor than retinol, ferulic acid, azelaic acid and kojic acid. When comparing the effects of the caffeic acid with retinol and the other products—there is a marked increase in inhibiting regular pigment formation in addition to ultraviolet-induced pigmentation. N-acetyl glucosamine (NAG) has been shown to inhibit the enzyme tyrosinase. NAG is the precursor to hyaluronic acid and is a natural component of the dermal layer of skin. N-Acetyl glucosamine combines with glucuronic acid to produce hyaluronic acid. NAG is a smaller molecule that can penetrate the skin and has been shown to be very effective in increasing glycosaminoglycans in the dermis and plumping the skin. NAG is also a natural non-acid exfoliant so that can help disperse pigment. NAG is frequently used in formulations in combination with retinoids as it is a non-acid and can be combined with retinoids in formulation and maintain the stability of the retinoids. Evidence Poster presentations at the American Academy of Dermatology revealed several clinical studies that were done using a product containing N-Acetyl glucosamine, caffeic acid and the turmeric derivative THC, an oligopeptide, and sunblock. The study measured the amount of pigmentation in the skin using a Mexameter and fluorescent photography to show the improvements after twice daily use over a 16 week period. The topical pigment lightening formulation inhibited all six steps that are involved in pigment formation. The study showed that with this combination of ingredients, pro-inflammatory cytokines were reduced, along with reduction of melanocyte packaging and decreased production of melanin by the melanoocytes. The N-Acetyl glucosamine provided exfoliation and
tyrosinase inhibition while the chlorogenic acid helped decrease the melanin production and the packaging transfer. Another ingredient in the formulation, Gigawhite, contains seven botanical plant extracts to inhibit pigment formation. Other ingredients include the designer peptide, liquorice extract which is also another potent tyrosinase inhibitor and stabilised vitamin c. The combination serves to help inhibit each step in the pigment formation unlike many of the other products available that affect one or two steps in melanin synthesis. In another clinical study of 40 females used this product over a 16 week period. Clinical grading using the chromometer, photography and self-assessment. Photos were taken at baseline, eight weeks and 16 weeks that show an overall effect of lightening. Not all cases of hyperpigmentation respond to the topical pigment lightening agents, so adjunctive procedures such as the chemical peels, microdermabrasion, or microneedling may be used for more stubborn cases. Lasers including the fractional, the IPL and the YAG can also be used with caution to treat hyperpigmentation. Lasers are not my first line of treatment but, I do use them in certain cases as they can induce PIH. I do not like to use them on darker skin types (iv,v,vi). I make sure I pretreat with pigment lightening agents and will add with hydroquinone to the regimen to minimise the pigmentation in the skin and reduce the chance of inducing post inflammatory hyperpigmentation. Chemical peels still remain a very popular and valuable procedure for treating hyperpigmentation an all skin types. Superficial Chemical peels, mainly the alpha hydroxyl acid peels (glycolic acid, mandelic and citric acid) can be used effectively for treatment of hyperpigmentation since they can be neutralized to control the reaction as they are water soluble. With TCA or some of the others this isn’t possible – once you’ve applied the acid it’s going to run its course. With glycolic peels, if the patient has an untoward reaction or they’re a little bit more sensitive than you initially thought, you can always stop the reaction. Glycolic peels enhances cell turnover and are nontoxic to the cells. They also have anti-ageing effects of dispersing the pigmentation, exfoliating it, plumping the dermis by increasing hyaluronic acid and glycosaminoglycans and collagen and giving you an overall visual plumping. I had a gentleman client with acne and psuedofolliculitis barbae with postinflammatory hyperpigmentation, so he started at 35% and we did a series of peels and even a stronger highpotency peel with pyruvic acid. With another female client, a picker, who developed post-inflammatory pigmentation, with just two peels she had a marked improvement. I’ve also had great results with treating clients with melasma—even after three peels I’ve seen a marked improvement. Again, you want to start slowly and work up. To summarise the approach: with any client you treat with a peel, it’s very important to assess their pigmentation to make sure that it is related to melanin production versus drug-induced and to alleviate phototoxicity. I also assess medications that could cause aggravation. I like to pre-treat with some of the mild pigment-lightening and exfoliating agents to prep the skin and prepare and maximise the barrier function. I ensure my clients use sunscreens and then combine with pigment-lightening procedures. Here we have a very effective treatment option for reducing hyperpigmentation in dark skins. Dr Beth Briden is a is the founder and medical director of Advanced Dermatology & Cosmetic Institute in Edina, Minnesota.
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/018/0313
body language I PRACTICE 19
Assessment in clinical practice KIMBERLY TAYLOR considers a patient centred approach to clinical assessment, and offers advice on how to deal with different personality types and management for effective outcomes
A
esthetic patients may present with many common features, however every patient is individual. Each person has a different perception of what is aesthetic and personalities and psychological features vary widely. Assessment of these factors and incorporation of such assessment into routine practice is crucial. The aim being to improve the patient journey, treatment uptake and to deliver on the ultimate aim: satisfaction with treatment outcome. As aesthetic practitioners our focus should be the patient. Patients are going to determine how we run our practice, how we organise and select our team and of course the treatments we offer. As a general rule, the aesthetic patient will be acutely aware of the aesthetics of your practice and your team and will expect a high level of service for this luxury purchase. Facial aesthetic treatments are in the main not undertaken for health reasons, they are elective treatments—patients want to feel like they’re enjoying a five-star experience. The patient will often know what they want—smoother lines for example—but be unsure how to best attain their goal. They may be aware of the initial options, but not which one may suit them best. Most patients will also have an idea of the types of treatments available, but perhaps not the exact distinction between them. They may fear the unknown and need a degree of reassurance when discussing unfamiliar treatments. Despite these generalisations it is important to remember that patients differ not only in their demographic background, medical history, facial anatomy and tissue type but perhaps most significantly
they’re going to be very different in terms of their vision of aesthetics in addition to personality and psychological features. The vision of aesthetics Aesthetics is concerned with beauty or the appreciation of beauty. More scientifically, aesthetics is defined as the study of sensory or sensoryemotional values and judgements of sentiment and taste. Aesthetics is personal, subjective and individual. What one person will perceive as aesthetic, another will not, and it is important that practitioners do not impose their opinion of what is aesthetic upon their patients. Our perception of aesthetics is influenced by a number of factors such as genetic features, upbringing and the media that we’re exposed to. Of course the patient, not the clinician, initiates aesthetic treatment. Patients do not need to have aesthetic treatment for their health, so evaluating each patient’s psychological condition from the first contact really is essential, in terms of general demeanour, personality, true motives for wanting to undertake treatment and any prognostic indicators. First impressions When the patient walks in through the surgery door, consider subtle signs in body language, eye contact and tone of voice. Obviously, a degree of anxiety is normal when attending a clinical environment, but is that anxiety relative to the environment, or extreme to the environment? Often your gut instinct will be correct. Personality categorisation Personality traits and behavioural clues can guide the clinician’s approach to the patient and help tai-
lor each approach to an individual. Categorising personalities can be very useful because it can enable adaptation of the approach to each individual patient—assisting in patient management, management of discussions of treatment options and treatment planning. It can also improve outcomes and tolerance of the process and of any adverse affects, because they understand why it may occur, this should enhance the probability of a successful treatment outcome. Disk profiling is a behaviour assessment tool that was developed by William Moulton-Marston. He proposed that various behavioural types originate from people’s sense of self and how they interact with their environment. Should all personality types undertake aesthetic procedures? There are several predictors of poor outcome. Early identification of
20 PRACTICE I body language
such predictors is crucial for patient protection. Treatment should never be undertaken that isn’t in the best interests of the patient. Predictors of poor outcome include: • Unrealistic expectations • Personality or psychological disorders • History of previous procedures with which the patient has been dissatisfied • Motivation for treatment based on external factors such as relationship issues • Minimal deformity Young and male patients are also slightly less likely to be satisfied with treatment outcome. Psychological disorders One of the most common psychological conditions with which patients may present is that of depression. Patients may seek aesthetic treatment in an effort to try and improve their feeling about themselves. Stressful life events may be a trigger and can result in constriction of thought processes and increased spontaneous behaviour. Despite wanting to have aesthetic treatments, sometimes patients won’t be optimistic about the outcome. They may anxiously repeat questions and demand guarantees of outcome. For this reason, if the patient isn’t being successfully treated for their depression, it may be advisable not to undertake treatment at that time. Following successful treatment however, pro-
vided expectations of outcome are realistic there is good evidence to predict a successful outcome of aesthetic treatment. One of the most significant psychological or psychiatric illnesses to be aware of in the field of aesthetics is that of Body Dysmorphic Disorder. This is a psychiatric illness concerned with the preoccupation about an imagined, or slight defect. If a slight defect is present, the degree of concern about it is disproportionate. It can be associated with significant distress and impairment in all areas of functioning, whether it is work, social or relationship issues. Sufferers will often engage in time-consuming camouflaging or mirror-seeking behaviours. With this in mind it can be useful to ask patients how long they spend each day thinking about or assessing their particular area of concern. The percentage of people in the general population with body dysmorphic disorder is indeed fairly low; however in patients presenting for aesthetic procedures it is estimated that between 14% and 17% will have a degree of body dysmorphic disorder. Comprehensive patient assessment is therefore crucial to identify markers of such disorders and ensure treatment that may not be in the best interests of the patient is not undertaken.
their motivations are appropriate. Internal motivations might include long-standing feelings about deficiencies in physical appearance that are rational and proportionate. The patient is likely to be generally satisfied with their quality of life and will have adopted a considered approach to the process. Such motivations would be good prognostic indicators of a satisfactory treatment outcome combined with realistic expectations. External motivations Such motivations may include a need to please others or the belief that the procedure or change in appearance will solve many problems, such as marriage, personal or professional relationships. The patient may feel pressurised to undertake procedures, sometimes appearing passive about the procedure. Patients should always be active in the decision-making process and not be influenced by others. Such external motivations may be poor prognostic indicators. Positive diagnostic indicators may therefore include the presence of actual disfigurement, wanting to improve appearance for occupational reasons where this is reasonable, or an emotionally stable patient who simply wants to look younger, has reasonable expectations of treatment outcome and an awareness and understanding of the limitations of treatment. A history of satisfaction with previous
Patients do not need to have aesthetic treatment for their health, so evaluating each patient’s psychological condition from the first contact really is essential
12 Internal motivations It is essential to assess patient’s motivations for treatment and whether
Four varying personality types and their optimal management strategies were identified
1. A patient with a predominantly Directing (D) style personality might be: Often a businessman / woman Permanently attached to the android, e-mailing or on a business call as they arrive Often in a hurry, short, sharp sentences and straight to the point communication style Determined, decisive and confident individuals, often business leaders Looking for you to provide to the point, relevant information based on results Needing to feel in control of the situation throughout Frustrated by too much small talk Key Traits: Determined, decisive, confident, practical Management Keys: Get to the bottom line. Express admiration for them, let them think they’re in charge.
2. A patient with a predominantly Influencing (I) style personality might be: Well turned out Outgoing and friendly individual who loves to talk Looking to you to listen to them enthusiastically and patiently, letting them be in the spotlight Requiring your undivided attention and reassurance of such Looking to buy not only results but also emotion so when describing options focus less on fine detail and more on how the results might make them feel Key Traits: Aesthetically aware, optimistic, confident, loves to talk, friendly and emotional Management Keys: Be their friend, get to know them, listen enthusiastically to them and let them be in the spotlight. They’ll require your undivided attention and will need reassurance of such. Let them talk to other staff and ask them about their treatment experiences. They are not only looking to buy into results but also emotions and how results might make them feel.
body language I PRACTICE 21
66 Continuously reinforce and clarify aims and don’t shy away from discussion of risks. Allow time for informed consent 99 aesthetic procedures is also a good indicator. Negative diagnostic indicators may include a history of psychiatric illness, a history of multiple aesthetic procedures and dissatisfaction with their outcome. A history of “doctor shopping” is a big signifier of body dysmorphic tendencies, as is minimal deformity with disproportionate concern and excessive time spent worrying about the perceived defect. Also, the belief that treatment will be the solution to all their problems and sometimes a whimsical or unconsidered approach. Of course, unrealistic expectations of outcome and inability to accept limitations of treatment would be potential indicators of dissatisfaction with treatment outcome. The patient assessment process Systematic patient assessment and spending time with the patient to build trust and encourage a flow of information is crucial. Consider the patient as a whole and gather
as much information about them as possible. Encourage elaboration and allow the patient to articulate in as much detail as possible their specific concern(s). Identify background influences and initially, focus on building rapport, listening to the patient and gathering information. Sound interested, empathetic, yet positive and employ open body language, good eye contact and a reassuring smile. Repeat back key facts to the patients intermittently to reassure them that you have listened to their concerns. The aim is to gauge expectations and reactions. Use open questions such as ‘what has prompted you to undertake treatment at this time?’ and ‘what do you hope to achieve from treatment?’ If there is a concern that the patient may have a psychiatric problem then it is the duty of the clinician to identify this and refer appropriately. After the initial rapport has been built, move on to education and demonstration. Encourage self-diagnosis, talking through with the patient in the mirror how particular areas of concern have formed and how best to treat that area of concern in the most natural way possible. Introduce limitations of treatment from the outset and manage expectations, tailoring this presentation to the individual’s personality. A directing style personality for example will need to know what the problem is, why
it’s there, what you’re going to do to fix it and whether it’s going to work. An I-style personality might want you to go through those factors, but with more of an emotional message. Having educated the patient regarding their area of concern, it’s time to outline treatment options. Continuously reinforce and clarify aims and don’t shy away from discussion of risks. Allow time for informed consent and move at each patient’s own pace, don’t rush or push. The final two stages are of course treatment provision and follow-up/review and maintenance. But, patient assessment continues throughout the patient journey. Each step must be tailored to suit each individual and their best interests respected throughout. Summary There are common features with which the aesthetic patient may present, but it is essential to respect their individuality, to assess their perception of what is aesthetic, and to understand their personality and psychological features. We can incorporate assessment of personality and psychological status into our clinical protocols and by integrating these tools into our clinical practice we can strive improve the patient journey, treatment uptake and most importantly maximise the probability of a successful treatment outcome.
34
3. A patient with a predominantly Steady (S) style personality might be: Relaxed, quieter than the I style yet still people focused Considering investigating treatment options for a while and will have approached the situation in a planned manner Looking to you to listen to their concerns and subsequently want to hear your opinions and solutions in a systematic manner, whilst not losing the emotional component Wanting to hear that results will be predictable and risks minimised Easy-going, cooperative individuals, let them respond at their own pace Vulnerable to having ideas imposed hence don’t push too hard, a gentle, friendly approach is required Key Traits: Easygoing, supportive, agreeable, calm, responds to people, likes to feel secure, appreciates a well-structured approach Management Keys: Listen to concerns, offer options and solutions in a systematic manner, don’t loose the emotional component of the description. Place emphasis on risk management and predictability of results. Let them respond at their own pace. Show empathy and concern.
4. A patient with a predominantly Cautious (C) style personality might be: A more reserved individual Precise in their manner Educated as to their options often having researched their options before attending Frustrated by too much small talk and instead will respect facts presented in an orderly, factual manner Unnerved by sudden changes in facts, options or plans, accuracy and consistency is key In need of time to consider the information in more detail prior to coming to a decision Key Traits: Analytical, cautious, diplomatic, serious, restrained Management Keys: Will feel secure by doing things right. No sudden changes to details, accuracy. Consistency is key, slow down approach, deal with facts, pro’s, con’s and why, expect doubt and questions, don’t rush, push or criticise. D and I styles are more extroverted and more likely to make decisions faster, in contrast to the more reserved or more introverted S and D styles.
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body language I SKINCARE 23
Damage limitation CHIZA WESTCARR looks at managing post-inflammatory hyperpigmentation risks in ethnic skin
U
S minorities now represent more than half of America’s population under the age of one. The US population has become more ethnically diverse with greater than 35% of the population classified as non-white in 2010. In 2050 white Americans will comprise 46.3% of the population, a historic demographic milestone with profound political economic and social implications. Alongside this there is also an
increased mixing of the races, so when addressing post-inflammatory pigmentation as a result of acne or trauma, we are increasingly observing patients of varying hues and colours and of a much more diverse ethnic mix seeking solutions to their skin concerns. Racial mixing presents some interesting dermatological implications, and along with higher Fitzpatrick phototypes, must be treated with added caution. Determing a patient’s heritage
FITZPATRICK CLASSIFICATION OF SUN REACTIVE SKIN TYPES Skin type
Colour
Reaction to first sun exposure
I
White
Always burns, never tans
II
White
Usually burns, tans with difficulty
III
White
Sometimes mild burn, tan average
IV
Moderate brown
Rarely burns, tans with ease
V
Dark brown
Very rarely burns, tans very easily
VI
Black
Burning extremely rare, tans very easily
or racial background at face value is becoming a little more challenging, because with racial mixing, it is quite feasible to have a very fairskinned patient present with blue eyes, but—due to their mixed heritage—have existing pigmentation concerns, or run an increased risk of post-inflammatory hyperpigmentation due to physician treatment selection. This is something that we need to make sure that we are aware of at the initial consultation and manage accordingly with prophylactic tyrosinase inhibitors for a two week minimum prior to the commencement of an in-clinic treatment strategy. So what exactly do we mean by ethnic skin or skin of colour? It includes people of African descent, Asian, Indigenous Australian, people from the Sub-Continent, Pacific Islander, people of Middle
24 SKINCARE I body language
Eastern and also Mediterranean descent. In this category we also include people of mixed heritage. These patients, outside of the typical concerns that most patients have—ageing, dryness, dehydration, blackheads, oily congested skin, dull lifeless skin, skin sensitivity—also experience melasma and post-inflammatory pigmentation as very real concerns. Hyperpigmentation Hyperpigmentation refers to a localised or more widespread increase of melanin in the skin caused by overactive melanocytes. In a dark skinned individual this creates a distinct darker colour than normal in the epidermis, and a greyish or blue colouration that is less defined in the dermis. It must be noted that in darker skins melanocytes are extremely active and sensitive to injury, whether it be sun induced or as a result of trauma.
DR GARRY CUSSELL
Melasma Melasma occurs in a butterfly formation, usually bi-laterally on both sides of the face, typically affecting the forehead, malar region, upper lip, with macules or larger pigment patches featuring more prominently in the higher Fitzpatrick phototype than in fairer skinned patients. There tends to be a genetic predisposition, and hormonal influences such as pregnancy, oral contraceptive pill and HRT are implicated. However, exposure to fragranced products such as perfumes, deodorants and fragranced soaps can also be possible causes. A link to hypothyroidism has also been established. Without sun protection, melasma is almost impossible to manage, so sun protection is encouraged.
PIH PIH or post-inflammatory hyperpigmentation which occurs after an inflammatory eruption or cutaneous injury, is due to a melanocytic response to trauma causing increased production of melanin and distribution into the keratinocyte, where it settles over the nucleus like a cap. Higher Fitzpatrick phototypes are more predisposed to PIH than lower Fitzpatrick phototypes, and for this reason skins must be well prepped, incorporating a tyrosinae inhibitor prior to in-clinic procedures. In a skin of colour, the causes of PIH are numerous – scratches, cuts, skin infections, allergic reactions, mechanical trauma, to name
a few. Even hair growth, reactions to medication or inflammatory disorders such as eczema and psoriasis can result in PIH. Sometimes the very tools used to treat hyperpigmentation can actually exacerbate the condition. Incorrect laser and IPL settings, aggressive microdermabrasion, aggressive chemical peeling, can all result in PIH. Hydroquinone Physicians must appreciate that treatment protocols for a higher Fitzpatrick phototype must be different than that for a Fitzpatrick I to III, because of the increased risk of PIH as a result of too aggressive a treatment. Hydroquinone has long been
Left and right: non-hydroquinone home care programme, before and twelve weeks after treatment
body language I SKINCARE 25
of such ingredients appear below and while it is by no means an exhaustive list, it provides a bit of an idea of the types of ingredients that are now being incorporated into clinical preparations available to medical practitioners and found to be successful in the management of hyperpigmentation.
A programme which involves sunscreen is vital for successful management
the gold standard treatment strategy for the management of hyperpigmentation. In prescription strength it is available at 4 to 6%, but it can also be obtained without a prescription in a 2% strength and typically it is not recommended to be used beyond three months due to tachyphylaxis and possible complications associated with long term use. In higher Fitzpatrick phototypes complications such as such as contact dermatitis, confetti like de-pigmentation and exogenous ochronosis have been observed
ALTERNATIVES TO HYDOQUINONE Arbutin
N-acetyl glucosamine
Azelaic acid
Hexyl resorcinol
Bilberry extract
Alpha linolenic acid
Kojic acid
Linoleic acid
Licorice extract
Soy
Bearberry
Aloesin
Coffee berry
Mequinol
Vitamin C
Rucinol
Mulberry
Ellagic acid
Niacinamide
Resveratrol
Rumex occidentalis
Dioic acid
Phytic acid
Tranexamic acid
with both short and long-term use. Where hydroquinone has been prescribed, during the aforementioned break, non-hydroquinone based products that contain tyrosinase inhibitors as well as melanin-transfer inhibitors are advised. In the EU, throughout Asia and South Africa Hydroquinone has been banned in cosmetic over-the counter preparations because of the increased risk of exogenous ochronosis. It is however available by prescription in higher strengths, and in higher Fitzpatrick phototypes requires careful administration due to the aforementioned risks. There is growing consumer-led demand for products that are suitable alternatives to hydroquinone due to patient concern about Hydroquinone-associated rebound pigmentation and long-term risks. This has resulted in cosmeceutical formulatioins becoming more technologically advanced and more effective at managing the condition. Such preparations are ideal because they can be used long-term with no rebound pigmentation association and do not have the irritant profile that Hydroquinone has. Examples
Preparation Hyperpigmentation is an ongoing challenge and while there is no cure, it can certainly be effectively managed. Patients must be adequately counselled so they understand that patience is important in order to successfully manage their concern and the physicianâ&#x20AC;&#x2122;s initial consultation is of utmost importance. Often the darker the Fitzpatrick phototype the more impatient the patient, because of the contrast in colour between the pigmented lesions and their skin. Aggressive treatment strategies can lead to a higher risk of complications, or a worsening of the condition, so itâ&#x20AC;&#x2122;s impoprtant that patients understand it can take up to six to 12 months for resolution to occur. Ingredients When analysing the process of melanogenesis, ingredients that target specific pathways can assist in the successful management of the condition. The importance of preparing the skin before in-clinic treatment cannot be over-estimated. Ingredients such as antioxidants, pigment inhibiting agents, retinoids, alpha hydroxy acids and anti-inflammatory ingredients along with sunscreen are a must. Vitamin C, anti-inflammatories, and an effective sunscreen during the day all help prevent the initial inflammatory cascade in the keratinocyte which will assist in regulating the amount of tyrosinase enzyme up-regulated in the nucleus of the melanocyte in response to the inflammatory signalling. Retinoids also assist in the down- regulation of tyrosinase in the nucleus. The incorporation of tyrosinase inhibitors inhibit the interaction between tyrosinase and tyrosine in the melanosomes and thereby inhibit pigment
26 SKINCARE I body language
In clinic treatment With regards to in-clinic treatments, lower Fitzpatrick phototypes do not require prior prepping on a pigment inhibiting agent. Pigment inhibition, however, is always recommended for Fitzpatrick IIIVI to ensure that all post-inflammatory hyperpigmentation risks are minimised as a result of treatment. Establishing how the patient typically heals in response to trauma comes in handy‚does initial inflammation as a result of tissue injury eventually fade to a white scar or does it result in hyperpigmentation? Everyone, including patients who appear very fair skinned or those who do not appear to be a likely candidate for PIH, will know how their skin heals due to trauma. This is an indication of whether or not tyrosinase inhibition is required prior to in-clinic treatment. The Wood’s lamp is a very effective tool to determine where pigment is located in the skin— whether it is epidermal or dermal. This lamp is extremely effective in assessing pigment distribution in lower Fitzpatrick phototypes, up
DR JOSEPH HKEIK
Sun protection In the darker or higher Fitzpatrick phototypes, getting patients onto a committed programme that involves sunscreen can be challenging, but without sunscreen successful management and in-clinic treatments are doomed to failure. The good news is that there is a growing number of elegant sunscreen formulations on the market that do not leave a chalky or white residue on a darker skin. Suitable products include micronised physical preparations that contain zinc and titanium oxide and chemical sunscreens that are fragrance free. No longer do they need to be heavy and occlusive, but ideally should be a 30 SPF minimum. Mineral make-up is another option or adjunct to using a sunscreen.
DR MARTIN KASSIR
production. Niacinamide is very effective in aiding the prevention of pigment transfer into the keratinocyte while retinoids and hydroxy acids assist with exfoliation of pigmented keratinocytes.
to Fitzpatrick IV, but in higher Fitzpatrick phototypes, it is not possible to determine pigment depth. Epidermal pigment is the easiest kind of pigmentation to address and topical agents such as hydroxy acids and retinoids encourage exfoliation. Treatment approach To successfully address hyperpigmentation, a multi-modal approach is always better than utilising one particular treatment strategy. Examples of different in-clinic options to consider are microdermabrasion, skin needling, chemical peeling agents and specific laser therapies. In conjunction with specific lasers, a series of epidermal chemical peels that include ingredients such as lactic acid, salicylic acid, retinoic acid as well as pigment targeting ingredients are successfully used to desquamate hyperpigmented epidermal cells and target hyperactive melanocytes. These options are less aggressive than traditional high acid-strength peels typically performed on lower Fitzpatrick skin types and have a reduced risk of post-inflammatory hyperpigmentation in higher Fitzpatrick photo-
types when the skin is adequately prepped before hand. A milder, less inflammatory approach, beginning with a series of low strength acid peels is recommended. Depending on the choice of agent used to manage hyperpigmentation, the use of anti-inflammatories as part of prescribed aftercare is also important to manage post-inflammatory pigmentation risks. Re-introducing a pigment management agent at this stage is also possible depending on the formulation, along with effective sun protection. Regardless of skin colour, everyone wants to have the best skin that they can have. A skin that is healthy, a skin that has a strong barrier function, a skin that is fully functional and well hydrated. A skin that is the best that it can be. Understanding the nuances of diagnosis and treatment of skin of colour populations will help ensure that all patients receive optimal care. Chiza Westcarr is the Global Clinical Education and Development Manager for Advanced Skin Technology, a Division of Device Technologies in Australia.
Top: before and after skin needling with kojic acid infusion. Bottom: Before and after a multi-modal approach using home care, medical needling and laser therapy
FACE 2015 Booth 67
Saturday, June 6th, 2015 11:30 - 13:00 Speaker: Dr Raminder Saluja Sunday, June 7th, 2015 9:55 - 10:20
28 FACE 2015 I body language
Held at the QEII Centre in Londonâ&#x20AC;&#x2122;s Westminster on June 4th -7th, FACE 2015 will host a world-renowned speaker panel, delivering a complete educational programme FACE 2015 will be one of the largest conferences in the world dedicated to facial aesthetics and will continue to dominate the high end UK market of medical aesthetics. In addition to the regular SKIN, Business, and now HAIR seminars at FACE, the BODY Conference will also be coming to FACE 2015 creating a complete highend educational aesthetic conference. We are also incorporating an Advanced Training course on Thursday 4th June which
will be directed by Dr Ali Piyaresh. The FACE 2015 weekend will be of a similar format to previous years for delegates and exhibitors with lectures across different agendas taking place throughout the day, along with exhibitor workshops and seminars. FACE 2015 will follow on from previous years by having a low-cost entry ticket allowing access to the exhibition area and exhibitor workshops which has proved very popular and successful
in encouraging new delegates/entrants into the market alongside a wider range of clinic personnel who may not normally attend the traditional scientific congress. With the marketing power of EuroMediCom and our 12 year heritage as a premier educational and scientific forum, this conference is on course to be the biggest and the best the UK has ever seen. A full list of confirmed speakers is available at faceconference.comâ&#x20AC;&#x201D;highlights below.
Dr Raj Aquilla Cosmetic Physician, United Kingdom One of the most skilled, experienced and trusted Cosmetic Physicians in the North West, member of the BACD.
Dr Syed Haq Consultant Physician, United Kingdom Dr Haq is the Founder of The London Preventative Medicine Centre and Clinical and Scientific Director of Daval International Ltd.
Prof Mukta Sachdev Professor of Dermatology, India Prof Sachdev runs a private cosmetic practice and a clinical trial unit specialising in dermatology trials in skin of colour.
Dr Charlene DeHaven Clinical Director of iS CLINCAL, United States Dr DeHaven is a board-certified physician, with an emphasis on age management and health maintenance.
Mr Chris Inglefield Consultant Plastic & Reconstructive Surgeon, UK Mr Inglefield has spent over a decade developing his private practice at London Bridge Plastic Surgery.
Dr Carl Thornfeldt Clinical Dermatologist, United States Dr Thornfeldt has 30 years of skin research experience and multiple scientific publications in the treatment of skin conditions.
Dr Diane Duncan Plastic Surgeon, United States Dr Duncan runs an aesthetic practice, travels and teaches internationally in the field of minimally invasive aesthetics.
Dr Michael Kane Consultant Plastic Surgeon, United States Dr Kane has been a consultant plastic surgeon in private practice since 1992 and is based in New York City.
Dr Ines Verner Specialist Dermatologist, United Kingdom Internationally renowned specialist dermatologist working for over 15 years in aesthetic and cosmetic dermatology.
Dr Rachael Eckel Cosmetic Dermatologist, Trinidad and Tobago Dr Eckel has trained under Dr Zein Obagi, and has perfected pioneering aesthetic techniques worldwide.
Dr Frank Rosengaus Facial Plastic Surgeon, Mexico Recognised as a world renowned leader in cosmetic and aesthetic plastic surgery, with over 20 years experience.
Dr Greg Williams Plastic Surgeon, United Kingdom Dr Williams specialises in hair restoration and is the only BAAPS member performing hair transplants full time.
Dr Bessam Farjo Hair Transplant Surgeon, Iraq/United Kingdom Dr Farjo is a leading hair transplant surgeon and coFounding Director of the Farjo Hair Institute.
Dr Christopher Rowland Payne Consultant Dermatologist, United Kingdom Active in all areas of clinical dermatology, notably surgical dermatology, treatment of skin cancer and melanoma.
Dr Stephanie Williams Dermatologist, United Kingdom Dr Williams has extensive clinical experience and a special interest in cutting edge skin research.
body language I FACE 2015 29
Pre-conference advanced masterclass FACE 2015 will be hosting an advanced masterclass with Dr Ali Pirayesh as the Scientific Director on ‘Essential anatomy and techniques for aesthetic procedures’
F
Objectives This is a Masterclass catering for advanced physicians. The course content is established with the following objectives in order that the practitioner will be able to: Keep abreast of recent non-invasive rejuvenation strategies and related products and technologies Learn practical and clinical essentials of each treatment strategy Holistically understand the “Full face” approaches with patient-centered care Integrate and apply the learned information into their practice with confidence Improve and excel their clinical performance on (advanced) aesthetic and rejuvenation procedures Live stream to Singapore With CFA Singapore 2015 — Clinical Facial Aesthetics Singapore, taking place on the same day, for the first time ever FACE 2015 will be streaming live coverage of the Pre-Conference Advanced Training Masterclass all the way to our delegates and friends in Singapore.
09:30 I 11:30 SESSION 1: UPPER FACE Emerging trends in Non-Surgical Facial rejuvenation from Beverly Hills to China Anatomy: Forehead and temples Toxins on upper face: Tips and tricks for advanced natural results Temple injections and lateral brow Energy-based devices for facial rejuvenation overview LIVE DEMO 1 11:45 I 14:00 SESSION 2: MIDFACE Anatomy: tear trough, cheeks and nose HA technology and characteristics Tear trough: choice of filler and techniques Zygoma and cheeks: choice of filler and technique Nose: choice of filler and techniques Filler complications and conservative management Treatment of major filler complications LIVE DEMO 2: EMPHASIS ON MIDFACE 15:00 I 17:30 SESSION 3: LOWER FACE & NECK REJUVENATION Anatomy: Lips and perioral region, mandible ,chin and platysma Non HA fillers and threads Lips and perioral region: choice of filler and technique Jawline, chin, neck and décolletage rejuvenation with fillers and toxins Energy based devices and combination therapy for lower face and neck The role of PRP, cosmeceuticals and peelings in your practice LIVE DEMO 3: EMPHASIS ON LOWER FACE Q&A
PROVISIONAL AGENDA
or the first time in FACE history, we will be running a Pre-Conference Advanced Training Masterclass on Thursday 4th June. Aimed at medical aesthetic practitioners across all levels of expertise, the course will be created with a view to keep the delegate in tune with non-invasive strategies and understand the key anatomy of the full face. Internationally renowned experts will share their “daily practice pearls” and tips and tricks on the most pertinent aesthetic medicine core and advanced topics. The SAFE and effective use of toxins, dermal fillers and energy-based devices will be covered with emphasis on essential anatomy and techniques. Clinically orientated presentations highly focused on practical aspects will include cadaveric anatomy videos, videos on “How I do it”, choice of products or devices and how to avoid and manage complications. By the end of the course, the delegate will be able to integrate and apply this information into their practice with confidence whilst improving and excelling in their clinical performance on aesthetic and rejuvenation procedures.
30 FACE 2015 I body language
Injectable agenda The core of FACE Conference, this agenda brings you up to date with the latest treatments and techniques using toxins, fillers, PRP, mesotherapy and fat transfer INJECTABLES Friday through Sunday will host national and international lecturers to help delegates maximise results and minimise problems when using cosmetic injectables for total facial contouring. Different techniques, new treatment approaches and concepts will be explored alongside practical demonstrations. GROUND FLOOR, CHURCHILL AUDITORIUM, Friday/Saturday/Sunday
FRIDAY
SATURDAY
SUNDAY
09:30 I 10:00 Preparing the skin for injectables, Dr Beth Briden
09:30 I 10:00 Lip augmentation techniques, Dr Ines Verner
09:30 I 10:00 Facial contouring with botulinum toxin, Prof Bob Khanna
10:00 I 11:00 Tissue stimulators; indications, evidence and techniques
10:00 I 11:00 Bio-dermal restoration with a new and advanced collagen—initial clinical results, Dr Chris Inglefield
10:00 I 11:00 The patient journey: tipping point from consumer to patient
11:00 I 11:30 REFRESHMENTS AND EXHIBITION 11:30 I 12:00 The advantages of introducing controlled trauma when injecting dermal fillers 12:00 I 12:30 Panel discussion—injection techniques, Dr Uliana Gout and Leslie Fletcher 12:30 I 13:00 The 15 minute nose job, Mr Ash Labib
11:30 I 12:00 Hyaluronic acid fillers—is there a real difference between the brands?
11:30 I 12:00 The happy face treatment—marionette lines and oral commissures, Dr Frank Rosengaus
12:00 I 13:00 Facial contouring workshop—practical techniques and approaches
12:00 I 13:00 Dealing with complications of injectables
13:00 I 14:30 LUNCH AND EXHIBITION 14:30 I 14:55 Vaginal rejuvenation debate—lasers, injectables and PDO threads
14:30 I 14:50 The ageing hand and the role of dermal fillers, Dr Uliana Gout 14:50 I 15:10 Dermal fillers for the feet, Dr Mark Hamilton
14:30 I 15:30 Advanced facial injectable techniques workshop
15:10 I 15:30 The treatment of the decolletage with cosmetic injectables
PROVISIONAL AGENDA
15:30 I 15:50 Casting light on “down under”, Dr Kathryn Taylor Barnes 15:50 I 16:00 Q&A
15:20 I 15:45 Focused cold therapy for dynamic wrinkes— the latest data, Dr Daniel Cassuto 15:30 I 16:00 New toxins, new data, Dr Michael Kane
16:00 I 16:30 REFRESHMENTS AND EXHIBITION 16:30 I 18:00 The science behind injectable fat reduction, PRP and mesotherapy, Dr Christopher Rowland Payne
14:55 I 15:20 Sweat reduction using microwave technology
16:30 I 18:00 Treating women across the ages 20s, 40s and 60+, Dr Raj Aquilla and Dr Frank Rosengaus
15:45 I 16:10 Injectable fat reduction
16:10 I 16:30 Fat vs fillers
16:30 I 17:00 Exhibition and Close
body language I FACE 2015 31
Body agenda For the first time, FACE will host the BODY Conference with a full agenda featuring non-surgical treatments targeting all indications within this evolving sector BODY As the BODY aesthetics market continues to grow with an ever increasing range of non-surgical solutions and indications, we will incorporate lectures on a wide range of treatment options into the traditional Equipment agenda sessions. The market is evolving with many platform systems having indications for both body and facial aesthetic treatments—and the BODY agenda will explore the latest concepts, practical tips and business models currently available. 4TH FLOOR, WESTMINSTER SUITE, Friday/Saturday/Sunday FRIDAY
SATURDAY
SUNDAY
09:30 I 09:50 Clinical standards and education in body sculpting, Dr Alexandra Chambers
09:30 I 09:55 Newer technologies for laser hair removal, Prof Mukta Sachdev
09:30 I 09:50 What we can do with newer technologies such as Hydrafacial, Geneo, Affinity and Delivery devices, Prof Mukta Sachdev
09:50 I 10:10 A closer look at cellulite and treatments to reduce its different grades
09:55 I 10:20 Advances in diode hair laser technology—is it really possible to effectively treat a back in four minutes? Lisa Mason
09:50 I 10:10 Tattoo removal—the latest technology
10:10 I 10:30 Weight management—what are the most effective services to offer? 10:30 I 10:50 Body contouring—supplements, devices and wellness; the legal aspects
10:20 I 10:45 Paradoxical hair growth—the evolution of the hair removal market and its impact on the professional marketplace, Godfrey Town
10:10 I 10:30 The classic red face—how to treat all skin types using new combination protocols, Dr Maria Gonzalez 10:30 I 10:50 Dermabrasion with plasma for soft blepheroplasty, Dr Lebbar Noura 10:50 I 11:00 Q&A
10:50 I 11:00 Q&A
10:45 I 11:00 Q&A
11:30 I 11:50 The future of non-invasive fat reduction using multipolar non-contact radiofrequency
11:30 I 11:55 Resurfacing in 2015—where do we stand? Dr Ines Verner
11:30 I 11:55 Internal anti-ageing—the market for supplements
11:50 I 12:10 Cryolipolysis—the latest clinical data
11:55 I 12:20 The benefit of internal and external temperature control in bipolar radiofrequency, Dr Diane Duncan
11:55 I 12:20 Anti-ageing—hormones and IV vitamins: science vs hype, Dr Syed Haq
12:10 I 12:30 Pyroptosis of fat using radiofrequency, vacuum and electrical impulse, Dr Diane Duncan
12:20 I 12:45 Pore refining with fractional diode laser
12:20 I 12:45 Telomere testing, Dr Mark Bonar
12:30 I 13:00 Q&A
12:45 I 13:00 Q&A
12:45 I 13:00 Anti-ageing debate—what is the market for internal anti-ageing treatments?
11:00 I 11:30 REFRESHMENTS AND EXHIBITION
13:00 I 14:30 LUNCH AND EXHIBITION 14:30 I 14:50 Advanced collagen remodelling and skin tightening using combined monopolar radiofrequency and HIFU ultrasound technology
14:30 I 14:50 Novel mixed technology—CO2 and non-ablative fractional resurfacing laser
14:50 I 15:10 Ultrasound for skin rejuvenation and tightening
14:50 I 15:10 The new darker skin tool, Prof Mukta Sachev
15:10 I 15:30 TBC
15:10 I 15:30 Radiofrequency and micro-needling, plus novel post-procedure care for anti-ageing, Dr Carl Thornfeldt
15:30 I 15:50 The treatment of striae utilising the power of fractionated bipolar radiofrequency, Dr Ines Verner
15:30 I 15:50 Combining fillers with energy based devices, Dr Ines Verner
15:50 I 16:00 Q&A
15:50 I 16:00 Q&A
PROVISIONAL AGENDA
16:00 I 16:30 REFRESHMENTS AND EXHIBITION 16:30 I 16:50 Minimally invasive methods for vulva-vaginal rejuvenation—the latest approaches and techniques, Dr Evgenii Leshunov
16:30 I 16:55 Novel permanent microwave treatment for axillary hyperhidrosis
16:50 I 17:10 Non-invasive labia remodelling—live demonstration
16:55 I 17:20 Leg veins—where does aesthetics end and medicine begin? Prof Mark Whiteley
17:10 I 17:30 Carboxytherapy for vaginal rejuvenation 17:30 I 17:50 Threads for vaginal rejuvenation 17:50 I 18:00 Q&A
17:20 I 18:00 Treatment of fungal infections with lasers and light
32 FACE 2015 I body language
Skin agenda Skincare is at the centre of the medical aesthetic industry—topical products and combined approaches to treatment are explored in depth SKIN With many different competing skincare lines, it can be confusing to establish which brands to choose. FACE provides a forum for practitioners to meet the true experts who understand ingredients, formulations and the arguments behind competing concepts and brands. This three day forum will focus on new topical approaches to preventing and treating signs and symptoms of ageing skin alongside the latest specific approaches to treating acne, rosacea and hyperpigmentation. 4TH FLOOR, ST JAMES’S SUITE, Friday/Saturday/Sunday FRIDAY
SATURDAY
SUNDAY
09:30 I 09:55 Ageing mechanisms: The four major causes of ageing, Dr Charlene DeHaven
09:30 I 10:00 The art of camouflage make up, Jane Maier
09:30 I 09:50 Photodynamic therapy in aesthetic dermatology is also providing effective treatment for non-melanoma skin cancers or their precursors, Dr Daniel Sister
09:55 I 10:20 Nutrition and skin ageing, Dr Stephanie Williams
10:00 I 10:25 Post-treatment camouflage make up approaches
09:50 I 10:10 Combined approaches to dermatological skin conditions in aesthetic practice, Dr Stephanie Williams
10:20 I 10:45 A practiacl guide to skin fitness through skincare, Dr Sandeep Cliff and Mr Paul Banwell
10:25 I 10:50 Prof Mark Birch-Machin
10:10 I 10:30 Dry skin—causes and treatment, Dr Charlene DeHaven
10:45 I 11:00 Panel debate: Should we be advising patients to buy nutritional supplements as well as topical skincare?
10:50 I 11:00 Q&A
10:30 I 10:50 Evidence based cosmeceutical herbs for skin conditions, Dr Carl Thornfeldt 10:50 I 11:00 Q&A
11:00 I 11:30 REFRESHMENTS AND EXHIBITION 11:30 I 11:50 Newer cosmeceuticals for lightening—what can we use and where? Prof Mukta Sachdev
11:30 I 11:50 The fountain of youth, Dr Beth Briden
11:50 I 12:10 Combined IPL and peel treatment for refractory acne, Dr Carl Thornfeldt
11:50 I 12:10 Safer, more effective therapy for hyperpigmentation, Dr Carl Thornfeldt 12:10 I 12:30 Tranexamic acid vs topical meso lightening mixture using medical skin needling in the treatment of melasma, Dr Raina Alsaied
11:50 I 13:00 Panel debate: Top tips on practical approaches to retailing and marketing skincare in your clinic
12:10 I 12:30 The latest topical approaches to the treatment of acne, Dr Rachael Eckel
12:30 I 12:50 Transdermal delivery of cosmeceuticals—a new technique
12:30 I 12:50 Microbiome and acne
12:50 I 13:00 Q&A
12:50 I 13:00 Q&A 13:00 I 14:30 LUNCH AND EXHIBITION 14:30 I 14:50 Formulation regulations for cosmeceuticals, Dr Curross Bakhtiar
14:30 I 16:00 Panel debate: Skincare ingredients—which are the most effective for treating ageing skin and why
14:50 I 15:10 Delivery systems and new innovative ingredients, Dr Marc Ronert 15:10 I 16:00 Panel debate: Topical approaches to the treatment of hyperpigmentation and melasma
16:00 I 16:30 REFRESHMENTS AND EXHIBITION PROVISIONAL AGENDA
11:30 I 11:50 Hormonal approach to acne treatment, Dr Terry Loong
16:30 I 17:00 Panel debate: Future topical and nutritional supplements for skin ageing—what is on the horizon?
16:30 I 16:50 An explaination of stem cell science and its application in skincare, Dr Charlene DeHaven 16:50 I 18:00 Panel discussion: Topical stem cells and growth factors and their use in aesthetics
body language I FACE 2015 33
Business agenda Marketing your practice is vital to secure success in a competitive industry. Our expert panel will guide you through, from social media to website development and PR BUSINESS In an increasingly competitive market everyone needs to raise their game and FACE provides a unique two day forum for clinic owners, managers and marketeers to explore a wide range of topics related to the art of marketing. Professional speakers including specialist marketeers, web designers, and social media gurus will give you the latest information on techniques that work specifically in the aesthetic market. 4TH FLOOR, HENRY MOORE ROOM Friday/Saturday FRIDAY
SATURDAY
09:30 I 10:00 Non-surgical vs surgical aesthetics—industry analysis of growth and trends, Constance Campion
09:30 I 10:00 Unlocking the power of cosmeceuticals—seven steps to doubling your clinic revenue and improving patient care, Alana Marie Chalmers
10:00 I 11:00 Marketing masterclass
10:00 I 11:00 Promises: delivering, measuring and keeping what it is your clients lust after most of all, Tony Gedge 11:00 I 11:30 REFRESHMENTS AND EXHIBITION
11:30 I 11:50 Business brand development, Gary Conroy
11:30 I 13:00 Aesthetic clinic marketing in the digital age, Wendy Lewis
11:50 I 13:00 Six expert web and Google tips to attract more clients, Adam Hampson 13:00 I 14:30 LUNCH AND EXHIBITION 14:30 I 15:00 The value of a consistent consultation framework and evidence based approach to patient assesment for aesthetic procedures, Anouska Cassano
14:30 I 14:50 Acne and rosacea: charity accredited clinic leads to major increase in aesthetic clientele for minimal cost, Prof Tony Chu
15:00 I 15:20 The anatomy of a claim, Eddie Hooker
14:50 I 15:10 Sweat smart centres—new niche marketing concept for the treatment of sweat 15:10 I 15:30 TBC
15:20 I 16:00 Social media workshop
15:30 I 16:00 Debate: New business models and how to evaluate them 16:00 I 16:30 REFRESHMENTS AND EXHIBITION
PROVISIONAL AGENDA
16:30 I 17:20 Use of PR and media in aesthetics, Wendy Lewis 17:20 I 17:40 Getting the most from a clinic CRM system to develop business focus and planning, Charles Southey
16:30 I 16:50 Unity, direction, stability. The role of the professional associations and overarching governance in self regulation, Andrew Rankin 16:50 I 17:10 European standards in non-surgical aesthetics—a progress report, Mike Regan 17:10 I 17:20 Save Face 17:20 I 17:30 Treatments you can trust, Sally Taber
17:40 I 18:00 What are people saying about your practice online? Rosie Akenhead
17:30 I 18:00 Industry debate: Self regulation—what impact can it really have? Sally Taber and Andrew Rankin
34 FACE 2015 I body language
Aestheticians agenda This agenda explores the latest advanced treatments for non-medically trained practitioners, providing a unique forum for therapists AESTHETICIANS This event is tailored specifically to exploring advanced treatments that are performed by non-medically qualified practitioners with different skill sets, interests and backgrounds. The last 10 years has seen the role of beauty therapists, laser technicians and other practitioners working in the aesthetics market rapidly evolve and many of the lectures are delivered by therapists who have specialist expertise and experience in their chosen field, with FACE providing a dedicated forum to share knowledge and stimulate debate amongst therapists. 4TH FLOOR, ABBEY ROOM, Friday/Saturday FRIDAY
SATURDAY
09:30 I 09:55 Understanding the natural barrier function of the skin and its impact on skin health, Sally Durant
09:30 I 09:50 Cryotherapy induced lipolysis with acoustic wave therapy, Barbara Freytag
09:55 I 10:10 Skincare ingredients—which ones for which indications?
09:50 I 10:10 HIFU for fat reduction—the latest clinical information
10:10 I 10:30 TBC
10:10 I 10:30 Radiofrequency for body contouring
10:30 I 10:50 Eyelash and eyebrow rejuvenation—the latest topical solutions
10:30 I 10:50 Weight management—the complete approach
10:50 I 11:00 Q&A
10:50 I 11:00 Q&A 11:00 I 11:30 REFRESHMENTS AND EXHIBITION
11:30 I 11:55 Latest technologies for laser hair removal—what are they and how much difference do they make? Jo Martin
11:30 I 11:55 Managing sweat—from iontophoresis to microwaves, Annie Eccleston
11:55 I 12:20 PCOS and treatment of transgender, Chris Hart
11:55 I 12:20 Benefits of using a hyaluronic acid and succinic acid combination vs cream as post-laser care, Maryam Borumand
12:20 I 12:40 TBC
12:20 I 12:45 TBC
12:40 I 13:00 Panel discussion: Avoiding and dealing with problems associated with hair removal, Jo Martin
12:45 I 13:00 Q&A
13:00 I 14:30 LUNCH AND EXHIBITION 14:30 I 14:50 Laser tattoo removal—the latest techniques and technologies, Jo Martin PROVISIONAL AGENDA
14:50 I 15:10 Treating pigmentation—practical approaches and treatment tips
14:30 I 16:00 TBC
15:10 I 16:00 Treating facial redness and vascular lesions: What is the best approach? 16:00 I 16:30 REFRESHMENTS AND EXHIBITION 16:30 I 16:50 The implications of HEE recommendations to the clinical beauty therapist, Sally Durant 16:50 I 18:00 Panel discussion: What is the best route to improving skills and training?
16:30 I 17:30 TBC
body language I FACE 2015 35
Hair agenda Androgenic alopecia and hair loss are common indications—learn about the latest treatments and techniques for effective restoration HAIR With so many different non-surgical and surgical treatment options now available for the treatment of androgenetic alopecia, alongside growing demand for solutions to hair loss, FACE are hosting a special one day symposium devoted to exploring this sector of the aesthetic market. A panel of experts will explore in depth the different potential treatment solutions available.
SATURDAY 09:30 I 09:55 Alopecia awareness, Jackie Tomlinson 09:55 I 10:20 Shampoos and haircare, Carole Michaelides 10:20 I 10:45 Wigs and hair systems, Lucinda Ellery 10:45 I 11:00 Q&A 11:00 I 11:30 REFRESHMENTS AND EXHIBITION 11:30 I 11:50 Scalp and hair loss concealers, Jason Saks 11:50 I 12:10 Medical treatments, Dr Paul Farrant 12:10 I 12:30 Non-prescription supplements, Dr Greg Williams 12:30 I 12:50 Low level laser therapy, Dr Nilofer Farjo 12:50 I 13:00 Q&A 13:00 I 14:30 LUNCH AND EXHIBITION 14:30 I 14:55 Mesotherapy 14:55 I 15:20 Platelet rich plasma 15:20 I 16:00 Hair transplant surgery, Dr Bessam Farjo 16:30 I 16:55 Hair greying and ageing, Gill Westgate 16:55 I 17:20 Promising science, Claire Higgins 17:20 I 18:00 Panel debate—the future of alopecia treatment, Dr Bessam Farjo, Claire Higgins, Gill Westgate, Dr Nilofer Farjo and Dr Greg Williams
Threads agenda A one day workshop to explore the latest thread lifts for facial rejuvenation THREADS The concept of the use of different types of threads for facial rejuvenation has been in development since the late 1990s and now many threads are promoted to the aesthetic community. This special one day workshop will explore the latest data evaluating the efficacy and long term safety of threads for facial rejuvenation, alongside the technical issues of placing threads and the experience required to deliver these treatments in aesthetic practice.
FRIDAY 09:30 I 09:55 A combined approach to facial ageing using aptos threads, Dr Albina Kajaia 09:55 I 10:20 TBC 10:20 I 10:45 New innovation in polydioxanone (PDO) threads for non-surgical face lifting, Dr Jacques Otto 10:45 I 11:00 Q&A 11:00 I 11:30 REFRESHMENTS AND EXHIBITION
PROVISIONAL AGENDA
11:30 I 11:55 Practical demonstration of threads for facial rejuvenation 11:55 I 12:20 3D facial rejuvenation using threads and dermal fillers, Dr Sarah Tonks 12:20 I 12:45 Panel debate: Avoiding and dealing with complications 12:45 I 13:00 TBC 13:00 I 14:30 LUNCH AND EXHIBITION
PROVISIONAL AGENDA
16:00 I 16:30 REFRESHMENTS AND EXHIBITION
36 FACE 2015 I body language
The FACE exhibition With over 80 exhibitors, a packed agenda of exhibitor workshops spanning three days and a choice of comprehensive exhibitor symposiums, FACE 2015 offers delegates every opportunity to explore the latest medical aesthetic products and services BRONZE SPONSORS DIAMOND SPONSOR: MERZ AESTHETICS
3D Lipo stand #27 ABC Lasers stand #20 Academy of Advanced Aesthetics
stand #38 Acne Clinic UK stand #44 PLATINUM SPONSORS: SURFACE PARIS and WIGMORE MEDICAL
Adare Aesthetics stand #19 AesthetiCare stand #75 Allergan stand #48 Anti Age Magazine stand #02 Asclepion Laser Technologies stand #40 Avita Medical stand #46
GOLD SPONSORS: GALDERMA and SKINCEUTICALS
BDR Advanced Skin Repair stand #38 Body Language Journal stand #82 Bottled Science stand #47 BTL Aesthetics stand #77 CCF Media stand #07
SILVER SPONSORS: AESTHETIC SOURCE, ALGENESS, BAUSCH & LOMB, CYNOSURE and SYNERON CANDELA
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body language I INJECTABLES 37
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body language I BUSINESS 39
Business models DR MARK TAGER shares his tips for a successful practice: how to convert prospects into customers and develop a strong brand.
T
he essential elements for business success in aesthetics are to develop a methodology in order to clarify your positioning, your offers and who you are to your customers. In this article I am going to look at some different business models, and the key ingredients of the patient experience which can lead to a successful practice. Different business models are appropriate for different kinds of practice. A physician-centric model is good for media leverage. Physicians can become key opinion leaders, presenters and conduct studies and workshops. But the downside of this is that there’s only one physician. It’s essential to be mediatrained if you’re going to be the individual who is representing your clinic—you are the brand. In a franchise-centric model the assumption is of a standardised service quality. It’s very easy to offer incentives and price reductions. You can reach a larger audience and there is the economy of scale. Savings are achievable in record keeping, discounts from manufacturers, insurance, supplies, training, staffing and launch costs. On the other hand the service can be perceived as impersonal, providers can come and go, and there is a danger that the best providers will set up on their own and take patients away with them. A single-focus centre allows specialisation in one area. This allows for focussed marketing, clear-cut demographics and treatment efficacies. It’s easy to train staff, but success can generate ‘me too’ competitors and you can lose clientele to them. Also it’s hard to drive revenue from product ‘up selling.’
The USP To build a brand you need a unique selling proposition. A popular method to devise your unique selling proposition is to consider what pitch you would make to a stranger given 30 seconds alone in a lift together. Be specific, clear and representative. Make your message easy to communicate. Ensure that everyone in the practice from the receptionist onwards has the same mind-set and message. Your USP has to be consistent with your value proposition, link with your principles of practice and driven through your marketing materials and reinforced by all your staff, because quality is meeting and exceeding patient expectations. Ensure you mystery shop your practice. Get someone into your practice to give you the feedback
that you need about how you are doing in order to enhance the quality of the patient experience.
Different business models are appropriate for different kinds of practice
Understand your patient’s motivations Patients come into clinic in different stages of readiness. It’s really important to understand what has motivated them to step through the door, and what it is that concerns them about their skin. A useful technique is to immediately give them a mirror and start assessUSP’s might include: The experience of the practitioners and their credentials The service element, such as extended hours Pricing Recognition/fame Latest, newest technology Holistic approaches.
40 BUSINESS I body language
ing together the ‘problem’ areas. That first encounter in your practice is critical. You really have to deliver the ‘wow’ for that patient, alleviate their anxiety, increase their comfort level and build brand attachment. Brand ambassadors One of the most useful ways to grow brand awareness is by developing brand ambassadors. Social media is key to the ambassador process and ambassadors that have an active following can be very useful to a growing business. Twenty percent of your patients are the most valuable ones in your practice—you need to reward these patients and make them feel special.
The conversion cascade I co-authored a book with plastic surgeon Stephen Mulholland, MD, in which we discuss the ‘conversion cascade.’ There are steps involved in attracting and moving people through your practice. It is crucial to understand the metrics associated with each step, to stop money leaking from your business. For example, what percentage of phone calls do you convert into treatments? Without data it is impossible to build a practice and make improvements. Also evaluation of patient co-ordination, the check-
out, the building and the perceived overall impression are essential to provide an understanding of the patient experience. Step 1: The phone call. The receptionist must be charming and engaging, and know the 30 second scripts on every service that you have. You will want to closely monitor conversion rates into bookings from that first phone call. Step 2: From the consultation to the treatment. Again look at conversion rates and how these can be driven higher. Make certain to spend enough time with the patient to build rapport. Some practices routinely set aside a unique block of time to see their new consults. Step 3: Post-treatment upsell. Booking in for maintenance. For example, in addition to sixmonthly treatments of neurotoxins or fillers, it may be appropriate to offer some form of skin health program that has people coming to you on a more frequent basis and that augments what you do. Adding a popular branded service such as Hydrafacial can help recruit patients, have them leave satisfied, and return frequently, often with their friends. You can also offer nutritional counselling, functional medicine and ancillary serves to help people get total health that is reflected in the skin. Don’t be afraid to say no There are patients that, if you’re going to be honest and ethical, you should turn away. Patients who over-negotiate. Patients with body dysmorphic disorder. If you know that your technology cannot provide the results that they want. If you don’t have the right technology to really address deep acne scarring. Patients with unrealistic expectations. For example a person over 55 who might not get a good result from a skin-tightening procedure might be better going to a plastic surgeon. It’s critical during the consultation process to underpromise and over-deliver, explaining the percentage improvements that may arise from a treatment. It is better to respectfully turn somebody away than to treat them badly. If you treat them and you do not meet their expectations, they will tell more people about the neg-
66 The first encounter in your practice is critical—deliver the ‘wow’ for that patient 99 ative experience than they would have done with a positive one. The importance of team Without doubt in any practice the physician is very important, but so are other staff members. Patients want to know who is doing the treating, how credible they are, and how they come across in the marketplace. However even the most caring, compassionate and talented clinicians can be undermined by the quality of their staff. Success really is a function of how good the team is. Different personality types perceive and interpret events differently. In general the physician tends to be directive, highly logical and litigable. But every staff member needs to understand who they are, their type, their temperament, their strengths and their weaknesses in order for you to model your business accordingly. No matter what your leadership style you have to be flexible in how you deal with the team members. Understand each individual’s skillset and match them to appropriate tasks based on competence, confidence and commitment. Ensure you build taskrelated feedback into your staff appraisal system, do it frequently, and don’t only comment on the negative. Ancillary sources of revenue Ensure your messaging and your service delivery are consistent with a value proposition. Look to the devices and treatments that have people coming back to your practice. Build skin health. This becomes a powerful driving message that allows you to sell nutraceuticals and herbal preparations. Dr Mark Tager is CEO of San-Diego based ChangeWell Inc., a training and consulting company that guides organizations and individuals to higher levels of health and performance W: changewell.com
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body language I MEDICAL AESTHETICS 43
Dealing with injectable complications The Expert Consensus on Complications of Botulinum Toxin and Dermal Filler Treatment, second edition was created by a group of UK practitioners headed by Mr Christopher Inglefield. MR INGLEFIELD outlines the motivations and aims for creating guidelines and MARIE DUCKETT offers her advice on the vital role of managing patient expectations in order to avoid complications
MR CHRIS INGLEFIELD Mr Inglefield is a pioneering consultant plastic and reconstructive surgeon with over 25 years experience. He has spent over a decade developing his private practice at London Bridge Plastic Surgery.
Mr Chris Inglefield: Our group came together following a Merz Aesthetics Partnership in Practice Conference, because we realised there was a lot of discussion about managing complications in toxins and fillers, but there was very little good data putting it all together. So we gathered a diverse group of individuals with some 25-30 years of experience in the aesthetics industry, bringing in as many experts as we could and putting it all together. We looked at why we need an expert consensus on this, who should be on this expert panel, the development of the consensus document, and then divided it into two sections, one: recognising and minimising complications, and two: complications and risk reduction. We all know that a lot of consumers are interested in this industry, otherwise we wouldn’t be here—and it’s an industry that’s rapidly growing. Most of the adverse events that we see are shortterm complications, especially with toxins and the use of HA fillers. Even some of the more disastrous complications with fillers can be dealt with quite successfully. What was evident to us from the outset was that there wasn’t a good consensus on how to manage specific
MARIE DUCKETT Marie Duckett is a nurse practitioner who specialises in the field of facial rejuvenation using dermal fillers, skincare and makeup. She runs a successful clinic in London’s Harley Street with her business partner Fiona Collins.
complications, which would act as a guide for new practitioners, as well as for experienced practitioners that come across the more unusual complications. So, creating that became our goal. Jenny Brown was our medical writer who brought us all together—she got us all in line and helped to ensure we were all doing the right thing. The project was started in May 2013. We agreed to focus on nonpermanent fillers, which are most commonly used in practice – hyaluronic acid, calcium hydroxyapatite, and poly-L-lactic acid, and we all contributed, depending on our areas of expertise. In the part one section it’s recognising and minimising complications. We looked at each area of the face, suggested toxin injection points and dosing; for fillers, looking at the different viscosities and why you should use a particular product in a specific area to deal with specific problems, because understanding the product is very important to avoiding complications. We looked at potential complications at each area, each site, and then recommended steps by reviewing the published evidence, and also taking into account our various experiences of how to minimise the complications.
Part two was looking at complications in general and how you reduce complications in your practice on a very practical level. We looked at dealing with patients—how do you look at that patient and then suggest a lip treatment, or a temple treatment, or a non-surgical nose treatment. We considered how we approach that patient to absolutely minimise the risk—we know we can’t eradicate, but we need to be able to minimise risks as much as possible. The significant complications of vascular compromise, infections, are well covered in the document. In the second edition we’ve added in a section on the use of hyaluronidase, which is extremely helpful. In the recommendations, we talk about the dosing for the use of hyaluronidase, how you can use it to refine your treatment and, much more importantly, in the emergency situation how you should use hyaluronidase in managing vascular compromise. Marie Duckett: Managing patient expectations is probably one of the simplest and easiest ways of ending up with a happy patient at the end of the treatment experience. The consultation is the key. If you haven’t done a thorough con-
44 MEDICAL AESTHETICS I body language
sultation you will never establish exactly what your patient understands of what may happen, what can happen and what can’t happen. A pre-treatment facial assessment is an absolute necessity. Without that, you will find that you’ll end up with patients who expect to be able to walk out with a pair of Angelina Jolie lips when they have a small heart-shaped face that really wouldn’t be able to accommodate lips of that size, nor do they have the dental structure underneath, nor the bony structure to support such lips. Pre-treatment photographs are comforting for clinicians, but more importantly are a good baseline for the patient to remember what they did look like. In my experience, patients suffer a degree of amnesia, which is selective when they have a treatment. If you haven’t established your baseline by having good pre-treatment photographs patients can often come back and say that they feel that they didn’t have an adequate treatment, or they have a line where they didn’t have a line before. Another essential is setting out the treatment plan. Make sure that not only do you have a copy of the written treatment plan, but also that the patient goes away with a copy of their written treatment plan so that they can refer to it and know exactly what you did and what you intend to do at further treatments. Most important of course is that you have your written patient consent, and you should document that, the fact that you’ve taken that, in the notes. The consent form these days has become much more wordy, much more complicated, and certainly the difference, when I look back through old patient notes of people I’ve been treating for the last 17, 18 years, the consent form 17, 18 years ago was just about two paragraphs, and now the actual written consent can be several pages, including things that I never expected to see on a consent form, like blindness. When dealing with patient expectations, I experienced several different types of patient. You have the normal patient who will listen to you and engage with you and be honest with you, and they can be what you would call plain sailing
66 “If in doubt don’t treat” has been my mantra for the last 20 years. I stick by it and I still believe that it’s the thing that’s saved me from many potential disasters over the years 99 really in as much as they’re taking it seriously and they’re not overly anxious. Of course, you’ll also have patients, which I personally dislike, that come in and just say they want to look ten years younger. I believe that you will not achieve ten years younger, with some of these patients with dermal fillers and toxin—an awful lot more intervention would be required and they’re the sort of people that will often walk away unhappy. The other ones that I dislike are the ones that are desperate to sign the paper without reading it or hearing about their procedure. They’re a dangerous group. I tell them that it’s my rules in my clinic and unless they listen to what I have to tell them and unless they honestly answer me when I ask them about their previous experiences then this isn’t the clinic for them. The know-all patient is equally bad—they interrupt you all the time, they are convinced they know all about their treatment already constantly. Again, they’re another group of people to whom I just say “my clinic, my rules” I get them to sit back and remind them we have to go through the process for their benefit. And then of course we have the “query” body dysmorphic disorder patient. There is no way that I would try and make somebody happy who I suspected was body dysmorphic. There are some useful questionnaires that you can download from the internet which patients can fill in if you are suspicious that you have somebody like this. My advice would be always to refer them to somebody else, preferably with experience in that field. Then we have the very nervous patient—I quite like the very nervous patient because they’re the ones that do listen. They sometimes feel that they get more and more nervous as you proceed through
the consultation, but I always reassure extremely nervous patients at the very outset that they will not be having a treatment today, and that often makes them feel an awful lot better. From here you can proceed through the consultation, establishing their expectations, without any fear on their part that you’re going to present them with a needle and syringe at the end of it. “If in doubt don’t treat” has been my mantra for the last 20 years, and I stick by it and I still believe that it’s the thing that’s saved me from many potential disasters over the years. If the patient won’t play ball with me I won’t treat, so if somebody is not going to talk properly—sometimes you get really flippant answers on the patient information questionnaire and I won’t accept that from a patient. I don’t mind people who are comical and I don’t mind people who are a bit jokey, but this is a serious part
When dealing with patient expectations, I experienced several different types of patient
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46 MEDICAL AESTHETICS I body language
The first thing patients do when you hand them a mirror post procedure is touch their face. I advise the not to, and to keep the area clean
of the procedure and that’s where I want them to stay, I want them to stay serious until we’ve established all the parameters. When it comes to dealing with expectations, if they’re terrified they very often can’t even imagine what they’re going to walk out looking like. They don’t know how they’re going to feel, they anticipate every possible complication and there is no way that addressing that patient even with the tiniest treatment at that point. Nothing is going to make them feel any better, because they imagine that every possible adverse event is going to happen to them. There are also people who come along with a list of practitioners that they’ve been to before. They have a serious problem I think when they’ve been to maybe five, six practitioners—very often people I know and respect, and they haven’t been able to meet their expectations and they have a long list of complaints about them, and I think that that’s another patient that is going to be seriously difficult to make happy. Managing expectations is all about creating a picture for the patient that is honest, and they need to know the difference between something which is a normal treatment event—so, bruising, redness, pinprick marks, swelling—those are all normal as far as I’m concerned, anything that I could achieve by simply sticking a needle in them without putting any product in is nothing to do with, in my mind, an adverse event, so making sure that the expectations of something being wrong at the end of a treatment is not confused with something which is normal. The
other expectation of how wonderful they will look with one cc of product—we all know that sort of patient that has a small budget but a big wish list; the patient that will walk in who wants to look like their friend, and their friend hasn’t abused the sun for the last 30 years, their friend doesn’t smoke and their friend doesn’t abuse alcohol; all these factors are going to make it very, very difficult for you to end up with patients who are going to match their expectations by what you can achieve. Another important part of dealing with patient expectations is to make sure that the aftercare that they receive will also not complicate the outcome of the procedure. The first thing patients do when you hand them a mirror post procedure is touch their face. I always say, no, hands off, don’t touch your face again—your hands have just opened that door handle that somebody else has just opened before you. Reminding them to keep the area clean and make sure that they don’t make anything happen that shouldn’t happen. The use of cool packs is very useful for five or ten minutes after the procedure— you’ll find that if you give them that little bit of time to soothe the area, to take the redness down, to apply some makeup if it is reasonable to do so. There are lots of makeups that are available now which are safe to apply immediately post-procedure, though I’m always very reluctant to apply any makeup in the area where I’ve just introduced a cannula because I feel that the entry point is too large and it goes too deep. But I do think if you don’t apply any makeup to a patient and
you allow them to walk out of your clinic holding a cotton swab to their face to dab little pinpricks of blood, that the first thing they will do is find the nearest bathroom and reapply some makeup from the bottom of their bag. Arnica and vitamin K are very useful should you suspect that you have a bruise, and even if you just have somebody with a history of bruising it’s very useful to make sure that they have a supply to apply. In terms of exercise it depends on what you’ve done, how much you’ve used, and what sort of exercise the patient is interested in doing, but usually a good recommendation is 24 or 48 hours without any strenuous exercise. Things like saunas should also be avoided. And finally it’s vital to ensure that they have an aftercare leaflet that will reiterate what you’ve told them and that they have a contact telephone number, and know that should anything untoward occur that it isn’t a problem to phone you and that you should be their first port of call rather than their GP or their local A&E department. Don’t skimp on your aftercare advice, it’s your last opportunity for avoiding patient-inflicted complications. Patients sometimes are less bright then we think when it comes to looking after themselves and they can go straight from you to go and have their top lip waxed, or to go and have a facial, or to go and swim 50 lengths in the local swimming baths, and it will only cause complications that really and truly shouldn’t have occurred in the first place. All of this information and more is delivered in our consensus document.
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48 PRODUCTS I body language
on the market The latest anti-ageing and medical aesthetic products and services Essential Recovery Kit Episciences has launched an aftercare range for patients who have undergone moderate to deep skin rejuvenation procedures. The Essential Recovery Kit was designed to help patients achieve better results after deeper resurfacing procedures, with less discomfort and downtime, and restore barrier function while providing a surge of hydration and soothe highly sensitive skin. The ‘take-home’ care kit aims to meet patients’ needs after treatments such as micro-needling, fractionated laser and chemical peel treatments. Included in the kit are Epionce’s Priming Oil, Enriched Firming Mask and Medical Barrier Cream. CEO of Episciences Dr Carl Thornfeldt says, “We created the Essential Recovery Kit to provide patients with an easy way to improve the results of their resurfacing procedures at home.” W: epionce.co.uk
The Time Machine LoveLite clinic are launching a new multitreatment anti-ageing skin system called The Time Machine. The machine is a noninvasive anti-ageing hand-held device for salon use; designed to reverse the skin’s ageing processes at a cellular level. It uses lasers in the infrared and green spectrum to help reform the collagen, recreate youthful elasticity within the skin and in turn reduce wrinkles, lines, spots and scars on the surface. The laser penetrates 2-3mm into the dermal layer, right down to the mitochondria within the cells and stimulates production of collagen and elastin which in turn makes skin tighter and more youthful in appearance. Lovelite also offer a one day training course for the device. W: loveliteuk.co.uk
Mineral Eye UV Defense SPF 30 SkinCeuticals have launched their new antiageing and sun protection eye formula. The Mineral Eye UV Defense is designed to protect the delicate skin around the eye with mineral SPF 30 Ultra Violet A (UVA) and Ultra Violet B (UVB) protection, enhance and unify the skin tone around the eye area and optimise make up application with a smooth non-migrating base for use under make up. The mineral filters in the Mineral Eye UV Defense SPF 30 are designed to act like mirrors, reflecting and blocking the suns’ harmful and damaging rays. W: rkmcom.com
Lutronic VENN Healthcare has acquired the UK distribution rights to Lutronic, who currently offer three aesthetic systems; Infini, Clarity and Spectra XT. These systems offer treatment for scars, stretch marks, fine lines, wrinkles, skin resurfacing, hair removal body shaping. W: vennhealthcare.com
Noel Asmar Grahame Gardner Ltd have announced their new partnership with the Canada based workwear brand, Noel Asmar. Noel Asmar’s range was developed for beauty therapists and spas, but has also been adopted in the US by cosmetic surgeries seeking to reinforce their identity. W: grahamegardner.co.uk
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body language I EQUIPMENT 51
Combination treatments Why use fractional radiofrequency when lasers give such great results? DR DIANE DUNCAN says the answer is simple: fractional RF can do things that laser cannot
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ith traditional Erbium and C02 lasers, the effect is purely ablative; they have the ability to remove a full layer of the skin’s surface area, and while that can reduce wrinkles and pigmentation, there is some definite downtime with that. I use the analogy of stripping the formica off a wooden countertop. The layer is quite superficial. Both laser types also have fractional applications, but the columns of tissue ablation don’t “speak” to each other like radiofrequency does. In order to affect deeper structures, radiofrequency may be a more ideal energy source. Both CO2 and erbium ablative laser treatments can be quite painful; general anesthesia is usually required for ablative treatments. Down time of at least 7-10 days makes the laser treatments relatively unattractive in terms of ‘cost’— both monetary and time away from work to recover. With fractional RF resurfacing, the down time and treatment discomfort are significantly less than what you might see with traditional laser. Because not all of the skin surface is treated, healing is much quicker. Some treatment heads have a ‘coating’ of the superficial part of the tip, so almost no pattern marks are visible because the epidermis is not treated. There is the advantage of being able to go quite deep. You can create micro channels that tighten the skin and superficial soft tissue, without having to cut any tissue out. With less down time between treatments, many patients are now choosing radiofrequency resurfacing versus laser, essentially allowing them the same results with less oozing and potential problematic recovery. Feedback from a patient that I treated about four years ago with laser, who recently had fractional radiofrequency of her neck, was that in retrospect the RF needling was so easy that she would never do the laser again—more for the downtime and discomfort than anything else. Of course there is no denying that patients choosing RF needling treatments
do need to do more treatments—in my practice generally it’s three instead of one. However the patient acceptance is greater—there is no need for general anaesthesia, and after a Friday treatment patients can return to work on Monday. The process Not all patients will respond well to laser resurfacing treatments. Depending on skin type, there can be a very real risk of “PIH”, or postinflammatory hyperpigmentation. Darker skin types are at significant risk for this. Another advantage of radiofrequency based aesthetic devices is that most of these are ‘color-blind’, meaning any skin type can be treated without the worry of recurrent pigmentation following treatment. You have to be very careful and not presume that every patient that you’re going to treat with radiofrequency won’t get PIH. However, it is possible to treat even skin type VI with fractional RF with a patch test and by using very conservative settings in order to make sure the patient can tolerate it.
So how does the radiofrequency needling work? There are several different types on the market. Not all needling devices have radiofrequency heat; devices such as the Dermapen are mechanical needling devices only. Viora has a device that is very superficial and doesn’t really go into the skin deeply. This device requires no topical anesthetic, and gives the skin a lovely glow following treatment. If a stronger effect is desired, then a device with needles that actually penetrate the skin may be more desirable. Fractional ablation can leave a little ‘grid’ mark that is generally gone after three to five days or so, depending on the level of energy used and the number of passes performed. If it is bothersome to the patient, they can generally use makeup after day three. Despite the superficial pins creating a micro-break in the skin, the area heals relatively quickly. Over time, the skin surface will appear to shrink slightly. The mechanism of action is very interesting; RF energy causes the immediate subcutaneous tissue to create a
52 EQUIPMENT I body language
66 RF fractional treatment is excellent for pigment, fine wrinkles, skin laxity, wrinkles of the lower eyelid, and textural abnormalities 99 new collagen network or scaffold, which shrinks in a manner similar to a wool sweater than gets tossed into the dryer. As the less dense and more responsive hypodermis thickens and shrinks up over time, the overlying skin will gradually accommodate to fit. Needling pins without RF—which are cheaper—do get great results, but for a very challenging patient who has extremely heavy pores and very difficult thick skin, RF needling makes the skin look not just slightly better, but beautiful and youthful. Adding RF to needling can give you a better result in fewer treatments. Plus, there’s the advantage of varying the depths of the needles with these devices to tailor the treatment to the required skin level. Pins that are relatively superficial treat the skin tone (126 pin tip). Other commonly used tip depths are mid-dermal for wrinkles (60 pin tip) or deep dermal for acne scars and deep wrinkles (24 pin tip). A standard 60 pin can be used for anything from pigment to telangiectasia or minor wrinkles. However, by adding the deep tip, and by doing multi-level tightening, you’re going to get better results. I generally used the coated 24 pin tip for areas that have more skin laxity or for acne scarring. The coated tip is good for darker skin types since there is no epidermal damage. For large pores, I like to combine the 24 pin uncoated and the 60 pin tip, as sometimes the pores are quite deep. The benefit is that you’re not limited to only using one tip, you can stack different pins on the region even during the same session to address a variety of patient skin concerns. In my practice RF fractional treatment is excellent for pigment, fine wrinkles, mild to moderate skin laxity, wrinkles of the lower eyelid, and textural abnormalities. Patient with darker skin types have less PIH risk with RF based treatments than with laser treatments. This treatment type is good for people who are scared of laser and want little pain and a relatively short downtime. A 63-year-old client who came in for erbium laser was very disturbed by the idea of looking terrible and burned for a week. Having thought about it for about
three months, she came back and had some radiofrequency fractional needling and experienced a 50% wrinkle reduction with one treatment. She was very pleased with her results, though they were somewhat less dramatic than a full aggressive laser treatment. Customising treatments and looking at what in particular bothers a patient before deciding what to do is very important. Radiofrequency needling can be added to laser and toxins and fillers. If the result with a previous laser is suboptimal, then RF can also be used for touch-up spots, because clients don’t want to have to go through that downtime again. With superficial skin laxity, where the problem is not soft tissue laxity underneath the skin, but the actual skin itself, it’s unadvisable to treat the hypodermis— it can create buckling and more vertical striations of the submental neck skin. A good way to treat subdermal laxity and skin laxity is a combination such as the Forma external RF Skin Tightening and Fractora RF Fractional Skin Resurfacing. Forma is basically a sublative general radiofrequency heater. Other examples of this are ‘movers’ like Pelleve. You can move them around and they don’t hurt as much as a ‘stamper’ like Thermage might be. Stampers like Thermage and Ulthera do have the risk of creating focal fat atrophy. In another patient who was a golfer and a tanner, I had to treat damaged, old skin with some soft tissue atrophy and mild to moderate skin laxity. A sublative radiofrequency tightener was used along her jaw line along with some fractional resurfacing. I gave her two treatments and I also did two filler sessions. Filler was inserted in places one would not normally—her pre-jowl area, the area where she had some notching behind her jowl, her mandibular angle and—because she had a short chin—in the anterior part of her chin to give her the illusion of an elongated jaw line. The magic wand, in my mind, is resurfacing plus fat grafting, since adding volume is one thing that consistently makes people look younger. A 65-year-old former beauty queen with some hypopigmentation from a previous CO2 laser came to
see me for treatment before a family reunion. She didn’t want anything invasive but she wanted something substantial, so I did some erbium laser resurfacing and some radiofrequency needling along the line of her jaw line, where her skin was really slack. If you do radiofrequency tightening underneath the jaw line you get a really nice submandibular shadow. This can be achieved with multiple passes over and over in those areas. That patient also received very conservative fat grafting in her face and along her jaw line. Sometimes I’ll add radiofrequency lifting plus platysmaplasty. I’ll generally do the superficial radiofrequency resurfacing after that ,because the RF lifting or tissue tightening underneath the skin tends to cause more of those textural problems. On another occasion I used RF to give a totally non-invasive neck lift to a lady in her 60’s who was trying to avoid age discrimination at work. She got some significant textural improvement as well as tightening of her neck with this combination without basically anything but three needle holes, two at the earlobe, one at the submentum and no skin excision. Of course radiofrequency resurfacing isn’t right for everyone, but I’ve had particularly good results with patients with some hyperpigmentation, sun damage and dyschromia. However, as with treating acne scarring patients, if it’s not 100% corrected then the patients aren’t totally happy. Radiofrequency needling is great for acne, because if you put heat under the skin and it draws that skin together then you’re going to get some really nice improvement. As with most minimally invasive treatments, with more sessions there’s a better outcome. In summary, I think that I generally see less temporary deformity with radiofrequency needling than with laser. In general a single laser treatment may give you a more dramatic result, but with radiofrequency needling there’s less downtime and less temporary deformity, therefore better patient acceptance. Radiofrequency energy can address some problems that are not always treatable with laser alone, such as jowls, central neck and submental laxity, and tealngiectasias. Diane Duncan is a Board Certified Plastic Surgeon and has been in practice in Colorado for over 28 years. She specialises in facial enhancement, breast surgery, and body contouring and teaches new surgical and nonsurgical techniques around the world.
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54 EDUCATION I body language
training TF
TOXINS AND FILLERS
7 April, Basic Botulinum Toxin Training Day, Honey Fizz, Newport W: honeyfizz.co.uk 10 April, Advanced Fillers—Tear Troughs (am) and Cheeks (pm), Wigmore Medical, London W: wigmoremedical.com 11 April, Combined Basic Training – Dermal Filler and Botulinum Toxin, Honey Fizz, Newport W: honeyfizz.co.uk 21 April, Basic Botulinum Toxin Training Day, Honey Fizz, Newport W: honeyfizz.co.uk 29-30 April, Intro to Toxins and Fillers, Wigmore Medical, London W: wigmoremedical.com 2 May, Combined Basic Training Courses – Dermal Filler & Botulinum Toxin, Honey Fizz, Newport W: honeyfizz.co.uk 5 May, Advanced Botox & Azzalure Training, Honey Fizz, Newport W: honeyfizz.co.uk 8 May, Advanced Botulinum Toxins (am) and Fillers—Lower face (pm), Wigmore Medical, London W: wigmoremedical.com 20-21 May, Intro to Toxins and Fillers, Wigmore Medical, London W: wigmoremedical.com 10-11 June, Introduction to Toxins and Fillers, Wigmore Medical, London W: wigmoremedical.com 12 June, Advanced Fillers – Tear Troughs (am) and Cheeks (pm), Wigmore Medical, London W: wigmoremedical.com 16 June, Hyperhidrosis Training, Honey Fizz Training, Newport W: honeyfizz.co.uk 11 July, Advanced Botulinum Toxins (am) and Advanced Fillers – Forehead (pm), Wigmore Medical, London W: wigmoremedical.com 22-23 July, Introduction to Toxins and Fillers, Wigmore Medical, London W: wigmoremedical.com
I
OTHER INJECTABLES
9 April, Sculptra, Wigmore Medical, London W: wigmoremedical.com 11 April, Mini-Thread Lift, Wigmore Medical, London W: wigmoremedical.com 20 April, Dracula PRP, Wigmore Medical, London W: wigmoremedical.com 9 May, Mini-Thread Lift, Wigmore Medical, London W: wigmoremedical.com 30 May, Microsclerotherapy, Wigmore Medical, London W: wigmoremedical.com 31 May, Microsclerotherapy, Wigmore Medical, London W: wigmoremedical.com 13 June, Mini-Thread Lift, Wigmore Medical, London W: wigmoremedical.com 15 June, Dracula PRP, Wigmore Medical, London W: wigmoremedical.com
27 June, Microsclerotherapy, Wigmore Medical, London W: wigmoremedical.com
26-28 May, ZO Medical Basic, Intermediate and Advanced, Wigmore Medical, London W: wigmoremedical.com
2 July, Sculptra, Wigmore Medical, London W: wigmoremedical.com
1 June, Medik8 Dermal Roller (pm), Wigmore Medical, London W: wigmoremedical.com
10 July, Mini-Thread Lift, Wigmore Medical, London W: wigmoremedical.com
4 June, Microdermabrasion Training, Eden Aesthetics, Liverpool W: edenaesthetics.com
13 July, Dracula PRP, Wigmore Medical, London W: wigmoremedical.com
9 June, Skincare & Chemical Peels, Wigmore Medical, London W: wigmoremedical.com
25 July, Microsclerotherapy, Wigmore Medical, London W: wigmoremedical.com
S
SKINCARE
1 April, Epionce Training Sessions, Eden Aesthetics, Warrington W: edenaesthetics.com 7 April, Micropigmentation Induction Day, Finishing Touches, West Sussex W: finishingtouchesgroup.com 13 April, Medik8 Dermal Roller (pm) , Wigmore Medical, London W: wigmoremedical.com 21-22 April, ZO Medical Basic and Intermediate, Wigmore Medical, London W: wigmoremedical.com 28 April, Skincare & Chemical Peels, Wigmore Medical, London W: wigmoremedical.com 28-29 April, ZO Medical Basic and Intermediate (Dublin), Wigmore Medical, London W: wigmoremedical.com 5 May, Micropigmentation Induction Day, Finishing Touches, West Sussex W: finishingtouchesgroup.com 19 May, ZO Medical Basic (Dublin), Wigmore Medical, London W: wigmoremedical.com 19 May, Skincare & Chemical Peels, Wigmore Medical, London W: wigmoremedical.com 20 May, ZO Medical Intermediate (Dublin), Wigmore Medical, London W: wigmoremedical.com
16-17 June, ZO Medical Basic and Intermediate, Wigmore Medical, London W: wigmoremedical.com
O
OTHER TRAINING
13 April, CPR & Anaphylaxis Update (am), Wigmore Medical, London W: wigmoremedical.com 9-10 March, Two Day Areola Masterclass, Finishing Touches, West Sussex W: finishingtouchesgroup.com 23-26 March, Four Day Scalp Masterclass, Finishing Touches, West Sussex W: finishingtouchesgroup.com 1 June, CPR & Anaphylaxis Update (am), Wigmore Medical, London W: wigmoremedical.com
18 June, Agera Training, Eden Aesthetics, London W: edenaesthetics.com
8 June, Areola Artistry Workshop, Finishing Touches, West Sussex W: finishingtouchesgroup.com
23 June, Epionce Training Sessions, Eden Aesthetics, Warrington W: edenaesthetics.com
9 June, Burns and Scars Workshop, Finishing Touches, West Sussex W: finishingtouchesgroup.com
23 June, Microdermabrasion Training, Eden Aesthetics, London W: edenaesthetics.com
10 June, Colour and Needles Workshop, Finishing Touches, West Sussex W: finishingtouchesgroup.com
23-24 June, ZO Medical Basic and Advanced, Wigmore Medical, Dublin W: wigmoremedical.com
11 June, Radiotherapy Marking Workshop, Finishing Touches, West Sussex W: finishingtouchesgroup.com
24 June, Agera Training, Eden Aesthetics, Warrington W: edenaesthetics.com
12 June, Peer Review Workshop, Finishing Touches, West Sussex W: finishingtouchesgroup.com
29 June, Epionce Training Sessions, Eden Aesthetics, Danbury W: edenaesthetics.com
15-16 June, Two Day Burns and Scars Masterclass, Finishing Touches, West Sussex W: finishingtouchesgroup.com
30 June, Agera Training, Eden Aesthetics, Danbury W: edenaesthetics.com
22-24 June, Three Day Medical Masterclass, Finishing Touches, West Sussex W: finishingtouchesgroup.com
1 July, Microdermabrasion Training, Eden Aesthetics, Danbury W: edenaesthetics.com
7 July, Micropigmentation Induction Day, Finishing Touches, West Sussex W: finishingtouchesgroup.com
13-14 July, ZO Medical Basic and Intermediate, Wigmore Medical, Dublin W: wigmoremedical.com
13-14 July, Areola Masterclass, Finishing Touches, West Sussex W: finishingtouchesgroup.com
20 July, Medik8 Dermal Roller (pm), Wigmore Medical, London W: wigmoremedical.com
20 July, CPR & Anaphylaxis Update (am), Wigmore Medical, London W: wigmoremedical.com
21 July, Skincare & Chemical Peels, Wigmore Medical, London W: wigmoremedical.com
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body language I EDUCATION 55
Inadequate training BARBARA FREYTAG discusses the impact of the rapid expansion of the aesthetics industry, and highlights how education is a vital part of regulation
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esthetic treatments are converging ever more with medical procedures and it is vital to consider the huge and growing risks associated with this. Shortcomings in care within the NHS are often reported in the press, but these failures occur despite lengthy and rigorous training of staff and an organisation used to evaluating risk in a medical treatment environment. What about the spa or clinic, who have invested in new equipment providing popular treatments for clients who are prepared to go to ever increasing lengths to maintain or create the slim and youthful persona they desire? As the market has grown, so have the dangers. The speed at which this has taken place has outpaced the understanding of the governing bodies and authorities. If we do not get a grip on this there will be accidents, and in all likelihood there may then be a period regulatory overreaction to the detriment of the industry. The insurance industry is caught in the middle of all this— they appear to be growing aware of the problem, but do not see a clear way out. Local authorities have become aware, but they have few constructive means at their disposal, they can only try and limit the damage. Heavy handed regulation and restrictions on trade by limiting access to powerful vested interests are not an answer. For example, cosmetic teeth whitening being restricted to dentists, restrictions on injectables and some procedures to sections of the medical fraternity only—are all cases in question. Yes, I believe there should be enforceable guidelines, but we should not be creating new monopolies and restrictive practices.
even more serious, then there is a real and growing danger of both more accidents and heavy handed over regulation. An urgent first step should be a set of guidelines for staff training in relation to the procedures they offer and if the insurance companies were to be a part of this process then many shortcomings will be addressed. This process will not be fool proof, but rather like a car driving test, where drivers show varying levels of competence. There are even those driving illegally, but it will broadly speaking, establish a ‘common denominator’ that is substantially better than a ‘free-for-all’. There are a growing number of specialist training establishments which offer courses. All specialist training in advanced procedures ought to have a more advanced test of operator competence than a half day training session by the equipment seller on how to operate the machine. The ‘certificate of attendance’ is hardly proof of competence—how happy would you be on our roads today if anyone over 17 could go to a car showroom and after being shown where the controls are in a car be allowed to drive off into the sunset? I founded the Academy of Advanced Aesthetics, and we concentrate on teaching core knowledge, important to a deeper understanding of the treatment. Any specific machine orientated learning will be on top of that. Not only should this be of immense benefit to the operator by increasing their confidence and competence—especially if anything unexpected ever happens— but it should also make changing from using one machine to another much easier.
Training A great part of the answer lies in better training. More needs to be done and the range of training available needs to be expanded, but the experience and expertise required to provide this is also in short supply. If the industry does not take a more proactive position in regulating itself before the problems become
Barbara Freytag specialised for many years working with ultrasound, and is now Pricipal at the Academy of Advanced Aesthetics, an accredited teaching establishment that offers varied training courses. W: academyofadvancedaesthetics.com
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body language I PSYCHOLOGY 57
Eye candy DR RAJ PERSAUD and PROF ADRIAN FURNHAM examine the latest psychological research on attraction and infidelity—can ‘eye candy’ always be resisted?
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esisting temptation lies at the heart of successful living—for example—not surrendering to the allure of fattening foods, nor buying too much stuff and resisting attractive alternatives to your current partner. Psychologists John Lydon and Johan Karremans from McGill University, Canada and Radboud University, The Netherlands, have recently published an academic review entitled ‘Relationship regulation in the face of eye candy: a motivated cognition framework for understanding responses to attrac-
tive alternatives’. The authors attempt to tackle the conundrum of how come there isn’t more infidelity, given the prevalence of eye candy (attractive alternative romantic partners). The availability of attractive alternatives predicts breakups and divorce, while the epidemic of mobile phone dating apps means the opportunity for infidelity has never been greater. Psychological research on how to resist temptation also predicts how likely you, or your partner, are going to succumb to temptation, and commit infidelity.
For example, the authors quote previous research which finds that those highly motivated to remain faithful, are quicker to reveal their relationship status, ie that they are already in a committed relationship, to an attractive alternative. Yet evolutionary psychologists argue how our brains evolved to adapt to our ancestral environment, means we may be biologically and genetically wired up to succumb to temptations the modern world presents. This is because what appears unhelpful today might have been advantageous in our past, as it
58 PSYCHOLOGY I body language
Given the presence of alternative attractive partners, how is fidelity achieved?
could have helped pass on more of our genes to future generations— which would be the evolutionary imperative. This kind of evolutionary analysis might suggest that men should be procreating with as many females as possible, and that women should always opt for the most reproductively fit male available at ovulation, meaning that infidelity in fact fulfils an evolutionary strategy to maximally pass on our genes to future generations. Yet despite evolutionary psychology suggesting we should be motivated to be impulsive, the reality is some, if not many, still manage to resist temptation. Given the presence of alternative attractive partners, how is fidelity achieved? John Lydon and Johan Karremans in their analysis published in the academic journal, Current Opinion in Psychology, conclude that although many of these questions haven’t yet been properly definitively answered by psychological research, there are already some useful pointers. In one study quoted, avoidance responses toward attractive alternatives were associated with activation in brain areas implicated in self-control. Upon seeing a good-
looking alternate, brain responses implicated in self-control were stronger to the extent that participants were more strongly committed to the current partner. These findings suggest that selfcontrol resources in the brain and the mind are actively engaged, and these are vital in helping committed individuals to inhibit responses toward attractive others, and to override temptations. Your current partner may say blithely how they didn’t even notice the eye candy at the party you have just been at, or at the office, or at the beach, but successfully resisting temptation involves a part of the brain being more active, than for others more prone to succumb to temptation. But some of that self-control ‘muscle’ involves the fact that individuals in committed relationships do tend to be more inattentive to alternatives. Even if they notice them, they also engage psychological processes whereby they judge or actually perceive the alternative as less attractive. It has also been shown that suppressing thoughts about romantic alternatives, avoiding them and selectively remembering negatives more than positives about desirable others, are all part of the temptation resistance process. When it comes to infidelity it seems there are strong parallels to battling enticement in other areas of life, for example resisting fattening foods. How faithful your partner is likely to be might be predicted by their general ability to exert self-control. This also suggests that the conditions under which people succumb to most temptations, such as eating or drinking more than is good for them, are very similar to those predicaments where even the self-controlled are more likely to succumb to infidelity. So people struggle more to resist temptations of any description, including romantic attraction, when tired, under stress, inebriated or just drained. Given these circumstances are not infrequent, it would appear that repelling temptation to the eye candy all around us might involve
a process that psychologists can break down into individual parts. Part 1 is to identify that there is a threat, part 2 is to be equipped with strategies to deal with the threat, while part 3 is to be able to enact the strategies. The power of this analysis is that it can help pinpoint where and when a particular individual might be most vulnerable to eye candy, and how to help them resist successfully. But should it really be such hard work? Or should resistance not come intuitively without such intellectual or emotional labour? John Lydon and Johan Karremans conclude that to understand why some are faithful and some aren’t, involves going back to grasping fundamentals of what drives all motivation. An ‘investment’ model may be illustrative—to the extent you feel you have invested in your relationship—and your partner has invested in you—how many ‘costs’ have been sunk into the partnership, and how irretrievable these ‘investments’ are, maybe this ultimately is what promotes, and tests, absolute commitment. If staying faithful involves a trade-off where long term interests are pursued at the cost of more immediate enjoyment, one key issue appears that of identifying with the relationship. This means if your very identity is tied up with being with your current partner, then you are most unlikely to stray. Maybe the real reason those highly motivated to remain faithful, are quicker to reveal their relationship status to an attractive alternative, is they are just explaining who they are. Dr Raj Persaud is a consultant psychiatrist and joint podcast editor for the Royal College of Psychiatrists with a new free to download app entitled ‘Raj Persaud in Conversation’ which contains many interviews with mental health experts from around the world. Adrian Furnham is a South African-born British organisational and applied psychologist, management expert and Professor of Psychology at University College London.
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body language I INJECTABLES 61
Using toxins therapeutically DR JAMES WILLIS examines how facial aesthetic practitioners can provide therapeutic use of botulinum toxin to benefit patients
B
otulinum toxin or botulinum toxin-A has been used medically since the 1950s by Dr Vernon Brooks and was developed further for therapeutic use by Dr Alan Scott in the 1970s. In 1987 Dr Jean Carruthers, while reviewing her botulinum toxin treatment of patients with blepharospasm made the seminal observation that many showed dramatic improvement of glabella and crowsfeet wrinkles. Subsequent investigation by doctors Jean and Alastair Carruthers laid the foundation for the protocols used for aesthetic facial enhancement. The increased demand for aesthetic treatments has been mirrored by a corresponding increase in the therapeutic uses of botulinum toxin. Treating hyperhidrosis Hyperhidrosis, or excessive sweating is a very real handicap for 2.8% of the population. Sufferers may produce up to 40 times more sweat than normal. Day to day social activities such as shaking hands become embarrassing and patients
can feel humiliation with stained and soaked clothes as well as perceived, or imagined smell. According to a study by Haider et al, 70% of sufferers reported feeling lacking in confidence, 49% were depressed and 81% felt restricted in their opportunities for meeting new social contacts. Iontophoresis and â&#x20AC;&#x2DC;weapons gradeâ&#x20AC;&#x2122; antiperspirants such as aluminium chloride hexahydrate can provide partial solutions, as have treatments with oral anticholinergics such as Glycopyrrolate or Amitryptyline. Treatment with botulinum toxin can provide a more satisfactory result with less unwanted side effects than those found with topical treatments. Botulinum toxin blocks the release of acetylcholine post-synaptically at neuro-muscular junctions, temporarily inactivating the relevant muscle fibres. Gradually new axons are formed and muscular function resumes after 4-9 months. There is some evidence to suggest that eventually the original neuro-muscular-junction reactivates too. Botulinum toxin also has effect at neuro-serrous junc-
tions and will inhibit sweating. Botulinum toxin is frequently used to reduce axillary or under arm sweating. The armpit to be treated is treated with an iodine solution and starch e.g. corn flour. The area of sweat glands shows up as a dark blue patch. The area can be marked out as a grid to aid the distribution of superficial injections of botulinum toxin. Between 50 and 100 units each side provides a satisfactory result for between six and twelve months. Botulinum toxin can also be used for hyperhydrosis of the forehead, upper lip together with palmar and plantar sweating, i.e. palms of the hands and soles of the feet. A similar technique is used to identify sweat glands with the iodine and starch method. In treating hands it is important to leave the fingertips untreated otherwise fine movements such as turning over the pages of a book become difficult. There is some evidence to suggest that blocking sweating in one area causes more sweating in other sites on the body. Some of my
62 INJECTABLES I body language
patients have reported this as an awareness, but not as a problem. Alleviating pain Migraine effects 23 to 29% of females and 15 to 20 % of males, contrary to the normally accept statistic of 10% of the population. It is caused by vascular changes, but sufferers find that the symptoms are often aggravated by recruitment of muscle fibres of the galea-aponeuritica, that go into spasm exacerbating the painful symptoms. Treating the muscle fibres of frontalis and those in the nape of the neck can greatly reduce the severity of symptoms and some reports suggest that this can also reduce the frequency of migraine attacks. There may be another mechanism involved in pain reduction too. Pain is modulated by the release of substance P. Botulinum toxin is found to inhibit this process. Ian and Jean Caruthers list some 25 uses of botulinum toxin for pain reduction. Botulinum toxin may also reduce pain by blocking the pre-synaptic release of calcitonin gene-related peptide. The author has successfully treated back pain with botulinum toxin. A thirty-year-old patient for example had suffered chronic back pain for a decade. Having 40 units of botulinum toxin injected into the muscle either side of the spinal column from L1 to L5 reduced a subjective pain score from 6/10 to 0/10. Mobility was increased markedly too. Some success has also been achieved in treating post herpetic neuralgia in the trigeminal nerve distribution and also in the treatment of painful scars. Obviously botulinum toxin should not be used as a substitute for appropriate investigation of pathology, diagnosis and conventional therapy for painful conditions. As an adjunct however it can subserve a useful role. This feature may also play a useful role in relieving conditions like atypical facial pain. Use in dentistry Dental bruxism or tooth grinding is a painful condition and is potentially damaging to tooth structure, the periodontium, TMJ and muscles of mastication. The periodon-
66 Treating the muscle fibres of frontalis and those in the nape of the neck can greatly reduce the severity of symptoms and some reports suggest that this can also reduce the frequency of migraine attacks 99 tal ligament that anchors a tooth in its socket contains proprioceptors that respond to biting forces. So, when one unexpectedly bites on an olive stone in one’s salad Nicoise, the proprioceptors are stimulated and initiate inhibition of the muscles that close the jaw. This is an effective protective reflex. If the upper and lower teeth are constantly biting together this protective reflex is gradually extinguished and replaced by a harmful reflex causing the teeth to bite together even harder. The condition is often treated with an occlusal guard— worn over the lower teeth at night. This interferes with the interdigitation of the maxillary and mandibular teeth and allows the protective reflex to gradually re-establish. Using botulinum toxin in the masseter and temporalis muscles reduces the biting force and supplements the benefit of the occlusal splint. The dosage for masseter treatment is between eight and 16 units on each side, keeping inferiorly within the body of the muscle to avoid the parotid salivary gland. A similar dosage is appropriate for the temporalis muscles. In more severe cases one can also treat the pterygoid muscles that are accessed intraorally posterior to the last molars. Dosage for the ptergoid muscles ranges between five to 10 units each side. Facial tics Facial tics often involve the orbicularis occuli muscles giving rise to involuntary twitches of the muscle. This is often unilateral and can be exacerbated by stress. Between 10 and 20 units of botulinum toxin injected superficially at least 1 cm lateral to the rim of the orbit is usually adequate to temporarily eliminate the tic. For the sake of aesthetic symmetry the contralateral side should be treated too, gen-
erally using half the dose used on the effected side. Treating depression Botulinum toxin can play a role in the treatment of depression. Via a process called Reverse Brain Engineering it seems that one’s mental and emotional state of well-being is dependent to an extent on what the face is doing—irrespective of why it is doing it. So for example if one is forcing a smile for a succession of tedious photographs at a wedding and actually one is feeling bored, negative and gagging for the reception, the mood can elevate purely because one is using the set of ‘smiling muscles’. Conversely if one is feeling normally buoyant but is scowling myopically to read small print on the monitor screen, the mood can fall because one is activating the corrugator or frowning muscles. In the first randomised, controlled study on botulinum toxin by Marc Axel Wollmer—the psychiatrist in charge of the trials being held jointly at Basel University, Switzerland, and Hanover University, Germany—researchers gave the first group of participants a single dose of toxin in the frowning muscles while the other group received a placebo. Depressive symptoms in the treatment group decreased 47 % after six weeks, an improvement that remained through the 16-week study period. The placebo group had a 9 % reduction in symptoms. With appropriate training the facial aesthetic practitioner can add significantly to the range of treatments on offer for patients. Dr James Willis has been involved with facial aesthetics for twenty years, and qualified as a dentist in 1981. He runs James Willis Faces in Totnes, and also provides training. W: jameswillisfaces.co.uk
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Now approved for crow’s feet lines
Bocouture® 50 Abbreviated Prescribing Information Please refer to the Summary of Product Characteristics (SmPC) before prescribing. 1162/BOC/AUG/2014/PU Presentation 50 LD50 units of Botulinum toxin type A (150 kD), free from complexing proteins as a powder for solution for injection. Indications Temporary improvement in the appearance of moderate to severe vertical lines between the eyebrows seen at frown (glabellar frown lines) and lateral periorbital lines seen at maximum smile (crow’s feet lines) in adults under 65 years of age when the severity of these lines has an important psychological impact for the patient. Dosage and administration Unit doses recommended for Bocouture are not interchangeable with those for other preparations of Botulinum toxin. Reconstitute with 0.9% sodium chloride. Glabellar Frown Lines: Intramuscular injection (50 units/1.25 ml). Standard dosing is 20 units; 0.1 ml (4 units): 2 injections in each corrugator muscle and 1x procerus muscle. May be increased to up to 30 units. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. Crow’s Feet lines: Intramuscular injection (50units/1.25mL). Standard dosing is 12 units per side (overall total dose: 24 units); 0.1mL (4 units) injected bilaterally into each of the 3 injection sites. Injections too close to the Zygomaticus major muscle should be avoided to prevent lip ptosis. Not recommended for use in patients over 65 years or under 18 years. Contraindications Hypersensitivity to Botulinum neurotoxin type A or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, Lambert-Eaton syndrome). Presence of infection or inflammation at the proposed injection site. Special warnings and precautions. Should not be injected into a blood vessel. Not recommended for patients with a history of dysphagia and aspiration. Adrenaline and other medical aids for treating anaphylaxis should be available. Caution in patients receiving anticoagulant therapy or taking other substances in anticoagulant doses. Caution in patients suffering from amyotrophic lateral sclerosis or other diseases which result in peripheral neuromuscular dysfunction. Too frequent or too high dosing of Botulinum toxin type A may increase the risk of antibodies forming. Should not be used during pregnancy unless clearly necessary. Should not be used during breastfeeding. Interactions Concomitant use with aminoglycosides or spectinomycin requires special care. Peripheral muscle relaxants should be used with caution. 4-aminoquinolines may reduce the effect. Undesirable effects Usually observed within the first week after treatment. Localised muscle weakness, blepharoptosis, localised pain, tenderness, itching, swelling and/or haematoma can occur in conjunction with the injection. Temporary vasovagal reactions associated with pre-injection anxiety, such as syncope, circulatory problems, nausea or tinnitus, may occur. Frequency defined as follows: very common (≥ 1/10); common (≥ 1/100, < 1/10); uncommon (≥ 1/1000, < 1/100); rare (≥ 1/10,000, < 1/1000); very rare (< 1/10,000). Glabellar Frown Lines: Infections and infestations; Uncommon: bronchitis, nasopharyngitis, influenza infection. Psychiatric disorders; Uncommon: depression, insomnia. Nervous system disorders; Common: headache. Uncommon: facial paresis (brow ptosis), vasovagal syncope, paraesthesia, dizziness. Eye disorders; Uncommon: eyelid oedema, eyelid ptosis, blurred vision, blepharitis, eye pain. Ear and Labyrinth disorders; Uncommon: tinnitus. Gastrointestinal disorders; Uncommon: nausea, dry mouth. Skin and subcutaneous tissue disorders; Uncommon: pruritus, skin nodule, photosensitivity, dry skin. Musculoskeletal and connective tissue disorders; Common: muscle disorders (elevation of eyebrow), sensation of heaviness. Uncommon: muscle twitching, muscle cramps. General disorders and administration site conditions; Uncommon: injection site reactions (bruising, pruritis), tenderness, Influenza like illness, fatigue (tiredness). Crow’s Feet Lines: Eye disorders; Common: eyelid oedema, dry eye. General disorders and administration site conditions; Common: injection site haemotoma.
Post-Marketing Experience; Flu-like symptoms and hypersensitivity reactions like swelling, oedema (also apart from injection site), erythema, pruritus, rash (local and generalised) and breathlessness have been reported. Overdose May result in pronounced neuromuscular paralysis distant from the injection site. Symptoms are not immediately apparent post-injection. Bocouture® may only be used by physicians with suitable qualifications and proven experience in the application of Botulinum toxin. Legal Category: POM. List Price 50 U/vial £72.00 Product Licence Number: PL 29978/0002 Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer Landstraße 100, 60318 Frankfurt/Main, Germany. Date of revision of text: August 2014. Further information available from: Merz Pharma UK Ltd., 260 Centennial Park, Elstree Hill South, Elstree, Hertfordshire WD6 3SR.Tel: +44 (0) 333 200 4143 Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard Adverse events should also be reported to Merz Pharma UK Ltd at the address above or by email to medical.information@merz.com or on +44 (0) 333 200 4143. 1. Bocouture 50U Summary of Product Characteristics. Bocouture SPC 2014 August available from: URL: http://www.medicines. org.uk/emc/medicine/23251. 2. Prager, W et al. Onset, longevity, and patient satisfaction with incobotulinumtoxinA for the treatment of glabellar frown lines: a single-arm prospective clinical study. Clin. Interventions in Aging 2013; 8: 449-456. 3. Sattler, G et al. Noninferiority of IncobotulinumtoxinA, free from complexing proteins, compared with another botulinum toxin type A in the treatment of glabelllar frown lines. Dermatol Surg 2010; 36: 2146-2154. 4. Prager W, et al. Botulinum toxin type A treatment to the upper face: retrospective analysis of daily practice. Clin. Cosmetic Invest Dermatol 2012; 4: 53-58. 5. Data on File: BOC-DOF-11-001_01 Bocouture® is a registered trademark of Merz Pharma GmbH & Co, KGaA. 1182/BOC/OCT/2014/LD Date of preparation: October 2014
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Botulinum toxin type A free from complexing proteins