Body Language Journal #72

june

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

SKIN PHYSIOLOGY OUR SKIN TELLS OUR LIFE STORY—DR BETH BRIDEN DISCUSSES HOW TO ENHANCE IT

ACNE VULGARIS

EQUIPMENT

RHINOPLASTY

The causes and topical treatments currently available

Key considerations when purchasing new systems for your aesthetic practice

The art of non-surgical nasal contouring with injectables

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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, Julie Brackenbury, Jane Lewis, Dr JJ Masani, Dr Shirin Sammi-Fard, Dr Zein Obagi, Gilly Dickons, Dr Raj Persaud, Dr Raj Kanodia, Dr Christopher Rowland-Payne, Dr Mark Tager 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

SKIN PHYSIOLOGY Dr Beth Briden discusses the physiology and functions of our skin

21 SKINCARE ACNE VULGARIS: A REVIEW OF THE TOPICAL TREATMENTS

with minimal or no scarring

33 RADIOFREQUENCY TREATING WRINKLES USING RF Dr Shirin Sammi-Fard discusses non-invasive approaches for face and body tightening

37 DERMATOLOGY FRACTIONATED MELANIN— A MAJOR ADVANCE IN SUN PROTECTION

Julie Brackenbury outlines cause, myths, and various topical treatment options currently available for acne

Dr Zein Obagi describes the benefits of topical application of fractionated melanin, including protection against the damaging effects of high energy visible light

26 DEVICES

41 CLINIC

LIGHTING UP ACNE TREATMENT

HANDLING ENQUIRIES: THE IMPORTANCE OF FIRST IMPRESSIONS

Jane Lewis reflects on using Isolaz, a device that can be used alone to treat acne, or combined with conventional therapies

29 MEDICAL AESTHETICS USING RADIO SURGERY FOR NAEVI EXCISION Dr JJ Masani takes us through the process of using radio waves to remove moles

Gilly Dickons explains the importance of making a good first impression to clients over the phone.

45 PSYCHOLOGY UGH! THAT’S SO DISGUSTING! HOW REPULSION PREDICTS YOUR SEX LIFE Dr Raj Persaud examines how

4 CONTENTS I body language

editorial panel 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.

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

She is now director of education at LCS Academy Ltd.

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

Dr Cummings works as an expert witness.

57 disgust may be inhibited in reproductive situations, and how attitudes to disgust could be linked to our mating, love or sex strategies

47 PRODUCTS ON THE MARKET The latest anti-ageing and medical aesthetic products and services

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.

49 INJECTABLES

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.

53 DERMATOLOGY

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

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

INJECTABLE RHINOPLASTY Dr Raj Kanodia talks about the about the art of non-surgical nasal contouring.

SIMPLE, EFFECTIVE AND INEXPENSIVE SKIN TREATMENTS Dr Christopher Rowland-Payne discusses alternatives to expensive devices for the treatment of moles, brown spots, unwanted thread veins and scars

57 EQUIPMENT GETTING THE RIGHT EQUIPMENT Dr Mark Tager advises on key considerations when purchasing equipment for your practice.

62 EDUCATION TRAINING A comprehensive course calendar for the industry

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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

LOOK HOW YOU FEEL Azzalure Abbreviated Prescribing Information (UK & IRE)

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

site(s) or when the targeted muscle shows excessive weakness or 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

(twitching of muscles around the eyes). Uncommon (≥ 1/1,000 to <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/021/0313

body language I NEWS 7

observations

MATHEMATICIANS ARGUE THAT ‘GOLDEN RATIO’ DOES NOT MEASURE BEAUTY CONDITIONS The Smithsonian stall has sparked a debate between mathematicians about whether beauty can actually be measured.

At the National Math Festival in the US this May, the Smithsonian showcased a stall which claimed that the golden ratio could be applied to human beauty.

The golden ratio is often cited as the formula that determines how beautiful something or someone is. Explained by Science Alert the golden ratio “was first described by mathematician Euclid in the third century BC, [it] can be calculated by dividing a line into a longer and shorter section. When the ratio between the whole line and the longest section is the same as the ratio between the longest and shortest section, the line is in the ‘golden ratio’.”

Speaking with The Independent, Mathematician and professor at Randolph–Macon College in Virginia, Eve Torrence stated “There are lots of ratios and proportions in the human body, but they are not all the golden ratio and they are not all precisely the golden ratio. It’s a very loosey-goosey, pseudo-science kind of thing that they are promoting.”

The ratio can be used as a measurement and has been applied in NEW APPOINTMENTS Nadine Francis has joined the SkinFirst team.

She has ten years’ experience working with top establishments in the UK and Canada, and will be specialising in body contouring, skin tightening, lifting and peels. SkinFirst distribute their systems to medical practitioners worldwide.

Vanessa Bird has joined BTL Aesthetics as their Sales Manager, covering the whole of the UK. Lee Boulderstone, UK Manager said, “We are extremely happy that Vanessa has chosen to join our award-winning team. With her passion, experience and professionalism, we only see BTL Aesthetics getting stronger over the coming months.”

architecture and by artists over the last few hundred years. It can also be naturally occurring in spiral patterns seen in plants and seashells.

Plastic surgeons have been known to cite the golden ratio as a way of measuring beauty. In 2009 US and Canadian researchers at the University of Toronto conducted a study into the perfect facial ratios.

The study involved Photoshopped images of women’s faces with different dimensions. Men were then asked to choose which they found more attractive. The study claimed to have found a new ‘Golden Ratio’ of beauty.

Many practices and surgeons do claim to follow the golden ratio calculations, using the mathematics to judge and measure the changes made to a patients face.

According to The Independent, plastic surgeon Dr Stephen Marquardt, chief executive of Marquardt Beauty Analysis in California, has patented facial grids derived from the golden ratio to guide surgery.

However Professor Torrence had this to say: “There’s not this number that’s got this perfection in the

way people think it does. It feels dirty to mathematicians. It’s hocuspocus.”

Other mathematicians seem to agree. According to The Independent Dr Keith Devlin, a mathematician at Stanford University, states that Euclid did not claim the ratio had any aesthetic qualities. Dr Devlin said that this idea came later in the way of Gustav Theodor Fechner, a 19th-century German psychologist.

Colm Mulcahy, a professor of mathematics at Spelman College in Atlanta tweeted “Here we go again, rubbish re: Golden Ratio. Horrah for Eve Torrence and @profkeithdevlin for telling it like it is!”

Dr Devlin went on to say that people prefer the shapes and proportions that they have become accustomed to, like a sheet of A4 paper.

There was general agreement between mathematicians that there is a lot more to contemplate than just the golden ratio when it comes to beauty.

However, Dr Marquardt responded “I would say they [mathematicians] haven’t done their homework...”

8 NEWS I body language

events 2-6 JUNE, Annual Meeting of the Canadian Society of Plastic Surgeons (CSPS), Victoria, Canada W: plasticsurgery.ca/annualmeeting.php 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/meetings

SURVEY FINDS BRITS ARE FAILING TO TAKE SKIN CANCER PRECAUTIONS The British Association of Dermatologists (BAD) survey reveals a worrying attitude towards the UK’s most common form of cancer.

The survey, released for Sun Awareness Week 2015 showed that 72 percent of people had been sunburnt during the last year. Sunburn more than doubles the risk of developing melanoma, which is the deadliest form of skin cancer.

The survey, which included answers from 1,018 people, also found that: • 96% of Brits fail to check their skin once a month for skin cancer (which is recommended) • 84% are worried about skin cancer in the UK climate • 88% don’t think skin cancer is any easier to remove than other cancers • 95% know skin cancer rates in the UK are still rising • 77% do not feel confident that they could recognise signs of a melanoma.

• 81% do not feel confident that they could recognise signs of a non-melano ma skin cancer.

Skin cancer results in around 2,148 deaths every year. Over 250,000 new cases of nonmelanoma and 13,000 new cases of melanoma skin cancer are diagnosed annually.

Johnathon Major of the British Association of Dermatologists said, “Almost threequarters of people we surveyed admitted that they had been sunburned in the last year,

which is shocking. With sunny days already making an appearance in parts of the UK, it is likely that this figure will remain high this year. This is a reflection of poor sun protection habits – people underestimate the damage that sunburn can do to their skin, and many think that skin reddening is just a harmless part of the tanning process, rather than a sure sign that you have damaged your skin irreparably.”

Charlotte Proby, Professor of Dermatology at Ninewells Hospital and Medical School in Dundee, and Chair of the British Association of Dermatologists’ Skin Cancer Prevention Committee said, “Rising skin cancer rates are a major health concern for the UK, and some dermatology departments are stretched to capacity trying to keep up with cases.

“Many people in the UK are aware of the dangers; however, this has yet to translate into a culture of sun protection and skin checking which would do a lot to curb the incidence and deaths from this disease. As summer comes around again we want people to consider the message that you can enjoy the warm weather whilst staying safe.”

Sun Awareness Week 2015 was organised in partnership with sponsor La Roche-Posay and was celebrated with events throughout the UK.

8-13 JUNE, World Congress of Dermatology (WCD), Vancouver, Canada W: derm2015.org 17-19 JUNE, International Course on Plastic and Aesthetic Surgery, Barcelona, Spain W: clinicaplanas.com 18-21 JUNE, International Eurasian Aesthetic Plastic Surgery Course, Istanbul, Turkey W: eurasian2015.org 25-27 JUNE, 2nd ICAD BRAZIL, Sao Paulo, Brazil W: euromedicom.com/icad-brazil/index. html 6-10 JULY, International Congress of the International Confederation for Plastic Reconstructive and Aesthetic Surgery (IPRAS), Vienna, Austria W: ipras2015.com 7-9 JULY, Annual Meeting of the British Association of Dermatologists (BAD), Southampton, UK W: bad.org.uk 8-9 JULY, Asia Sun Protection & AntiAgeing Skin Care, Hilton Singapore W: summit-events.com 31 JULY – 2 AUGUST, IMCAS Asia 2015, Bali, Indonesia W: imcas.com 5-7 AUGUST, FIME, Miami, USA W: medicamatch.com/en 3-6 SEPTEMBER, 5CC: Laser and Aesthetic Medicine (Five Continent Congress), Cannes, France W: 5-cc.com 4-6 SEPTEMBER, Controversies, Art & Technology in Facial Aesthetic Surgery, Gent, Belgium W: coupureseminars.com 9-12 SEPTEMBER, Annual Meeting of the European Society for Dermatological Research (ESDR), Rotterdam, Netherlands W: esdr.org 18-19 SEPTEMBER, 8th Mediterranean Congress of Aesthetic Surgery - Focus on the Face Lift and the Face AntiAging, Montpellier, France W: isaps.org

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body language I NEWS 11

PLASTIC SURGERY CAN LEAD TO INCREASED HEALTH CARE COSTS FOR OBESE PATIENTS A new study finds that overweight patients are more likely to use health care during their postoperative period.

NEW TOOL HELPS PHYSICIANS TO DIAGNOSE SKIN CONDITIONS A computer-assisted device is improving diagnostic accuracy with the help of a photo database.

A major study by researchers at the Perelman School of Medicine at the University of Pennsylvania found that software diagnostic tool, VisualDx, helps physicians to assess dermatologic conditions without calling on dermatologists.

Published online in Diagnosis, the study found that after VisualDx was introduced to Hospital of the University of Pennsylvania, the rate of dermatologic consultations did not change for 18 months. This differed from the previous 12 months.

Computer-assisted, photo-driven differential diagnosis generators aim to improve accuracy and reduce misdiagnosis, as this can cause serious problems. The VisualDx for skin conditions lets physicians enter information such as the type and location of a rash, and symptoms such as pain or itching. The tool then generates a range of possible diagnoses and photographs, so that physicians can quickly compare skin conditions to the image database. It contains 1,300 paediatric and adult skin conditions represented by nearly 30,000 images.

Dr Craig A. Umscheid is senior author of the study and assistant professor of Medicine and Epidemiology and director of the Penn Medicine Centre for Evidence-based Practice. “These tools by design suggest numerous potential diagnoses, which could result in an increase in unnecessary testing and specialty consultation, and associated costs and harms, particularly in the hands of less experi-

enced clinicians,” he explains.

“Conversely, if there were a significant reduction in dermatologic consultations, it would have suggested that general internists, emergency room physicians, family doctors and pediatricians, all of whom by definition are not specialists in dermatology, may have relied on the tool to make dermatologic diagnoses, rather than consulting a dermatologist for help.”

Throughout the 18 months of the study, researchers found a median of 474 unique monthly VisualDx sessions by users. VisualDx was mainly accessed through mobile devices (35%) and inpatient electronic health records (34%).

“Technology like this has great promise, but it can’t help patients unless it’s actually used,” says Dr Umscheid. “Previous studies have been primarily simulations, where researchers take variables from case studies and input them into the software to retroactively assess the diagnostic accuracy of the software. However, our purpose was to determine if a differential diagnosis generator like VisualDx would actually be used by providers if implemented in a hospital, and we found that it is—most often on mobile devices and by inpatient providers.”

Lead author, Dr John Barbieri adds, “The technology can help users overcome cognitive shortcomings such as availability bias, in which providers diagnose patients with conditions they’ve recently seen or can easily recall, rather than those conditions that are most likely to occur.”

Published in the May issue of Plastic and Reconstructive Surgery®, the study reports that in the 30 days following common plastic surgery procedures, overweight and obese patients have more complications than those who are not overweight.

The study reported that obese patients were likely to have health care charges of £7,400 more than patients who were not overweight.

The study authors used ambulatory surgery databases from four different US states, reviewing 48,000 liposuction, abdominoplasty, breast reduction, or blepharoplasty procedures.

Nearly 4 percent were obese patients based on their body mass index and had higher rates of comorbid medical conditions like diabetes and cardiovascular disease.

Within 30 days after surgery, 7.3 percent of obese patients made an emergency department visit or were admitted to the hospital, compared to just 3.9 percent of nonobese patients. After adjustment for comorbid conditions and other factors, relative risk was 35 percent higher for obese patients.

The relative risk of serious adverse events within 30 days after plastic surgery was 72 percent higher for the obese patients.

Dr. Sieffert and coauthors write, “Throughout the perioperative period, it is important to educate overweight and obese patients regarding their risk of complications, as well as the importance of medical optimisation of their comorbid conditions.”

Syneron Candela Launches Breakthrough Technology. Again.

Introducing PicoWay. PicoWay is a remarkably innovative dual wavelength picosecond laser from Syneron Candela, the most trusted brand in lasers. With both 532nm and 1064nm wavelengths, PicoWay can treat a very broad range of pigmented lesions and tattoo types and colors on any skin type.

PicoWay has the highest peak power and the shortest pulse duration of any picosecond laser for superior efficacy, safety and comfort. Proprietary PicoWay technology creates the purest photo-mechanical interaction available to most effectively impact tattoo ink and pigmented lesions, without the negative thermal effects of other lasers.

And, PicoWay has the reliability physicians want.

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Š2014. All rights reserved. Syneron and the Syneron logo are registered trademarks of Syneron Medical Ltd. and may be registered in certain jurisdictions. PicoWay and Candela are registered trademarks of the Candela Corporation. PB85961EN

body language I NEWS 13

FDA APPROVES TREATMENT THAT REDUCES FAT BELOW THE CHIN A deoxycholic acid, Kybella, has been approved by the FDA as a treatment for submental fat.

Kybella has recently been approved by the U.S. Food and Drug Administration as a treatment for adults with moderate-to-severe fat below the chin, known as submental fat. Kybella is a deoxycholic acid, which our bodies produce naturally to help us absorb fat. It destroys cell membranes and fat cells when injected, so is only approved and recommended for the treatment of fat in the submental area. The safety and effectiveness of Kybella for treatment was established in two clinical trials across 1,022 adults with moderate or severe submental fat.

Kybella is a cytolytic drug, administered to patients as an injection. According to the FDA, patients can receive up to 50 injections in a single treatment.

They can have up to six single treatments, which must be at least one month apart.

“It is important to remember that Kybella is only approved for the treatment of fat occurring below the chin, and it is not known if Kybella is safe or effective for treatment outside of this area,” says Dr Amy G. Egan M.P.H., deputy director of the Office of Drug Evaluation III in the FDA’s Center for Drug Evaluation and Research.

In both clinical trials, participants were randomly assigned to receive Kybella or a placebo for up to six treatments. The results showed that reductions in submental fat were more frequent in participants who received Kybella versus the placebo.

Side effects can include nerve injury in the jaw, which can lead to facial muscle weakness and trouble swallowing. The most common side effects of Kybella include swelling, bruising, pain, numbness, redness and areas of hardness in the treatment area.

The FDA advises that Kybella should not be used if there is an infection at the injection site and should be used with caution in patients who have had prior surgical or aesthetic treatment of the submental area.

WILL SOCIAL MEDIA IMPACT ON COSMETIC SURGERY IN 2015?

2014 saw a drop in cosmetic surgeries, but some predict that social media will see it rise again.

In early 2015, the British Association of Aesthetic Plastic Surgeons (BAAPS) announced that cosmetic surgery in the UK had decreased by 9% for the first time in over 10 years. The BAAPS acknowledged that this was positive as it meant that the public were becoming more educated about surgery, no longer seeing it as just a quick fix. However The Telegraph believes the slump may have been caused by a “post-austerity boom” correcting itself, with patients unwilling to pay for expensive surgeries.

The Telegraph also reported that Key Note, a market intelligence agency, expects cosmetic surgery to rise in 2015 and continue to increase in coming years due to an ageing population and spread of social media ‘selfies’.

Smaller procedures, such as facelifts and eye surgery, have remained much the same, but tummy tucks and nose jobs reduced significantly, with breast augmentation decreasing by 23 percent.

However, breast augmentation was still the most popular procedure and surgical liposuction actually increased by 10%. So although 2014 saw a fall in cosmetic surgery overall, it may also mean

that the types of surgery the public want is changing.

In 2014, researchers at the University of Strathclyde, Ohio University and University of Iowa surveyed 881 female college students in the US. They found a link between time they spent on social networks and negative comparisons about body image.

The American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) also did a members survey in 2014 which they used to predict a rise in certain surgeries in 2015. The survey says that “people are also seeking cosmetic procedures due… a desire to look better in selfies, Instagram and other social media platforms.” President of AAFPRS, Dr Stephen S. Park said, “We live in the digital age where social media platforms capture events in real time, and we get tagged in photos that are posted online for everyone to see. Trends like the Selfie Stick make people look at their faces in a hypercritical way.”

An earlier study by the AAFPRS also revealed that one in three surgeons surveyed saw an increase in requests for facial procedures due to patients “being more self aware of looks in social media.”

14 DERMATOLOGY I body language

Skin physiology DR BETH BRIDEN discusses the physiology and functions of our skin

O

ur skin tells our life story. It shows whether we are healthy, or if we have internal disease; it shows if we have had a life with a lot of outdoor activity and a lot of ultraviolet sun exposure, and it shows our age. This means it’s important to understand the physiology of the skin and what we can do to enhance it.

The skin is a very unique organ with many functions. One of it’s main functions is to protect us from environmental dangers such as extreme heat, cold, ultraviolet light, pollutants, external irritants. It also helps maintain internal hydration, and protects our internal organs. It is very important in temperature regulation, containing sweat glands to dissipating heat through sweat-

ing and helping generate heat by forming “goose bumps” and a shivering reaction. It is also very important in producing vitamin D, which is involved in multiple functions. Researchers have found recently that vitamin D levels are markedly decreasing with the use of sunscreens, so it’s important to make sure that we maintain healthy levels of vitamin D, either with limited sun exposure or oral

body language I DERMATOLOGY 15

supplementation.

The skin is the largest organ of the body, weighing nearly 9 lbs. It’s one of the few organs that has the ability to continually renew itself, allowing us to heal well after superficial cuts and scrapes. About every 30 days our epidermis renews itself, with older, dead cells being shed off and replaced by new cells.

66 With ageing we see a significant redistribution of the subcutaneous fat on our facial area—when we’re young we have a nice round face 99

The subcutaneous layer Skin is comprised of three layers: epidermis, dermis and subcutaneous. The deepest layer of subcutaneous tissue is the fat layer. We all have a given number of fat cells , which enlarge and shrink, depending on how much fat we store. The fat layer can store lipophilic hormones—such as oestrogens that can remain in the fatty layer for years and can be released into the body for years.

Our fat layer provides energy storage and stores and releases energy by breaking down fat into triglycerides and fatty acids. This occurs in “starvation” states to release energy in our system as needed. The subcutaneous tissue is helpful in maintaining body heat in winter. Animals that hibernate, like bears, have a thicker fat layer to help them keep their

body temperature and maintain their warmth throughout the cold winter months.

As dermatologists and cosmetic surgeons, we try to manipulate the subcutaneous layer to enhance beauty. We currently have technology to tighten the skin by using lasers (ultrasound, radiofrequency, and infrared) that affect the fibrous connective tissue between the fat cells. We can also reduce the fat cells with liposuction to remove fat cells, and newer technology allows us to use LED lights to “break down” fat into triglycerides to be removed in targeted areas. In the case of liposuction, since we do not generate new fat cells, if a patient then regains weight and has lost fat cells in a certain area, the skin becomes lumpy and is not uniform throughout.

The LED photo-modulation

16 DERMATOLOGY I body language

these changes if we are going to address the full aspects of ageing. We can correct the volume redistribution that occurs with ageing with surgery, tissue tightening, fillers and liposuction.

The Dermis The dermis is one of our main structural components of the skin and it is also the thickest layer. It contains our structural proteins, collagen and elastic tissue and ground substance containing acid

mucopolysaccharides, which bathe our collagen and elastic fibres. It also contains some of our immune modulators, including Langerhans cells and mast which involved in our body’s immunity. Mast cells release histamine and heparin, which are responsible for allergic reactions and hives.

The dermis contains the blood supply and the pain sensors. The dermis also is continually reproducing itself, but, at a slower rate than the epidermis. Enzymes such as collagenase, elastase and hyaluronidase that are constantly breaking down the ground substance, the hyaluronic acid, the collagen molecules and the elastic fibres so they can be reformed. Our fibroblasts work overtime there and always produce new collagen elastic tissue and ground substance.

80% of the dermis is comprised of the collagen, which is usually Type 1 and Type 4. This can actually become damaged with ultraviolet and glycation forming age products, which are called the advanced glycation end-products.

The skin is the largest organ of the body and has the ability to continually renew itself, allowing us to heal well after superficial cuts and scrapes

66 The elastic fibres, which provide the recoil and the elasticity of the skin, represent only a small percentage of the dermis 66

stimulates a starvation state and break down fats from the adipose tissue into the triglycerides and fatty acids. Then the triglycerides are circulated in the blood and can be burned off by exercising within 2-3 hours of the procedure. If the triglycerides are not burned off, they are re-deposited back into the fat layer. This treatment allows us to target fat reduction in specific areas such as the thighs or “love handles”. This technique does not remove fat cells, but shrinks the size, simulating a more realistic physiologic state.

With ageing we see a significant redistribution of the subcutaneous fat on our facial area. When we’re young we have a nice round face.

With ageing the muscles relax, they cannot maintain their tightness, the facial bones resorb and get smaller, and the epidermis and dermis thin and the elastic fibres in the dermis lose their recoil ability, and connective tissue and elasticity comes out of the skin. The elastic tissues and collagen gets damaged and glycated so that the skin becomes stiffer and less resilient.

Subsequently the subcutaneous fat tends to fall and we get a more triangular-shaped face with jowls and fat on the chin. We need to address

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18 DERMATOLOGY I body language

mide, which is an acetylated amino acid that has been shown to plump dermal thickness. These can just be applied topically in addition to the injectables to enhance and maintain dermal thickness.

The extracellular matrix of the dermis contains macrophages, which are phagocytic cells that are involved in clearing up pigment or debris. We have our immune system, the lymphocytes, the mast cells and the neutrophils in the dermis, and the fibres that give it the structure, that are constantly renewing themselves.

If you can combine some of the dermal repair plumping agents, studies show that there is a synergistic effect. If you combine retinoids with alpha-hydroxy acids and poly-hydroxy acids you get a much more dramatic affect.

If you combine retinoids and N-acetylglucosamine you will also plump up the dermal matrix much more than by using either agent on their own. Peptides, like the Matrixyl, can combine with retinoids to provide skin maintenance and fitness. Using some of these compounds means that skin doesnâ&#x20AC;&#x2122;t keep atrophying, because by itself it canâ&#x20AC;&#x2122;t keep up with the normal production and tends to atrophy and thin with age.

We need to be able to protect ourselves from environmental insultsâ&#x20AC;&#x201D;sunscreens that contain antioxidants are better than just sunscreens alone

These accumulate and can give skin that yellow sallowness colour.

The elastic fibres, which provide the recoil and the elasticity of the skin, represent only a small percentage of the dermis. With aging and photo-damage they become shorter and clumpy and lose their ability to elongate and recoil as illustrated with laxity of the skin and solar elastosis.

The ground substance also decreases in the dermis with aging as production decreases. This is

where fillers like hyaluronic acid can be added to help plump up and restore volume to the dermis.

We can also stimulate production of new ground substance, elastic fibres and collagen by applying topical lotions, such as retinoids, alpha-hydroxy acids and poly-hydroxy acids.

A very effective topical agent, N-acetylglucosamine is a precursor to hyaluronic acid, which is absorbed and plumps the skin.

There is also N-acetyl tyrosina-

The Epidermis The top layer of the skin, the epidermis, provides our epidermal/ dermal barrier, which protects us from absorbing harmful chemicals.

We need to look at the structure of its lipid components to understand how molecules can penetrate. Only small molecules can really penetrate the epidermis. Large molecules, such as high molecular weight hyaluronic acid, are unable to penetrate the epidermal barrier.

To understand the barrier function of the epidermis is important to look at the stratum corneum, which is the top, dead layer of the epidermis. With ageing, the stratum corneum becomes more compact and thinner. This can make our skin look dry, sallow and leathery. The dead cells of the stratum corneum need to be shed off naturally and return it to its nor-

body language I DERMATOLOGY 19

mal basket-weave pattern, to give us that normal skin barrier.

There are many lipids, including the ceramides, cholesterol and fatty acids, that comprise this barrier. Using harsh products that contain alcohol or dehydrating agents will dry this out, make it become more compact and lose its normal barrier function.

The barrier function of the stratum corneum is very important in maintaining the hydration of the skin. We know that when we lose some of the oils and lipids of our skin barrier, that water can evaporate causing our skin to become very dehydrated, red, cracked and irritated.

We can measure the effectiveness of our barrier function by looking at transepidermal water loss—the water that evaporates from the skin. If the barrier is disrupted and not functioning properly, water will be lost from the skin. There are certain things that can actually improve on trans-epidermal water loss and the barrier function. These are poly-hydroxy acids, bionic acids and ceramides.

Sometimes retinoids can irritate and break down the skin barrier a little bit, even though they are good exfoliants.

Our normal cell renewal process is called exuviation. Every 28 days our whole epidermis and stratum corneum renews itself. This does tend to slow down, as the cells get a little bit stickier. 50% of the skin diseases that we know of are due to abnormal keratinisation or exuviation, so if we can normalise the skin barrier and the process of exuviation, we can actually improve many of our skin disorders and restore the tolerability.

Ageing of the epidermis creates a more compact, thickened stratum corneum. In the dermis, photodamage causes solar elastosis—where the elastic fibres clump together and are not uniform. This is frequently called the grenz zone of sun damage or solar elastosis. After some topical treatment like alphahydroxy acids you can restore a normal basket-weave pattern, collagen, glycoaminoglycans and normal elastic fibres. The epidermis

also becomes thicker and plumper, you maintain the ridges and that normal underlying pattern, and you can actually restore.

Factors in skin function Internal ageing also has an effect on the skin. The normal process of cell renewal, both in the epidermis and dermis, slows down naturally with ageing. Other external factors such as pollution can damage our skin. The reactive oxygen species and free radicals that form from exposure to ultraviolet light and pollution set up an inflammatory

cascade of enzymes such as MMPs, collagenase, elastase and hyaluronidase that damage our skin.

We need to be able to protect ourselves from environmental insults. Sunscreens that contain antioxidants are better than just sunscreens alone. We also need to moisturise the skin barrier and restore some of the natural skin barrier function and natural oils, like ceramides.

Dr Briden is founder of the Advanced Dermatology and Cosmetic Institute in Edina, USA.

SKIN TYPES Knowing the type of skin that patients have is essential for choosing the right products, cleansers and moisturisers.

Dry skin usually has reduced water content and often has less oil on the skin to serve as a barrier and to trap the water in the skin.

People with oily skin usually have enlarged pores that are more prone to seborrheic dermatitis and acne. For this we want to use more surfactant type cleansers to reduce some of the oil, but not to disrupt that barrier and dehydrate the skin.

Combination skin has a higher concentration of oil glands across the forehead and down the centre of the face, so this is important in our teenagers, young adults and even older adults as their skin gets drier.

Regular skin that usually tolerates normal stimuli and irritants without a heightened response.

Sensitive skin reacts to everything. It can sometimes be a little bit drier, but there is always a heightened sensory response. When surveyed, over 70% of women feel that they have sensitive skin. This could be due to all the cleansers, cosmetics and toners that we put on our skin which may disrupt the skin barrier. Rosacea patients have sensitive skin and we have shown in several studies and publications that by even doing glycolic peels we can improve that skin barrier and make the skin more tolerant to reduce some of the erythema. Antioxidants are also great for doing this.

Fitzpatrick skin-types do contain pigments and we need to know a patient’s skin type. Type I has red-hair and a freckled face; Type II usually burns and then tans; Type III has minimal skin-burning.

The darker the pigment, the more the risk for post-inflammatory hyperpigmentation, and less risk for photo damage. However they can still get photo damage and should still use sunscreens.

Ageing skin is characterised by any number of things—from fine lines, wrinkles, age spots, and pigmentation, to the uneven skin tone and the redistribution of the skin volume. These are things that you need to address and have a good understanding of.

Photo ageing is just an accelerated decline in the normal skin turnover and renewal process.

You get damage to the collagen, elastic tissue, the ground substance and thinning of the epidermis. It’s important to be able to use cosmetics, to understand patients’ skin type, to enhance exuviation, to prep them for continued renewal for your cosmetic procedures, and also for maintaining the effects and decreasing the degradation after your cosmetic procedures. We need to affect all layers of the skin, from the stratum corneum down to the subcutaneous. Understanding all these compartments is very important in the treatment of skin disease and anti-ageing features in our cosmetic procedures.

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body language I SKINCARE 21

Acne vulgaris: a review of the topical treatments JULIE BRACKENBURY outlines cause, myths, and various topical treatment options currently available for acne

A

s an aesthetic nurse practitioner who suffered from severe acne at age 18, helping others who suffer from this disease has become one of my passions. There are various topical treatments available as per guidance and recommendations from NICE. Whilst examining these, I would like to share my insight into how a patient may have already been managed in primary care before deciding to seek a second opinion from a private dermatological service.

Introduction Acne is a chronic inflammatory disease of the pilosebaceous unit resulting from androgen-induced increased sebum production, altered keratinisation, inflammation, and bacterial colonisation of hair follicles on the face, neck, chest, and back by Propionibacterium acnes.

Cause and effect According to Goulden et al, although the pathogenesis of acne is multifactorial, the key factor is genetics and they suggest that familial factors are important to bear in mind both when determining an individual’s susceptibility to acne and in medical consultations. An

evolutionary perspective as outlined by Eckel suggests that sebum (oil naturally produced within our skin) has no purpose apart from causing skin disease. He suggests that dryness, eczema, rosacea, large pores, fine lines, pigmentation and age spots are all down to the presence of oil and advocates that as humans evolved, we lost the hair from all over our bodies—however, the oil glands designed to lubricate our hair follicles remained.

Myths about acne There are plenty of ‘old wives’ tales about topical treatments that are reported to help acne, but actually have no therapeutic effect. Some example include using aloe vera, egg white, honey, sudocrem, TCP, distilled white vinegar, cucumber, teatree oil and toothpaste—this is certainly not an exhaustive list.

With reference to the teatree oil as a myth, recent research from the International Journal of Antimicrobial Agents has challenged this and found that in fact, tea tree oil does reduce lesion numbers in patients with mild-to-moderate acne. It’s tolerability is similar to other topical treatments whilst the efficacy may be attributed to antimicrobial and anti-inflammatory activities.

More importantly, experts believe

that dispelling ‘myths’ is an integral component of the management of acne thus, practitioners need to be mindful about educating patients about such myths.

However, one of the challenges we face in practice is the internet and mass media, which can often result in our clinical judgement and expertise being questioned.

Fig.1 demonstrates the stages of acne from a normal follicle to a pustle and may be useful in showing a patient such a diagram/illustration to assist in understanding.

Dietary link A systematic review of the literature found no clear evidence of dietary components increasing the risk of acne development. However, one small randomised controlled trial Grading

Presentation

Mild

Non-inflamed comedones

Moderate

Non-inflammatory comedones, inflmmatory papules andmay extent to the back and shoulders

Severe

Nodules and cysts as well as inflammatory papules and pustules

22 SKINCARE I body language

showed that low glycaemic index (GI) diets can lower acne severity.

Evidence suggests that Western diets, particularly dairy products, require closer scrutiny.

Fat or fibre intake may also mediate the effect of diet on acne risk.

A study by Burris et al found that a high glycemic load diet, processed cheese, a high-fat diet and iodine play a role in the exacerbation of acne in Korean adults. In addition, irregular dietary habits may also aggravate acne.

First line topical treatments for mild acne Benzoyl Peroxide (BPO)  Acnecide (Galderma UK Ltd)  Brevoxyl (GlaxoSmithKline Consumer Healthcare)  PanOxyl (GlaxoSmithKline Consumer Healthcare) If papules and pustules are present, BPO is recommended as a first-line treatment. It is a potent bactericide that reduces the P. acnes and is effective in treating mild to moderate acne. P. acnes cannot live in the pres-

ence of oxygen and BPO strength of 2.5% or more, applied once or twice daily is needed for it to have any effect. BPO is available over the counter, but generally patients will be unaware of this. There is good evidence from placebo-controlled trials that benzoyl peroxide reduces both inflammatory and non-inflammatory lesions, although, it is important to note that combination treatment is rarely necessary at this stage for mild acne.

Combined preparations Duac Once Daily from Stiefel, contains BPO and clindamycin and has demonstrated a better tolerability profile than combined antibiotic/BPO during the first two weeks of treatment. Both agents are effective in reducing overall acne severity and achieving high levels of patient satisfaction, and continued use for a further six weeks may be associated with better adherence to therapy, clinical improvement in acne, and quality of life.

Quinoderm from Alliance

Pharmaceuticals, is available over the counter is an effective combined preparation of benzoyl peroxide and potassium hydroxyquinoline sulphate which also has antibacterial and antifungal actions. It is included in this medicine to reinforce the antimicrobial actions of the benzoyl peroxide. It is the only topical acne treatment available without a prescription.

Azelaic acid (Skinoren, Finacea from Bayer HealthCare) is a second-line option that should be considered if other treatments are unsuitable. There is evidence from two small placebo-controlled trials that azelaic acid is effective in the treatment of acne. However, these were taken from small samples and had methodological shortcomings.

Azelaic acid has been shown to be effective in the treatment of comedonal acne and papulopustular, nodular and nodulocystic acne.

Skinoren is a 20% cream licensed for acne vulgaris. It is applied twice a day, but this may be reduced to once a day during the

If papule and pustules are present, BPO is recommended as a first line treatment

body language I SKINCARE 23

over several months according to clinical outcome, although it should be stopped after one month if there is no improvement or deterioration occurs. It is important to note that azelaic acid can lighten the colour of the skin, but this is rarely problematic in practice (it also has a role in reducing post-inflammatory hyperpigmentation in people with dark skin). Similarly, photosensitivity can occur but this is rare and usually mild.

Moderate acne treatment In moderate acne, inflammatory lesions (papules and pustules) predominate. The acne may be widespread and there may be a risk of scarring resulting in considerable psychosocial morbidity - all of which are indications for aggressive treatment. A topical retinoid combined with BPO is an alternative, but this may be poorly tolerated.

Fig. 2 shows the trends in prescribing of topical preparation in general practice in England

first week if the patient has sensitive skin. It is licensed for six months, although it is frequently used for longer periods by specialists.

Finacea is a 15% gel licensed for facial acne vulgaris. It is applied twice a day and can be continued

Topical retinoids  Adapalene (Differin, Galderma UK Ltd)  Adapalene combined with benzoyl peroxide (Epiduo, Galderma UK Ltd)  Isotretinoin (Isotrex, Stiefel)  Isotretinoin combined with an antibacterial (Isotrexin, Stiefel)  Tretinoin combined with antibacterial (AknemycinPlus, Almirall Limited) Topical retinoids normalise follicu-

lar keratinisation, promote drainage of comedones, and inhibit new comedone formation. Unfortunately, they have no direct impact on P. acnes. Therefore, treatment with both a topical retinoid and topical antimicrobial is recommended. It is important to note that there is a lack of evidence from comparative randomised controlled trials to show that any particular topical retinoid is superior to another. Moreover, retinol doesn’t come without it’s side effects, such as redness, dryness and peeling so it is paramount that patients are educated about what to expect. This treatment is absolutely contraindicated in pregnancy due to its teratogenic effects.

Topical antibactericals  Dalacin T (clindamycin1%) (Pharmacia Limited)  Stiemycin (erythromycin2%) (Stiefel)  Zindaclin (clindamycin 1%) (Crawford Healthcare Ltd)  Zineryt (erythromycin 40 mg, zinc acetate 12 mg) (Astellas Pharma Ltd) Topical antibacterial agents are indicated for mild-to-moderate acne and are most effective against papules and pustules. A topical antibiotic combined with BPO or a topical retinoid is the preferred regimen, as it is proven to be effective and may limit the development of bacterial resistance.

Where possible, a topical antibiotic course should be limited to a maximum of 12 weeks. All of the above are licensed for twice daily application, except for clindamycin gel which is licensed for once daily application.

There is no data available to guide practitioners on clinical selection, although topical erythromycin has been associated with increased rates of bacterial resistance.

Topical antibiotics usually cause less irritation than BPO, and have no specific contraindications.

Where possible, treatment with topical antibiotic should be limited to 12 weeks duration. There is good evidence that topical antibiotics are an effective treatment for inflammatory acne, but there is a

24 SKINCARE I body language

lack of reliable comparative data to guide choice of antibiotics.

Fig. 2 shows the trends in prescribing of topical preparation in general practice in England and highlights that topical erythromycin and combined BPO preparations are the most prescribed, whereas tretinonin and azelaic acid are the least prescribed—suggesting that research is being implemented in practice. With any treatment process, treatment concordance is a predominant factor for successful treatment. Relapses are frequent, which ultimately can result in treatment fatigue that may contribute to overall adherence difficulties.

Psychology Acne’s manifestation is not just physical—it’s also emotional.

Qualitative research from a study conducted by Murray and Rhodes study revealed that adults suffering from acne experience;  Feelings of powerlessness  Poor self-image and identify  Negative experiences with social situations, relationship with family and friends, gender, sexuality, romantic relationships.

Private practice Topical preparations constitute, for many, the soul of acne vulgaris therapy. It is vital that practitioners have an historical understanding of the topical treatment regime a patient has been prescribed in the past, to enable a more effective management plan. Moreover, the patient will have more confidence knowing that a practitioner has an overall understanding of his or her history—this will also enhance rapport and the patient-practitioner relationship. It is also important to be aware that patients seeking an initial consultation, or even second opinion within private dermatological practice to discuss their acne, will have a higher expectation. In addition, practitioners must be aware that new research is still required into the therapeutic comparative effectiveness and safety of the many products available, as well as better understanding of the natural history, subtypes, and triggers of acne.

66

Conclusion Topical therapies when used in combination usually improve

Julie Brackenbury is an Aesthetic Nurse Practitioner and Independent Prescriber based South West of England.

References 1. Eckel (2014) Rosacea the Strawberry Fields of Dermatology PRIME Europe Jun 2014 Volume 4 Issue 4 2. National Institute for Health and Care Excellence (2013) Clinical Knowledge Summaries. Acne vulgaris. http://tinyurl.com/qfsoc65 (Accessed 15.04.15) 3. Haider, A. and Shaw, J.C. (2004) Treatment of acne vulgaris.

Journal of the American Medical Association 292(6), 726-735 Williams and Garner (2012) Acne vulgaris The Lancet.

Vol.379(9813):361–37 4. Goulden V, Glass D, Cunliffe WJ. Safety of long term high dose minocycline in the treatment of acne. Br J Dermatol.

1996;134:693–5 5. Bhate, K., and H. C. Williams (2013) Epidemiology of acne vulgaris. British Journal of Dermatology 168.3: 474-485 6. Hammer, K. A (2015) Treatment of acne with tea tree oil (melaleuca) products: A review of efficacy, tolerability and potential modes of action. International Journal of Antimicrobial Agents Vol.45(2):106–110 7. Dawson, Annelise L., and Robert P. Dellavalle (2013) Acne vulgaris. BMJ 346: f2634 8. Smith, Robyn N., et al (2007) A low-glycemic-load diet improves symptoms in acne vulgaris patients: a randomized controlled trial.

The American Journal of Clinical Nutrition 86.1: 107-115 9. Spencer, Elsa H., Hope R. Ferdowsian, and Neal D. Barnard (2009) Diet and acne: a review of the evidence. International Journal of Dermatology 48.4: 339-347 10. Burris, Jennifer, William Rietkerk, and Kathleen Woolf (2013) Acne: the role of medical nutrition therapy. Journal of the Academy

Acne’s manifestation is not just physical—it’s also emotional 99 and can control mild to moderate acne. Ultimately, managing acne vulgaris requires patience, reassurance and time, whilst transparency and authenticity with your patient will enhance rapport and possibly medication concordance. There is no one ideal treatment for acne, although a suitable regimen for reducing lesions can be found for most patients. Overall, knowledge and understanding is key, for both the practitioner and the patient to enable a successful treatment plan.

By combining both disciplines of dermatology and aesthetic medicine, patients with this skin condition can certainly benefit and are more likely to have a successful journey.

of Nutrition and Dietetics 113.3: 416-430 11. Jung, Jae Yoon, et al (2010) The influence of dietary patterns on acne vulgaris in Koreans.” European Journal of Dermatology 20.6: 768-772.

12. Purdy, S., Langston, J. and Tait, L. (2003) Presentation and management of acne in primary care: a retrospective cohort study.

British Journal of General Practice 53(492), 525-529 13. Eichenfield, Lawrence F., and Andrew C. Krakowski (2012) Moderate to severe acne in adolescents with skin of color: benefits of a fixed combination clindamycin phosphate 1.2% and benzoyl peroxide 2.5% aqueous gel. Journal of Drugs in Dermatology: JDD 11.7: 818-824 14. Acne Working Group (2008) Management of mild and moderate acne vulgaris. GP Review 1: 1–11 15. James WD (2005) Clinical practice. Acne. N Eng J Med 352(14) 1463–72 16. Shalita A (2001) The integral role of topical and oral retinoids in the early treatment of acne. J Eur Acad Dermatol Venereol 15(Suppl 3): 43–9 17. Strauss JS, Krowchuk DP, Leyden JJ et al(2007) Guidelines of care for acne vulgaris management. J Am Acad Dermatol 56(4): 651–63 18. Murray, Craig D., and Katharine Rhodes (2005) Nobody likes damaged goods: the experience of adult visible acne. British Journal of Health Psychology 10.2: 183-202.

Fig 1. http://acner.org/acne-info/clogged-pores/acne-stages/(Accessed 15.04.15) Fig 2. NHS Business Services Authority (2013) Skin preparations.

National charts http://tinyurl.com/nhj3xrj (Accessed 15.04.15)

26 DEVICES I body language

Lighting up acne treatment JANE LEWIS reflects on using Isolaz, a device that can be used alone to treat acne, or combined with conventional therapies

I

’ve been practicing as a nurse in this industry for 29 years and I love treating acne patients. Not everybody wants to deal with acne patients, but I find it to be very rewarding, as you can really change people’s lives.

Acne is an inflammatory skin disease, for which there is no cure—what we do as practitioners is help the patients manage their condition. Acne manifests with both blackheads and whiteheads. I often get people coming to me thinking that they don’t have acne at all because they just have blackheads, so part of managing the condition is about education and allowing them to understand their disease and how they may be able to manage it better.

In my clinic we see clients with different grades of acne and we use the“Leeds scale” determine what treatment the clients may be offered.

Using Isolaz for acne Isolaz (Inside Out Light Amplification Treatment Zone ) is a device that treats PHYSIOLOGICAL CHANGES OF ACNE  Increased size of sebaceous glands (hyperplasia) and increased sebum oil production  Hyper proliferation of keratinocytes (increased numbers) with abnormal desquamation blocking outlet of sebaceous glands follicle  Colonisation of follicle by Propionibacterium acnes (“P. Acnes”)  Inflammation and immune response 1 and 2 are stimulated by androgens at puberty  Acne affects mainly the face, the chest, the back and the top of the arms.

acne. This device gently sucks the pore outwards, opening it up and emptying the pore. Isolaz has FDA approval to treat mild to moderate acne.

It uses photopneumatic therapy, which offers a unique combination of vacuum extraction, broadband light and the ability to have an enhancement in topical product application. It was developed and first marketed by Aesthera Corporation in 2002, was bought by Solta Medical in 2008 who are part of the Valeant group of companies. Currently there are three generations of this device on the market, the latest being Isolaz two.

Treatment Isolaz is a simple treatment to perform and allows safe treatment for all skin types with less energy. The device manipulates the skin, pulling it closer to the surface, so that you change the optics of the skin, reducing some of the side effects of other lasers. To treat, the tip is placed over the skin and passed over the whole of the affected area, changing the amount of suction you need.

Patients’ feedback is that they see changes within 24 to 48 hours, including flattening of the lesion and reduced redness.

It uses a positive vacuum, which doesn’t cause trauma on the skin. Pores are mechanically cleansed through vacuum suction The vacuum stretches skin by 23% which changes the optics which gives better light absorption. Ssebum is evacuated while follicular ostia dislodged.

Isolaz uses broadband light (4001200nm) which kills bacteria beneath the skin and creates heat shock to sebaceous gland which reduces oil production.

The clearance rate is good. Sometimes patients leave looking a little bit more swollen than when they came in, but they can have treatments on as little as a

weekly basis.

I always tell my patients that this is not a cure for acne. I use the VISIA from Canfield to take a base line and on-going pictures and then compare the improvement it show the clients the decreasing size of the pores, the reduction in porphyrins and spot count and redness. They’ll also see some of the redness that’s associated with the red macular scarring reducing even after one treatment Jane Lewis has been the Director of Clinical Training of Solta Medical for four years and has been using Isolaz for eight years in clinical practice.

A patient after two treatments; there are still some lesions there but the red and inflamed ones have settled.

Mild acne on the chin, before and after two treatments.

A patient with mild acne—she had three treatments over two weeks

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body language I MEDICAL AESTHETICS 29

Using radio surgery for naevi excision DR JJ MASANI takes us through the process of using radio waves to remove moles with minimal or no scarring

T

here are two important things to know about scarring when doing a mole or naevi excision.

One, is that no matter what equipment you are using, if you touch the dermis you will scar a patient.

However it is possible to slice so thin that you can still get histology slides without scarring.

The second is that instead of lasers you can use wavelengths,

which are of high frequency and reduce the energy—this is called radio surgery. We do this with a 16-year-old Ellman generator— an advanced technology which produces minimal lateral thermal spread, reducing the injury to surrounding tissue.

The clinical benefits are minimal scar tissue formation, enhanced healing and minimal post-operative pain—all highly desirable for aesthetic surgery.

Contraindications The radio waves will always take the shortest path of least resistance, meaning that the presence of any jewellery is a contraindication.

If someone is wearing jewellery, you may burn a part you want to avoid. A cardiac pacemaker should also be counted as a contraindication and although pregnancy and breast feeding are not technically contraindicated, it is wise not to carry out the procedure during

30 MEDICAL AESTHETICS I body language

Diagnosis To reach the diagnosis of whether a naevi is malignant or not, one has to observe three factors with the aid of a Dermascope. The criteria of a benign mole would be: 1. There should be vertical and horizontal symmetry.

2. Pigment distribution is equal 3. Absence of blue/white vail within the mole

state of pregnancy and breast feeding unless a diagnosis of malignant melanoma is considered on clinical grounds.

Understanding radio surgery The first person who used radio surgery successfully on a myeloma was the modern father of neurosurgery Harvey Cushing who first described the symptoms that we now call Cushingâ&#x20AC;&#x2122;s syndrome. With the help of his friend physicist William Bowie, Cushing removed the myeloma from the head of a 64-year-old patient. It was Ellman however who was the first person to produce the generator for common use.

During the Korean War, soldiers using cellular phones were having their ears burnt. The aerial was cold and yet their ears were burnt. From this observation it was noted that they were using a frequency that was very high radiofrequency. Radio waves used in surgery are between 1.7 to 4 megahertz. Mobile phones now use non-ionising radiation at around 600 kHz so they are safe.

If you were to put your finger into a plug point, the oscillation of positive to negative will go 50 times in one second. So one hertz is one cycle in one second, 50 times is 50 hertz. We are using 1.7 to 4 megahertz (a million times), so the oscillation is fast, the voltage and wattage is very low. The Ellman machine is 50 watts I use the generator at 25 to 30 watts.

The new machines now go up to 100 watts. With greater power you can do many other things, such as Pelleve for skin tightening. There

are different types of waves you can use but the sinus wave has the least heat and has the best results.

The Process When you apply radio waves to any living being it offers resistance from the water and the proteins of the subject. We are working with radio waves to cut at 5060 degrees Centigrade. Collagen becomes denatured at about 52 degrees and carbonisation takes place at about 200 degrees. We can get histology because nothing that we do with radiowaves reaches more than 100 degrees Centigrade. With radiowave there is desiccation or vaporisation, of tissues and not carbonisation. The domestic microwave and mobile phones are using the same principle as radiowaves used in surgery, except the frequency is different.

Prior to removing naevi, as in all branches of medicine, a proper history and clinical examination is required. This is further aided by using a Dermascope (polarised light) which improves diagnosis between benign and malignant. An attachment to the smart phones can aid direct pictures to be taken with a Dermascope for good record keeping.

At the start of a treatment local anaesthetic can be given to reduce the pain of vaporisation. We can then remove the naevi almost intactâ&#x20AC;&#x201D;depending whether we need to send it to the lab for testing or not. Bigger naevis can be more complex to remove, because of the depth of pigmentation, so we warn the patient of possible scarring.

Evolution of Naevi All moles start at the junction of epidermis and dermis and they are described as junctional naevi. They appear dark on the skin.

Nature always likes to protect us and not to allow the naevi to turn malignant. To do so it makes the melanocyte naevi move deeper into the dermis over time. Once it is in the upper dermis it is called an intermediate naevi. The next stage is the naevi moving into deep der-

66 The use of a radiowave surgery is an important armamentarium in aesthetic practice, especially now that patients seek advice from medical aesthetic practitioners 99 mis and is called compound naevi.

At this stage the naevi will be more prominent and sitting proud of the skin and losing its dark colour to almost skin colour.

There are other uses of radio waves such as treating spider veins on the face, or any other part of the body. You can also use it for treating keloid scars and hair removal by epilation. You can epilate each hair with a very fine needle using radio wave current and the same goes for spider veins, telangiectasia and to stop bleeding from surgical wounds. It can also be used successfully for treatment of rhinophyma.

The use of a radiowave surgery is an important armamentarium in aesthetic practice, especially now that patients seek advice from medical/aesthetics practitioners.

Dr JJ Masani has extensive experience in both NHS and Private Medicine including Plastic Surgery, Dermatology, Orthopaedics, and Accident & Emergency along with General Practice. He has his own private GP & Aesthetic practice in Mayfair.

Benefits of radiowave or radiosurgery to remove naevi: 1. Rapid healing.

2. Minimal or no bleeding.

3. Usually no scarring or minimal scarring that is aesthetically pleasing.

4. Swift treatment time.

5. Safe, effective and painless (with use of local anaesthetic)

body language I RADIOFREQUENCY 33

Treating wrinkles using RF DR SHIRIN SAMMI-FARD discusses non-invasive approaches for face and body tightening

A

s a dermatologist I see an increasing number of patients in Germany who are not willing to go under the knife. They prefer a more natural look and less invasive methods. In my work, I don’t perform any kind of surgical operations or facelifts, what I offer are different treatment modalities using laser or lightsystems and radio- frequencies.

Thermage Thermage is a monopolar radiofrequency device, which uses a reverse thermal gradient. It is a seven mega-hertz RF generator, which includes a cooling module. It has the FDA clearance to treat lines and wrinkles on the face and on the body, and it’s the only device which also has FDA clearance for the upper and lower eyelid treatment. It also has the clearance for the temporary improvement of cellulite – though I don’t use it for this at all, just for contouring and tightening on the face and on the body.

The first generation of the Thermage device, the TC3 with an external cooling module, came out in November of 2002, so it’s now been on the market for 12 years. The current third-generation model, the CPT—or Comfort Pulse Technology—has two hand pieces, depending on whether we are treating the face or the body.

When we apply RF to the tissue it produces a special resistance to this electrical current and this generates the heat that produces the collagen shrinkage and new collagen formation. What we get is a twofold response. First we have an immediate result that we can already see when the patient leaves the office—which is an immediate contraction of the collagen fi-

bres—and then we also have a secondary wound healing response. When we denature the collagen fibres up to 62 degrees centigrade, we get a wound healing and a new collagen deposition that takes place over time. The end result is visible after five to six months, so it’s important that our patients are made aware of this. From a psychological point of view when they leave the office they see a little tightening, but they have not yet achieved the full result.

The CPT system has evolved to include three new key factors. Pulse technology is a pulse delivery of radio frequency—the delivery of five micro impulses of radio frequency each of 200 milliseconds of length, but perceived by

the patient as just one pulse. The CPT handpiece has three different levels of vibration, which is a good way to distract the patient from the heat. The tips used to perform the treatment have changed also. They now have a little frame outside and offer a better distribution of the heat throughout the whole surface of the electrodes and also in the depth of the tissue.

We get higher temperature levels which are much more comfortable. With the new vibration handpiece the heat stays much longer in the tissue, which is effective because the shrinkage of the collagen fibres is dependent on the temperature and on the time. The CPT has cooling bursts, which occur automatically before we deliver the RF, during this delivery Here are some common vector options to help you achieve maximum results for your patients.

34 RADIOFREQUENCY I body language

and also after the delivery in order to always protect the epidermis.

Total Tip A new treatment tip, the total tip, was launched in 2013. These are 3.0 square centimetres. Before this we had several Thermage tips: for the eyes, for the face, and a small and big body tip. Now with the total tip we have a two-fold higher increase of heating in the tissue and therefore better immediate results when the patient leaves the office. This has greatly increased my Thermage business. Before that, when I used the former face tip, I sometimes had the feeling I wasn’t seeing anything and the patient came back after six months and I didn’t see anything then either. But now, since we are heating up more volume of tissue, we’re also getting deeper into the tissue and we see very good results much sooner.

Brain et al published a study in 2010, which showed that the total tip is also safe to use on the face and on the jowls. The protocol is basically the same as before, so the patient is not getting any numbing cream on the skin. I start with a moderate level of energy like 3 to 3.5 and then I’m dependent on patient feedback. So whenever the patient can take the heat, we can go a little bit higher in the energy and if it is too painful we go lower. There is a total of 1200 shots on these tips and I like to give all these shots on one patient in order to get a better result.

Some colleagues of mine in Germany like to split the tip and give only 600 shots to a patient. I think you really need to build up the heat in the tissue in order to get a nice result, so I give a whole 900 shots on the face and if I also do the neck then I give the total 1200 shots. I always ask my patients to rate their pain on a scale between 0 to 4, where 4 is very painful and 0 is no pain. The optimum is around 2.5.

Treating procedures When I start to treat I do two complete passes on the area and then we have to follow our vectors. We have a cheek vector, a jowl vector, a jaw line vector or neck vector that we have to follow with our hand piece at least five times in order to get a nice lifting effect of the forehead, of the cheek and of the neck.

If a patient comes to me with a lot of sagging skin I like to start with one side of the neck, right cheek, right forehead and

then I give the patient the mirror to see the nice tightening effect compared to the untreated site.

With Thermage the patient has no downtime at all. You can do it all year round; you can do it in all the Fitzpatrick skin types because it’s independent of your melanin in the epidermis.

With some patients there may be slight redness, but this redness will go away after 30 minutes and then they are ready to wear makeup.

I treated a 68-year-old lady who suffered from breast cancer and was not willing to go under the knife again. She had Glogau IV wrinkles and severe sagging and I wasn’t keen to treat her, but she knew I could offer a non-invasive treatment option. We tried Thermage on her and she got a very nice benefit on the jawline and on the neck. I would have liked to do some fractionated CO2 lasers in order to get these lines also smoother on the cheek but she didn’t want to have any downtime at all.

Combining RF with other treatments I also like to combine the RF treatments with other treatment modalities like Radiesse volumisers. Since patients don’t see much lifting results at the beginning with RF, I like to give them a little bit of Radiesse in their cheekbones and do the RF treatment right on top. When we finish with the treatment they see an immediate difference and they don’t have to wait five to six months without seeing anything.

To summarise, it’s a perfectly safe combination on all skin types and you can do it all year round. Patients benefit from a single treatment and it’s much less painful then before with superior results.

I use the total tip on the face and on the body (arms, thighs) and I use a big body tip 4x4 cm for the abdomen. Using only these two types of tips I can treat a much wider range of patients. Plus, the ones that I would have sent away in earlier times benefit from a good result.

Dr Shirin Sammi-Fard is a dermatologist in private practice in Germany and is the medical director of the Derma Loft. She has worked for 20 years with different laser and light devices. Since 2009 she has also studied energy devices in particular radiofrequency devices.

CASE STUDIES

The above images show the immediate result on the left upper eyelid opening.

The patient had been previously treated several times with a regular face tip and then we included her in our study with the total tip. Just one week later she’d noticed very strong tightening, which was unlike treatments before and she was very happy with the result. She also got less sagging of the mandibular line. From the other side you can also see much less nasal labial folds, nicer tightening of the cheek.

Thermage use is not reserved solely for the face, it’s also cleared for body treatments. These images show a very young girl but she had three pregnancies so far and we also used the total tip.

She was pleased about the tightening effect on her skin. Some stretch marks remain, which we cannot treat with radiofrequency so in this case we would combine it with a non-abalative fractional laser device to get these better.

body language I DERMATOLOGY 37

Fractionated melanin a major advance in sun protection

DR ZEIN OBAGI describes the benefits of topical application of fractionated melanin, including protection against the damaging effects of high energy visible light

F

acial skin is remarkable for its ability to reveal health or disease of the skin, as well as that of the other organs of the body. Genetics, environmental exposure, hormonal changes, and metabolic processes, alone or together, lead to changes in skin structure, function, tolerance, and appearance.

For profound beneficial clinical changes, skin must be treated on the cellular level with agents that target different layers and cells of the skin. My personal approach to the restoration and maintenance of skin health is based on the anatomical and physiological properties of the skin.

Ageing types In any discussion of skin ageing, it is important to differentiate between biological ageing (chronological ageing) and photoageing that is a direct result of exposure to sunlight. Clinically, the appearance of photoaged skin is distinctly different from biologically aged, sunprotected skin. The most visible signs of biological ageing include laxity, paleness, smooth-to-fine wrinkling, deepening of expression lines, dryness, and general thinning. Bruising is more common and healing is slower.

In contrast, visibly photoaged skin is more yellowish in pigmentation with marked areas of hyperpigmentation, coarser and roughened in texture, more lax and more deeply wrinkled.

These differences are readily evident when comparing skin areas of the elderly that are usually covered, and thus photoprotected, with areas that have not been photoprotected. As a general rule, individuals with biologically aged, photo-protected skin appear younger than individuals with photodamaged skin who are of the same chronological age.

In biological ageing, most skin functions are slowed, and there is atrophy of

tissues while, in photoageing, there is an increase in irregular activity with hypertrophy of certain tissues. Although exposure to UV radiation is the most important extrinsic factor in skin ageeing, other external factors such environmental toxins and infectious agents may also play a role.

Ongoing photoageing results in marked changes to both the epidermal and dermal layers that are distinct from those observed with biological ageing.

Photoageing of the skin is broadly characterised by hypertrophy. Sebaceous glands become enlarged, and neoplastic growths are frequent.

In marked contrast to biologically ageing skin, the dermis of photodamaged ageing skin thickens and small blood vessels become dilated and deranged. The microvasculature collapses, showing only a few dilated, thickened, tortuous vessels.

In addition, the number of hair follicles is reduced and hair thinning is more prominent than in biologically aged skin.

Excessive sun exposure causes significant changes in the epidermis. Melanocytes increase, enlarge, and become more branched.

Keratinocytes may become vacuolated, atrophy, become necrotic, or show variation in size, shape, and staining properties.

The thickness of the photodamaged epidermis is variable with alternating

areas of atrophy and hyperplasia. It is thought that atrophy may result from depletion of cells from the basal layer, while areas of hyperplasia may reflect compensatory overgrowth of UV-damaged tissue.

The effects of HEV light While consumers are now well educated regarding the dangers associated with cumulative exposure to sunlight and especially the ultraviolet, UVA and UVB wavelengths, findings in recent years indicate that we have yet to explore the full spectrum of benefits and adverse effects related to sun exposure. One of the more striking scientific discoveries is that skin damage caused by high energy visible light may be as harmful as the damage caused by UVA and UVB light combined.

High energy visible (HEV) light is a high frequency light in the violet/blue band with wavelengths from 400 to 500 nm in the visible spectrum. Studies conducted to evaluate the effect of HEV light on skin demonstrated damaging effects to the epidermal and dermal tissues that was mediated via the generation of a variety of reactive oxygen species (ROS).

These can result in indirect DNA damage and gene activation of matrix metalloproteinase (MMPs) enzymes that degrade

CLINICAL APPEARANCE OF BIOLOGICALLY AGED AND PHOTOAGED SKIN Biologically aged skin

Photoageing

Lax

Leathery

Deepened expression lines

Dry

Dry

Nodular and hyperthrophed

Overall thinning

Yellow Telangiectasia Deep wrinkles Accentuated skin furrows Sags and bags Variety of benign, premalignant and malignant neoplasms

38 DERMATOLOGY I body language

Effects of HEV light • Weak barrier function and fragility • Elevation is senescent cells • Harmful effect to essential proteins that may lead to depressed immunity, inflammation and cancer • Uneven pigmentation • Destruction of the dermal fibre network that over time can be expressed in wrinkles and skin sagging

the dermal fiber network and may lead to premature ageing.

Like UVA, HEV light may be another silent, long term ageing wavelength. It does not generate the immediate erythema or edema reactions triggered by UVB and UVA. It may induce carcinogenesis and accelerated photoageing. While the effect of UVB radiation is associated with direct damage to the DNA since it is absorbed by it, the cellular damage caused

by HEV radiation is less direct and is associated with the generation of free radicals and the induction of oxidative stress.

Melanins are heteropolymers formed by oxidative polymerisation of the amino acids tyrosine or tryptophan.

Liposhield HEV Melanin Melanin occurs naturally in the human body where it is released from melanocytes into the skin as a first line of defence against exposure to certain damaging light waves. Liposhield HEV Melanin is a novel, patent pending ingredient that is the first cosmetic ingredient designed to protect the skin from damaging high energy visible light.

Liposhield HEV Melanin is a fractionated melanin designed to be used topically as an additional defence. It shields the skin from high energy blue/violet visible light (HEV) that may induce premature ageing according to recent scientific studies. Red visible light is deemed to have beneficial effects, and Liposhield HEV Melanin is tailored so that red light can be transmitted to the skin.

We have been able to successfully incorporate this breakthrough ingredient into a novel formulation while maintaining its efficacy. ZO Oclipse Smart Tone Broad Spectrum SPF50 is a highly advanced broad spectrum SPF 50 sunscreen designed to blend into almost any skin tone. Patented, customisable colour beads utilising a comprehensive UVA/UVB photostable sun protection system helps

provide daily protection from damaging ultra violet rays, while fractionated melanin helps shield against damaging HEV light. The addition of Vitamin C helps to achieve an even-toned complexion by inhibiting pigment formation, and we have enriched the formulation with skin conditioners to improve skin texture.

The Smart Tone Broad Spectrum SPF50 also helps prevent future oxidative stress with DNA repair and protection and minimises the irritants that can cause skin redness.

It has an exclusive 12-hour time release antioxidant system which helps to guard against photo-damage and the sunscreen restores hydration with skin conditioners that aid in strengthening the skin barrier We believe that this novel ingredient represents the future of sun protection.

For more information on Dr Obagi’s Acne Recommendations, buy his breakthrough new book—The Art of Skin Health Restoration and Rejuvenation (CRC Press) at http://www.crcpress.com/product/ isbn/9781842145968—with a 15% discount at check-out using the promotional code DBP36

REFERENCES 1. Zastrow L., Groth N., Klein F., Kockott D., Lademann J., Ferrero L. “Detection and identification of free radicals generated by UV and visible light in Ex Vivo human skin.” IFSCC Magazine 11(3) (2008) 297-315.

2. Besaratinia A., Kim S.I., Pfeifer G.P. “Rapid repair of UVA induced oxidized purines and persistence of UVB induced dipyrimide lesions determine the mutagenicity of sun light in mouse cells.” The FASEB Journal 22(2008) 2379-2392.

3. Denda M. and Fuziwara S. “Visible radiation affects epidermal permeability barrier recovery: selective effects of red and blue light.” J. Invest. Dermatol. 128 (2008) 1335-1336.

4. Lee J.H., Roh M.R., Lee K.H. “Effects of infrared radiation on skin photo-aging and pigmentation.” Yonsei Medical Journal 47(4) (2006) 485-490.

KEY INGREDIENTS  Avobenzone 3% Provides UVA protection  Homosalate 10%, Octisalate 5% and Octocrylene 10% Provide primarily UVB protection  Fractionated Melanin Designed to shield skin from high-energy visible (HEV) light  Iron Oxides and Mica Patented pressure-release colour system for customisable skin tone  Tetrahexyldecyl Ascorbate Pigmentation inhibition  Helianthus Annuus (Sunflower) Seed Oil, Ethyl Ferulate, Rosmarinus Officinalis (Rosemary) Leaf Extract, Disodium Uridine Phosphate, Panthenyl Triacetate, Ethyl Linoleate and Tocopherol Helps provide DNA protection and encourages DNA repair  Tocopheryl Acetate, Ascorbic Acid, Retinyl Palmitate 12-hour time release antioxidant complex fights against free radical damage  Petasites Japonicus Root Extract and Beta Glucan Provides anti-redness benefits  Argania Spinosa Kernel Oil Aids in lipid repair

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body language I CLINIC 41

Handling enquiries: the importance of first impressions GILLY DICKONS explains the importance of making a good first impression to clients over the phone.

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ou never get a second chance to make a first impression and creating the right first impression is the key to success. At Aesthetic Response we focus on frontline call handling, ensuring that a customer’s first real experience of a practice is speaking to a knowledgeable person.

There are of course other ways to create first impressions: A website is a first impression, marketing gives a first impression, your practice creates a first impression when someone walks in. The first treatment is also something that first

impressions will be based on. However, whilst it’s not the only first impression, the experience people have when they make their initial contact with a person at your practice by telephone is an extremely important one.

That first 15 seconds of somebody picking up the phone to your business is make or break as to whether you can turn them into a new consultation.

There’s no second chance. The great news is that if you get it right with your new enquiries, you should be getting it right for your existing clients.

The Galderma Impact Study The Galderma Impact Study was carried out in six countries and looked at over 12,200 women, about 2,500 of who were based in the UK. The study highlighted key areas where practices can really make a difference to their client’s journey. For example 32% of people interviewed said they couldn’t get through to the clinic the first time that they tried to call. 43% contacted several clinics before deciding where to make the all-important first appointment. Women took an average of two years to pick up the phone after considering

42 CLINIC I body language

The Galderma Impact Study was carried out in six countries and looked at over 12,200 women

treatment. The study also stressed that “first contact is to reassure and recruit” those clients.

The research showed that 37% of people change practice and go for treatment elsewhere because of poor customer service. A previous client being unable to get through to a clinic after receiving treatment

66 With well-trained staff handling your enquiries it is perfectly possible to achieve 70% to 85% conversion rates with calls and 35% to 40% on emails 99

can constitute poor customer service. This frustration comes from not being able to get through to the practice rather than because of poor treatment and highlights the importance of the clients’ entire patient journey.

Without doubt all of the above points indicate the importance of having well trained staff to handle those valuable incoming calls.

Achieving high conversion rates will increase your revenue The first impression you give can have a substantial impact on your conversion rates of call to appointment. The recognised industry gold standard is 60% conversion of call to appointment and the average is about 45%. The current email ‘gold standard’ conversion across the industry is estimated to

be about 10%.

With well-trained staff handling your enquiries it is perfectly possible to achieve 70% to 85% conversion rates with calls and 35% to 40% on emails – we do this in our business every single day of the week. It’s also very important to us that we make good quality appointments, meaning that people actually turn up for their initial consultation.

I would recommend that at least once a quarter you take the time to evaluate your call handling service, putting yourself in your client’s shoes and working your way through what your client’s experience might be. Ask yourself what impression they’re getting when they try to reach your practice or clinic? It is worth investing time every now and again to review your processes as even if you have the right things in place as you may be surprised by results. You could consider asking friends and family to undertake mystery shops to support your evaluation of this aspect of your service.

We have practices that come on board with us after using a generic call handling service, where the calls have been answered with a very basic and swift style of response. At Aesthetic Response we believe that call handling is not an administrative process, and treating it so can be costly in terms of lost leads – in fact I will go as far as to say that we believe that first phone contact should be exceptional. Since it can take up to two years for a client to even pick up the phone and make a call, if they get an answering machine, no answer or somebody can’t help them, the chances are that caller is then going to ring somewhere else in an attempt to speak with someone who can help them. It’s also frustrating for clients if they get through to somebody who can’t help them with their initial questions the first time they call, the chances are they won’t come back.

The Galderma study identified that staff must be “easy to talk to, attentive and helpful”. Callers needed to feel as though the call handler had time to listen and dis-

body language I CLINIC 43

cuss the treatments that they were interested in. It may sound like common sense, but it pays to listen to your call handler to make sure that they are getting it right.

You might have a brilliant righthand support person in your practice who is very adept at ordering, bookkeeping and handling appointments in the clinic, however that does not mean they are exceptional at controlling a call and getting a booking into your diary. It is important that staff are trained to control the call. When the client gets on the phone it’s vital that they can open up to a person at the other end who will listen, then bring the call back at the end and make the appointment.

Getting it right first time It’s hard to be available all the time when you have a busy schedule, or are juggling work and family life.

If you are running your practice from a mobile phone, are you able to keep on top of clients and have a really helpful attitude at all times?

If you are struggling to maintain a healthy work life balance, it is time to assess how it would improve if you no longer had to pick up the phone.

The person on your phones has to be a great customer service advisor first and foremost. But even if you have a dedicated person greeting and speaking to new and existing clients, phone calls can lapse to answerphone, which means clients are likely to go elsewhere. We work with a lot of practices who have a receptionist who needs to deal with the client in front of them before answering the phone, and so it goes to answerphone. Remember the client who has taken two years to decide to make that call? Do you think they will leave a message or try elsewhere?

Measuring success Customer service should be reflected in your practice’s vital statistics.

It can be easy to assume that you have a brilliant conversion rate, but until you look at the figures in detail, you will not be able to see where there’s room for improvement. So how can we do this?

1. All enquiries should be recorded This can be done on a CRM system or an Excel database. It doesn’t have to be complicated but it’s better for small, growing practices to invest in a CRM system imminently than wait until they’re big.

Not everybody is going to decide to make an appointment the first time they pick up the phone.

If you capture their name, number, where they found out about you and an email address you can send them a newsletter.

Reminding them that you’re there means they’ll remember you when they’re ready to decide.

2. Monitor the appointment booking rate from enquiries We say that we deliver over 70% and I’m accountable for that every month. My client reports go out and there are questions to be asked if we’re not hitting that 70% benchmark.

You need to know if your staff are converting at these rates, because those enquiries are incredibly valuable to your practice.

3. Make good quality appointments If 70% of people are booked for an appointment and half of them don’t turn up then you need to know why you are getting poor

66 Customer service should be reflected in your practice’s vital statistics 99 leads. Monitoring consultations will help. Anything upwards of 75% is a good attendance rate and there are things you can do to reduce no-shows such as holding card details, taking deposits, or refundable deposits with a 24 hour cancellation policy.

You can also send out reminders because people do genuinely forget —a CRM system can usually be set up to do that for you.

4. Find out how many clients are being treated after consultation I’ve worked with many Consultants/Practitioners who say they convert 90% but you won’t know until you do the maths.

There might be room to improve the consultation technique.

80% is very good, but if you think it could be higher then you should develop it further.

5. Have a recall system Every practice needs returning clients, but the Galderma study sug-

You should achieve 35% to 40% conversion rates on emails

44 CLINIC I body language

To increase the opportunity to keep clients loyal, we need to remind them we are there

gests that only 43% of clients stay loyal. To increase the opportunity to keep clients loyal, we need to remind them that we are there.

Many clients we have try to forward book appointments—their next treatment is booked ahead just by carrying out treatment ‘review’ recalls.

Having some control over that recall system means that people are less likely to go somewhere else in several months’ time. Until a third visit for treatment there is not necessarily concrete trust between a client and your practice.

6. Understand cost per enquiry This is a valuable piece of information because enquiries can cost a lot of money to generate. If you put money into SEO, or run adverts in a local paper, it pays to know exactly what the return is that you are getting on these investments and your average spends per visit for a client. Once you have worked these figures out you can share them with your front of house staff.

If they understand that a call might have cost you a £100 to generate, it gives them a better under-

Q&A Q: Can you use a call centre to pick up the phone and then transfer a call, or is that too much?

Gilly Dickons: If a call centre could pick up a call and transfer it to you every time, that would be fine, but if you use a generic call handling company who doesn’t know your practice and then can’t get through to you (maybe your phone is engaged or you are unavailable to take the call), it’s frustrating for the client. I’ve worked in the industry 25 years and, having seen both the best and the worst in customer service standards, this is why I’ve set up Aesthetic Response. The client wants to engage from the very first call that they make to your practice. This is where we are unique because everyone is trained to engage, they’re patient advisors, not call handlers and are on the phone all day, every day. That being said we do have clients where we pick up calls and transfer them for diary bookings.

standing of your business and what the value is when that person does turn up. One lost lead is a great deal of lost revenue, but retaining a client is high value over time.

A happy client is likely to refer a friend so there can be a lot of longterm value.

Plastic surgeons might not have the same control over the client relationship if they work in a hospital but they can still influence it.

If you work from a local private hospital the chances are that an enquiry from someone wanting to spend £7000 on facial surgery is handled through the same staff as someone who wants the ‘choose and book’ service. We work with several hospitals now where Consultants have influenced the system and the aesthetic and cosmetic calls come via our team.

Putting yourself in the shoes of your enquirers, understanding what they need and looking at your practice statistics will help you to get higher conversion rates.

Recruiting or contracting skilled and experienced call handling resources and building a robust client database will increase your revenue and make sure your practice goes from strength to strength.

Gilly Dickons is the founder of Aesthetic Response, a specialised aesthetic and cosmetic call and enquiry handling service.

Q: How do you deal with out of hours clients?

Gilly Dickons: We open from 8:30 – 20:00 Monday to Friday and 9:00 – 17:00 on Saturday and we pick up about 10% of peoples’ enquiries after 5pm. As a company we take them on behalf of our clients as if we were sitting in that clinic and we book into client’s diaries directly for them. Prospective new clients are often surprised to speak with a knowledgeable call handler outside of office hours and this frequently results in a booking.

Q: If businesses are very small and haven’t got premises but don’t want to compromise, what do you suggest?

Gilly Dickons: I suggest us of course. If you’re catching up and returning calls at the end of the day you will sometimes find that people don’t answer their phones or they have gone somewhere else. You need to work out a cost-effective solution and that does not require taking on full-time staff. That’s how people grow with us, because we are a cost-effective solution.

body language I PSYCHOLOGY 45

Ugh! That’s SO disgusting!

How repulsion predicts your sex life DR RAJ PERSAUD examines how disgust may be inhibited in reproductive situations, and how attitudes to disgust could be linked to our mating, love or sex strategies

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cademics at the Department of Psychology, Northern Illinois University, USA, point out in a recent study, that to have sex, we have to overcome strong feelings of disgust. Their study published in the journal Archives of Sexual Behaviour, was partly inspired by the observation that basically the human body is pretty disgusting.

It secretes fluids and harbours germs, and, generally, we find contact with anything that has been in a stranger’s body orifices extremely unpleasant. The genitals and mouth involve sex, yet are also the regions that might be associated with most disgust. Yet despite all that possible repulsion of such orifices and secretions, we still make love.

The authors of the study entitled ‘Effects of Subjective Sexual Arousal on Sexual, Pathogen, and Moral Disgust Sensitivity in Women and Men’, point out that physical intimacy presents us with an evolutionary dilemma: we want to avoid contamination from potentially dangerous substances, but we are also motivated to attain mates, to pass on our genes.

Study authors, Ellen Lee, James Ambler and Brad Sagarin, found a possible way nature has resolved this dilemma: an internal mechanism that evolved in our brains inhibiting disgust in ‘reproductively-relevant situations’—sexual arousal reduces feelings of disgust.

The study found that in women, sexual arousal significantly lowered sensitivity to sexual disgust. The authors argue that their findings support the evolutionary theory that erotic arousal inhibits sexual disgust, which facilitates a willingness to engage in high-risk, but evolutionarily necessary, procreation.

The authors also argue that this effect could be particularly important for women. In the research, men showed very low levels of sexual disgust, even when not sexually aroused, indicating a potential ‘floor effect’—in other words, the meas-

ured disgust was so low in the first place that it had nowhere to go in terms of getting lower with sexual arousal. Previous research has found women more sensitive than men to disgust, particularly to sexual disgust.

Now a new study published in the academic journal Evolution and Human Behavior, entitled ‘Disgust and mating strategy’ has found that our feelings and attitudes to disgust could also be part of our personality or orientation, and in particular is linked to mating, love or sex strategies. The study from The University of Texas at Austin, and Bilkent University, Turkey, argues that it is well established that people generally vary in the attitudes and desire for longer-term, committed relationships versus short-term, uncommitted connections.

The authors, Laith Al-Shawaf, David Lewis and David Buss, point out that successful short-term mating strategies typically involve multiple sex partners, desire for sexual variety, and brief intervals of time before sexual intercourse.

This strategy should be difficult to implement in the presence of high levels of sexual disgust: those with higher levels of repulsion are less likely to be comfortable with casual sex, multiple partners, and sex that occurs before sufficient information can be acquired about the health and hygiene status of potential mates.

The authors therefore propose that a crucial component of a successful shortterm mating strategy is lower sexual disgust. In contrast, less repulsion over certain aspects of sex are not necessary for the successful pursuit of a more monogamous strategy.

One possible speculation from these new findings is that higher levels of sexual disgust may even facilitate the implementation of committed mating strategies by inhibiting short-term mating and deterring those in committed relationships from sexual infidelity. This reasoning suggests that sexual disgust as an aspect

of personality should be lower among individuals pursuing a short-term mating strategy relative to those pursuing committed relationships.

The study found that a stronger disposition toward short-term mating is associated with reduced sexual disgust.

The research asked participants to rate how disgusting they find a variety of potentially repellent situations, such as “A stranger of the opposite sex intentionally rubbing your thigh in an elevator” and “Performing oral sex”.

A stronger drive toward short-term mating was associated with reduced sexual disgust among both men and women.

But the study also found that the relationship between physical attractiveness and short-term mating was stronger in men. More physically attractive men are keener on short-term flings, while more physically attractive women are not more interested in such an approach to their sex lives, compared to less attractive women.

Women’s attractiveness in this research was not associated with desire for or positive attitudes toward short-term mating.

This absence of a connection between women’s attractiveness and short-term mating psychology suggests not that physical attractiveness activates shortterm mating among women, but rather that physically attractive women accumulate a larger number of sex partners.

The authors argue that shorter-term mating looms larger in men’s than in women’s relationship psychology because as a strategy is has evolutionary benefits for men, such as passing on more genes.

Physical attractiveness is desirable in a mate, so attractive individuals should be better able to implement their preferred mating strategy. And because successful short-term mating strategies were more reproductively beneficial for men than women during human evolution, the reasoning suggests that physical attractiveness should lead men—but not women— to pursue uncommitted mating.

body language I PRODUCTS 47

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body language I INJECTABLES 49

Injectable rhinoplasty DR RAJ KANODIA talks about the about the art of non-surgical nasal contouring.

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s a plastic surgeon I work on all noses endonasally to ensure there is no columellar scar. However, through experience doing surgical rhinoplasty, I have learned that there are certain patients who can benefit from medical or injectable rhinoplasty.

Some primary noses can undergo augmentation by HA injections where there are post-traumatic or saddle deformities. Injections can also be used for post-rhinoplasty indentations and divots. Sometimes, despite our best attempts, we may not get perfectly smooth surfaces and there can be indents, particularly in the upper lateral cartilage areas. These can be easily fixed with small amounts of HA injections.

Taking precautions It is essential to be aware of artery placement when carrying out any injections. However, we are injecting blindly, so even if we know their location, we cannot always do much about it. Tiny little blood vessels run all along the periosteum and perichondrium, so I recommend to inject at the base of the columellar and the dorsum. A wise precaution to take is to always withdraw on the needle, or the cannula, ensuring it is not inside a blood vessel, or clogging the artery.

The upper lateral cartilage sometimes gets weak, despite the spreader graft, because it is a hard surface. When you carry out rhinoplasty and shave the bone and cartilage to take the hump down,

sometimes the upper lateral cartilage loses its connection with the bone and immediately avulses itself. Itâ&#x20AC;&#x2122;s possible to correct this aesthetic deformity using injections.

Although infection is rare, it has been reported in studies and literature. Sterility is of course a vital preparation for injections â&#x20AC;&#x201C; and

injecting in a closed space is very different from injecting a chin or a cheek. If a re-entry is needed after the first injection, I use a different sterilised needle as a precaution. I double cleanse the skin using Betadine and give patients antibiotics before and after treatment, to prevent infection.

I have learned that there are certain patients who can benefit from medical or injectable rhinoplasty

50 INJECTABLES I body language

Using injections for augmentation I recently treated a patient with a shallow glabella. The lower third of the nose looked more bulbous, because the upper half was not as well developed. We injected the dorsum and created a better silhouette and the tip did not look as bulbous. It’s a visual illusion you can create by augmenting the bridge of the nose.

To do this, make a little entry point with the needle, then pull the needle out and put the cannula in. I use 25 gauge by 40 and if you hold your finger on it, you can mould it to wherever you want. One of the greatest things about this medical augmentation is that in ten minutes you are done, rather going in intranasally and putting an implant there.

At my practice in Los Angeles we have a lot of ethnic groups coming in for this kind of augmentation. Many will want an alternative to the implants. Surgically, we can augment the implant or do rib grafts, but there are problems with grafts moving, extruding and becoming infected, so injections are a very good alternative in this instance.

Patient choice is also paramount. We also find that many ethnic and some black patients have a very shallow dorsum. This means, particularly if they have primary noses with no surgery, injections are a brilliant alternative tool to augment the bridges.

Sometimes patients desire a gradual augmentation because they don’t want too much alteration.

It can also be good for the practitioner to treat this way. One of the risks with injecting is if you inject a lot of material you may compress the blood vessel, despite that fact that HAs are gel. As a precaution we should avoid injecting a lot of material, especially thick material.

We often do sessions with patients using half a cc at a time.

As surgeons, we can do dorsal augmentation intranasally where the cannula enters from inside.

Compared to the extranasal approach, intranasal has better angulation of the cannula and no anaesthesia is needed. Cannula is also

useful if we want to layer the product. If we do a superficial treatment but don’t feel it’s adequate enough, the cannula allows you to change the superficial plain and go a little bit deeper.

Primary vs post-rhinoplasty When augmenting a primary nose, all the blood vessels remain intact on the dorsum because no surgery has been done. Even if you traumatise, or compress one of the blood vessels, the other blood vessels will take over and there is no compromise to the circulation of the skin.

Every time a rhinoplasty is done and the skin has been skeletonised over the dorsum, there is a possibility of traumatising one of those small arteries. If a patient has five small arteries on the dorsum, and in the first surgery we traumatise two, the patient is left with three, so there might be some collateral circulation, neovascularisation. If the patient then goes through a second surgery, you might be left with two. The more surgery the patient has, the more careful we have to be to adhere to the principles of withdrawing on the needle.

The arteries on the dorsum are responsible for supplying the nutrition to the skin, so loss of circulation there will cause necrosis. The more surgeries a patient has had, the more problems they could have.

The convex columellar between the lip and the nose can be very retrusive in some people, because the anterior spine is not as developed. If you inject this area you get some tip support, some cephalic rotation and a confluence. You can create this confluence between the base of the columellar and the cupid’s bow which has wonderful results.

It’s also possible to combine surgical versus medical rhinoplasty in the same patient. Instead of injecting the columellar, we can create a pocket where the anterior nasal spine is, and take a plumping graft.

Very rarely the plumping grafts can move and shift, creating a little bit of asymmetry. If this happens we just need a tiny augmentation in that area at base of the columellar.

We use something like Evaluna, or

a Perlane which give two to three years of augmentation and tip support.

Sometimes surgery is the only answer. If someone wants his nose slightly smaller and his septum fixed, we could not inject him on the glabella as it would make his nose even bigger. We can take his nose down a little, straighten the septum and keep a strong, masculine bridge. An injection would see his nose coming straight out of his forehead, so if he does not want surgery we would have to say we could not help him. We want to appease and help the patient, but we want to do something which is aesthetically right, so we always need to be discerning about our methods.

Dr Raj Kanodia is world-renowned plastic surgeon from California.

Before and immediately after 1cc HA

Injection of dorsum of the nose with micro cannula technique. Before, after 0.5cc HA and four months later after 0.5cc HA

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body language I DERMATOLOGY 53

Simple, effective and inexpensive skin treatments DR CHRISTOPHER ROWLAND-PAYNE discusses alternatives to expensive devices for the treatment of moles, brown spots, unwanted thread veins and scars

G

ood communication is the basis of mutual trust and confidence. Eye contact is critical. You get many clues from watching people’s eyes and their faces when talking to them. All this plays an important part in patient selection.

Demonstrate any asymmetries or abnormalities to the patient before starting treatment. As a rule, what is explained to patients beforehand is knowledge and what is explained afterwards is excuses.

Informed consent is advisable.

Do we actually need the most expensive and up-to-date devices? There are some inexpensive and simple things we can do that work just as well.

Moles The domed intradermal naevus—the ordinary mole—can be taken off by tangential excision. Driclor is a very efficient haemostatic. The tangentially excised base may then be touched with dermabrasion to soften the edges. This is a very simple treatment—very swift and with virtually no scars (Fig 1).

Dermabrasion can be used for other things too. If a rhinophymatous nose has some pits and bumps, spot dermabrasion can reduce the bumps. The patient will have eschars for perhaps six days. Then there will be a pink mark for a couple of weeks, which can be hidden with make up.

Keeping a wound greasy allows it to heal

Fig 1

best. Cloramphenicol ointment, which is an antibiotic in Vaseline, is suitable.

Taking the top off a mole is rather like taking the top off an iceberg, a little bit may rise up from the base, “the iceberg effect”. If this happens, at three months we just take a little bit more off the tip of the iceberg. Avoid doing this before three months have elapsed as the healing process is still active until then.

Sometimes, when the top is taken off a pigmented mole, a little bit of pigment may appear in the base of the healed wound. It may look a little alarming and it is best to take that off. A good rule is to send that bit for histology and explain to the histologist what you have done, otherwise they will not be able to diagnose a pseudomelanoma, which is a benign phenomenon (Fig 2).

Brown spots Brown spots or macular seborrhoeic warts are very simple to treat using a liquid nitrogen spray gun. With a spray gun, you can go very quickly and spray a very light spray. It is a cryo-peel. When the patient leaves the room they will be a little bit reddened.

Over the next couple of days the treated brown may temporarily darken slightly. These dark marks last 4-8 days on the face. On the hands they will be black for three weeks. As long as we warn the patients, they do not mind. The treat-

Fig 2

ment is repeated twice more at six weekly intervals.

If you do this over three sessions, you can get a perfect result. If you try and do it in one go the patient may end up with a white scar or some of the original brown spot may persist. Thus it is advised to do this treatment over three sessions, each separated by four to six weeks. If you treat someone who has a slightly darker skin or who is very tanned then post-inflammatory pigmentation is a risk and it is well worth warning patients of this possibility.

Thread veins of face Thread veins of the face, including rosaceous telangiectasia and spider naevi, are another very common problem. There are very expensive lasers available to treat these. However there are easier ways to treat them. A very simple, radiosurgical treatment administered over three sessions, separated each by four weeks, can achieve the same result as an expensive device. An excellent and inexpensive such device is the Conmed hyfrecator. The tip used is a fine epilation needle. It is a very simple and quick treatment. Sometimes, if there is a dermatographic urticarial tendency, there may be an immediate dermatographic response and we need to explain this to the patient. Once treated the patient washes briskly, applies make up and is then on their way. Although it is a little uncomfortable, it is swift and very effective and it can also be used for postradiotherapy telangiectasia.

54 DERMATOLOGY I body language

Fig 3

Sclerotherapy for leg veins Thread veins of the legs are a very common problem and very easy to treat. Sclerotherapy is the easiest way to do this.

First of all examine the patient standing, observe for slow filling veins, perforator veins and superficial veins, palpate for palpable veins—everything needs to be treated. If you don’t treat the bigger veins first, then all the little ones will reform very quickly.

The agent I use is polidocanol, which is very non-irritant, even if it is accidentally injected extravascularly. With sclerotherapy, a large area can be treated with a simple injection whereas a laser would have to shoot each of the little tiny veins.

To treat a starburst mark, don’t start with the starburst venules, you must try and inject the feeder vein. Clearance is achieved over three or four visits, each separated by eight weeks.

In the first 48 hours, we cover all the treated areas with cotton wool balls and tape them in place. Then for three days we use compression support stockings. Thereafter we advise them not to go in the sun for six weeks.You have to remember to ask the patient whether they are going to be in the sun, because that would raise the likelihood of post-inflammatory hyperpigmentation.

There is blushing in some patients afterwards, if you use quite a lot of the material. This can be rather alarming for the patient but it is only likely to last up to 20 minutes. Patients who are susceptible to migraine may develop one after treatment. Complications include post-inflammatory hyperpigmentation and very occasionally after unintended extravascular injection a tiny bit of ulceration, which may be followed by atrophie blanche.

Compression is useful and reduces the likelihood of bruising or the development

of sclerotherapy-induced mat telangeictasia. Sometimes you get intravascular entrapment of blood and sometimes the inflammation can lead to post-inflammatory pigmentation. These are things we try to avoid. If there is intravascular entrapment, we simply puncture with a needle and express it.

Post-entrapment pigmentation is more of a nuisance because it may persist on lower limbs for many months so prevention by post-sclerotherapy compression bandaging is better.

Scars We can treat hypertrophic scars, white scars or depressed scars. For hypertrophic scars, the standard treatment is intralesional triamcinolone. With white scars, manual needling is very good. For a small scar we would do this twice, each visit separated by eight weeks. If there are larger areas we might use a dermaroller or needle pen or something similar.

The problem with the dermaroller is that as the spikes pass through, they cause slits, so there is a bigger epidermal than dermal injury. The epidermal injury is uncomfortable and leaves marks for a couple of days. It is to be avoided if possible, so perpendicular needling is better.

Needle pens deliver up to 1300 punctures per minute. There are up to 13 needles in the tip and it goes very fast. It produces an equal epidermal and dermal injury. With the pen you don’t need any anaesthetic on the lateral face. It can be more uncomfortable around the central face but it is tolerable with topical anaesthetic. Combined with platelet rich plasma (PRP) it works particularly well.

Depressed scars, such as chicken pox scars, are also a very simple thing to treat and are very common. You can do this by

subcision, which is effectively horizontal or tangential needling using an 18-30 gauge needle. It is a two stage procedure and the stages are separated by six weeks.

Immediately after treatment the scar will be lifted slightly. The only small inconvenience might be an intradermal bruise, which may last for about four days.

The next thing you can do is inject into a depressed scar serial microdroplet silicone. This is a controversial treatment but there is no other filler which can do what silicone does. You can precisely put the silicone exactly where you want it but you would need to have the technique taught to you personally. You cannot put hyaluronic acid into a tight fibrotic scar but silicone you can. It is particularly suitable for depressed scars.

A patient who had elsewhere had a percutaneous rhinoplasty was left with disfiguring scarring across the dorsum of his nose. Hyaluronic acid into the larger depressions and serial microdroplet silicone into other scars, together with spot dermabrasion to elevated papules and needling to white scars, produced useful improvement over four to six treatment sessions. This could be termed a complex medical repair rhinoplasty (Fig 3).

Conclusions These are very simple, everyday treatments that can be applied in most people’s practice. They are easy to carry out and most are best done over three visits.

Dr Christopher Rowland Payne is a Consultant Dermatologist at the London Clinic.

Q&A Q: What depigmenting cream would you use after sclerotherapy if needed?

Dr Christopher Rowland Payne: I would use a Kligman type of formula, very accurately applied and only if they did get pigmentation. Prevention is always better if you possibly can. If you do sclerotherapy near the knees, the bandages may move a little. This means the inflammation isn’t compressed, so there is a bit more inflammation which means post-inflammatory pigmentation is a little more likely.

Q: Do you caution against flying?

Dr Christopher Rowland Payne: I advise avoiding transatlantic flights for a week but that is me being very cautious.

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body language I EQUIPMENT 57

Getting the right equipment DR MARK TAGER advises on key considerations when purchasing equipment for your practice.

T

hose of us who been practicing aesthetics for some time are quite familiar with the dead equipment closet. It is the space where our unused lasers and devices go and do nothing but take up space. Making wise purchasing decisions is critical to the success of your practice. This is made considerably more challenging by some of the hype and unrealistic promises made by aggressive sales people.

There are some steps that you can take to determine whether to adopt a new technology.

Crystallise the need A new piece of technology must fulfil a specific need for your patient population. Begin by asking yourself, “What types of condi-

tions am I currently unable to treat to a high level of patient satisfaction?” You may already have technology, for example, that addresses facial skin rhytids, pigment and vascularity; but nothing for body shaping and firming. Are your patients inquiring about these conditions? Are you losing them to the competition? Do you want to begin attracting new patients who want these services? If the answer is yes, then you should earnestly begin assessing the new technology.

Begin by asking yourself, where the technology fits in terms of the patient flow in your practice. Each of us must recruit, retain, wow and grow our patient base. Some treatments, like fillers or neurotoxins, only have patients returning every six months, at which time they

must spend a considerable amount of money on their treatment. Alternatively, there are less invasive treatments that encourage patients to come to your practice more frequently and spend less money.

These are great traffic builders and also allow for cross selling.

These less invasive treatments must deliver enough of the “wow” factor to meet patient expectations, while at the same time providing a rapid return on your investment.

One of the devices that consistently exceeds patient expectations in my experience, is the HydraFacialMD (Edge Systems, USA), a hydradermabrasion device that builds skin health by exfoliating, hydrating and infusing topicals.

Most practices pay back the cost of the machine within four to six

58 EQUIPMENT I body language

months, making it a powerful revenue generator.

Do a thorough and thoughtful demo There is no substitute for hands on assessment of a device, not just in the confines of a conference, but in the comfortable environment of your practice where you and your staff will ultimately be using the technology. Before you buy a piece of equipment, everyone in the practice needs to understand its features and benefits.

If a practice is buying for example, a laser machine, it should be tested on three different skin type patients to make sure that it is the right treatment for that practice. Testing is very critical to understanding efficacy as it can take around six to eight weeks to see final treatment results as created by your staff.

ask the manufacturer to speak with three or four other aesthetic GPs who are not in a competitive position and ask about service, quality, parts and accessibility.

One issue to consider is whether buying a brand name product means that the manufacturer will help drive patients to you. If a device is both manufactured and sold in the USA, for example, the company enjoys a large margin on a device and can afford to do marketing and promotion for practices. However, if that same device is now marketed outside the USA by a distributor, then the margin for the distributor is substantially reduced – closer to 35-40% versus 65-80%, so the distributor has fewer dollars available for practice marketing. Ask your salesperson – and get confirmation in writing – what marketing assistance you can expect.

Do your homework Another way of deciding what equipment to adopt is to work with the manufacturer and get references from practices similar to your own.

For example aesthetic GPs should

Cut expectations in half When looking for new technology you want to have predictable, consistent results. It’s crucial to meet patient expectations, so whatever you buy you need to fully under-

stand the outcomes, get the consultation process completely right and advise on what patients can expect.

For example, if you purchase technology that, according to the literature and the studies done by the company claims to “reduce the appearance of acne scars buy 60% with several treatments,” you will be doing a disservice to both your patient and the practice if you set this expectation in your patient’s mind. Try cutting it in half, asking

There is no substitute for hands-on assessment of a device

66 One issue to consider is whether buying a brand name product means that the manufacturer will help drive patients to you 99 the patient whether she would be satisfied with a reduction of 30% in her acne scars. Always under promise and over deliver. Make sure that during the consult you get good

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60 EQUIPMENT I body language

photography to document the patient’s baseline. Patients always forget how they looked prior to treatment. I recommend incentivising staff to take good photographs so that patients can see the change.

This is an important and legally useful step in using equipment for treatments.

Different equipment for different patients It is important to get clear on the different protocols for different types of patients. Patients with skin types 3 or more are at risk for post-inflammatory hyperpigmentation secondary to thermal skin treatments. If the right settings are not utilised for skin rejuvenation or hair removal, we can bring out PIH or exacerbate melasma.

In aesthetics we basically wound the skin—we create an inflammatory response with the objective of healing skin either at the epidermis or the dermis. With skin tightening thermal devices, we attempt to bring enough heat to denature the collagen and start the process of collagen neogenesis, the results of which are often not fully evident for three or four months. If the device we employ for skin tightening is dependent upon new collagen remodelling, we must realise that this process is much less effective as we age. Rarely will a person over the age of 55 or 60 have an adequate response. Age affects both the rate of collagen neogenesis and the type of collagen being deposited in the skin.

Take into consideration that facial skin differs from that of the neck, chest, and body parts. This was made graphically evident with full-face carbon dioxide laser resurfacing. While this methodology— removal of entire layers of the skin —provides what may be the best skin tightening outside of surgery and leads to a face devoid of wrinkles, it also has a high incidence of depigmentation. About 20% of patients who have undergone full face CO2 resurfacing develop depigmented white alabaster facial skin. Using this technology on the neck results in scarring; thus contraindicating its use on this anatomical area. Because repopulation

of the skin is dependent upon the deeper dermal stem cells at the base of the hair follicle, and these are significantly reduced in neck skin, aberrant healing occurs.

Getting the most from equipment Cost effectiveness, return on investment and efficacy are important factors to consider when buying equipment. For clinics that do not have a lot of space and can’t have a lot of different types of devices, a platform device is a reasonable solution. There are many different treatments like laser and IPL that are available on a platform.

For an established patient base, one of the best ways to get early payback on your investment is to introduce new technology with an open house. It’s new, exciting and people can get free skin care samples.

Another question to ask is, is there consumable cost? Your consumable cost ideally be 15% or less of the treatment price. For a £100 treatment, a consumable whose cost is 10, 12, or 15% will leave you with an adequate profit margin. In designing devices, manufacturers have increasingly created consumables—some of which are completely necessary (like solutions). Others are built in as solely as high margin sources of revenue; most notably those in which you must purchase energy for a number of treatments.

Make certain you know what the

true cost of operation will be, and keep in mind if the patient price for a given treatment drops and the consumable stays fixed, a larger percentage of your revenue is going to the company. See if you can negotiate a large starter kit of consumables when you purchase your machine.

Keep abreast of the consumer trends From recent reports we note the resurgence of liposuction in the UK, with a stunning increase of 41% as compared to the previous year. The British Association of Aesthetic Plastic Surgeons credits the rise in liposuction with a possible backlash against non-surgical treatments for body contouring.

They claim the patients may have found these “less effective than advertised”. So we must make sure that whatever we advertise we can deliver on.

So when choosing what equipment to invest in, we need to choose wisely and make sure we’re fulfilling a need. We should go for practice building devices that can get people in time and time again and wow them with long-term service.

Dr Mark Tager is CEO of ChangeWell Inc (www.changewell. com), which promotes health and productivity for personal and organisational transformation. W: mtager@changewell.com; Twitter @marktager

The HydraFacialMD device can encourage multiple patient visits, provide predictable results, and has an early return on investment

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1 CPR & Anaphylaxis Update (am) 4 ZO Medical Basic 1 Sculptra* 2 Sculptra* FB 8 Core of Knowledge—Lasers/IPL 5 ZO Medical Interm.

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19 Intro to Toxins* 22 ZO Medical Basic (Dublin) 21 Skincare & Peels 18 Neostrata by Aesthetic Source 20 Intro to Fillers* 23 ZO Medical Interm. (Dublin) 22 Intro to Toxins* 23 ZO Medical Basic (Dublin) 23 Intro to Toxins* 23 Intro to Fillers* 24 ZO Medical Adv. (Dublin) 24 Intro to Fillers* 25 Microsclerotherapy* 26 Mini-Thread Lift & Dermal Filler* FB 28 ZO Medical Basic 27 Microsclerotherapy* 29 ZO Medical Interm.

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

62 EDUCATION I body language

training TF

TOXINS AND FILLERS

Medical, London W: wigmoremedical.com

2 June, Basic Botulinum Toxin A Training, Honey Fizz, Newport W: honeyfizz.co.uk

4 June, Microdermabrasion, Eden Aesthetics, Liverpool W: edenaesthetics.com/events.php

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9 June, Skincare & Chemical Peels, Wigmore Medical, London W: wigmoremedical.com

11 June, Introduction to Fillers, Wigmore Medical, London W: wigmoremedical.com

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12 June, Advanced Fillers – Tear Troughs (am) and Cheeks (pm), Wigmore Medical, London W: wigmoremedical.com

18 June, Neostrata by Aesthetic Source, Wigmore Medical, London W: wigmoremedical.com

13 June, Combined Basic Training Day – Dermal fillers and Botulinum Toxin, Honey Fizz, Newport W: honeyfizz.co.uk

18 June, Agera Skincare, Eden Aesthetics, London W: edenaesthetics.com/events.php

13 June, Foundation Botox & Dermal Filler Training, Cosmetic Courses, Buckinghamshire W: cosmeticcourses.co.uk 16 June, Hyperhidrosis Training, Honey Fizz Training, Newport W: honeyfizz.co.uk 19 June, Advanced Botox & Dermal Filler Training, Cosmetic Courses, Buckinghamshire W: cosmeticcourses.co.uk 21 June, Foundation Botox & Dermal Filler Training, Cosmetic Courses, Leeds W: cosmeticcourses.co.uk 4 July, Combined Basic Botulinum Toxin & Dermal Filler Training, Honey Fizz, Newport W: honeyfizz.co.uk 11 July, Advanced Botulinum Toxins (am) and Advanced Fillers – Tear Troughs (pm), Wigmore Medical, London W: wigmoremedical.com 22-23 July, Introduction to Toxins and Fillers, Wigmore Medical, London W: wigmoremedical.com 7 August, Advanced Fillers - Tear Troughs (am) and Lower Face (pm), Wigmore Medical, London W: wigmoremedical.com 15 August, Combined Botulinum Toxin and Dermal Filler Training Day, Honey Fizz, Newport W: honeyfizz.co.uk

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OTHER INJECTABLES

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12-13 June, Mini-Thread Lift & Dermal Filler, Wigmore Medical, London W: wigmoremedical.com

13 July, Advanced Facial, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com

15 June, Dracula PRP, Wigmore Medical, London W: wigmoremedical.com

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26 June, Mini-Thread Lift & Dermal Filler, Wigmore Medical, London W: wigmoremedical.com 27 June, Microsclerotherapy, Wigmore Medical, London W: wigmoremedical.com 29 June, Platelet Rich Plasma Training, Cosmetic Courses, Buckinghamshire W: cosmeticcourses.co.uk 2 July, Sculptra, Wigmore Medical, London W: wigmoremedical.com 10 July, Mini-Thread Lift & Dermal Filler, Wigmore Medical, London W: wigmoremedical.com 13 July, Dracula PRP, Wigmore Medical, London W: wigmoremedical.com 25 July, Microsclerotherapy, Wigmore Medical, London W: wigmoremedical.com

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SKINCARE

1 June, Holistic Microneedling Training, White Lotus Anti Aging, London W: whitelotusantiaging.co.uk/dermarollertraining 1 June, Skinrölla Dermal Roller (pm), Wigmore

14 July, Microdermabrasion, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com 20 July, Skinrölla Dermal Roller (pm), Wigmore Medical, London W: wigmoremedical.com 21 July, Skincare & Chemical Peels, Wigmore Medical, London W: wigmoremedical.com 25-26 July, Advanced Skin Restoration, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com 4-6 August, ZO Medical Basic, Intermediate and Advanced, Wigmore Medical, London W: wigmoremedical.com 13 August, Neostrata by Aesthetic Source, Wigmore Medical, London W: wigmoremedical.com

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OTHER TRAINING

1 June, CPR & Anaphylaxis Update (am), Wigmore Medical, London W: wigmoremedical.com

8 June, Areola Artistry Workshop, Finishing Touches, West Sussex W: finishingtouchesgroup.com 9 June, Burns and Scars Workshop, Finishing Touches, West Sussex W: finishingtouchesgroup.com 9 June, Non-surgical Facelift Training, Cosmetic Courses, Buckinghamshire W: cosmeticcourses.co.uk 10 June, Colour and Needles Workshop, Finishing Touches, West Sussex W: finishingtouchesgroup.com 11 June, Radiotherapy Marking Workshop, Finishing Touches, West Sussex W: finishingtouchesgroup.com 12 June, Peer Review Workshop, Finishing Touches, West Sussex W: finishingtouchesgroup.com 12-14 June, Ultrasonic Lipo-Cavitation, Academy of Advanced Aesthetics, Guildford, Surrey W: academyofadvancedaesthetics.com 12-14 June, Radio Frequency, Academy of Advanced Aesthetics, Guildford, Surrey W: academyofadvancedaesthetics.com 12-14 June, Cryotherapy Induced Lipolysis, Academy of Advanced Aesthetics, Guildford, Surrey W: academyofadvancedaesthetics.com 15-16 June, Two Day Burns and Scars Masterclass, Finishing Touches, West Sussex W: finishingtouchesgroup.com 17 July, Cryotherapy Induced Lipolysis, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com 18-19 June, Radio Frequency, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com

W: academyofadvancedaesthetics.com 24 July, Infrared, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com 27-30 July, Four Day Scalp Masterclass, Finishing Touches, West Sussex W: finishingtouchesgroup.com 1-3 August, Acoustic Wave Therapy, Academy of Advanced Aesthetics, Guildford, Surrey W: academyofadvancedaesthetics.com 1-3 August, Cryotherapy Induced Lipolysis, Academy of Advanced Aesthetics, Guildford, Surrey W: academyofadvancedaesthetics.com 5-6 August, Ultrasonic Lipo-Cavitation, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com 7-8 August, Radio Frequency, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com 12 August, Cryotherapy Induced Lipolysis, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com 13 August, Acoustic Wave Therapy, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com 25 August, Pressotherapy, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com 26 August, Beautiful Image, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com

20 June, Ultrasound for Skin Rejuvenation, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com

27 August, Ultrasound for Skin Rejuvenation, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com

21 June, Pressotherapy, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com

1 September, Infrared, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com

22 June, Non-surgical Facelift Training, Cosmetic Courses, Buckinghamshire W: cosmeticcourses.co.uk 22-24 June, Three Day Medical Masterclass, Finishing Touches, West Sussex W: finishingtouchesgroup.com 24 June, Cryotherapy Induced Lipolysis, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com 25 June, Acoustic Wave Therapy, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com 29-30 June, Ultrasonic Lipo-Cavitation, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com 7 July, Micropigmentation Induction Day, Finishing Touches, West Sussex W: finishingtouchesgroup.com 10-12 July, Ultrasound for Skin Rejuvenation, Academy of Advanced Aesthetics, Guildford, Surrey W: academyofadvancedaesthetics.com 13-14 July, Areola Masterclass, Finishing Touches, West Sussex W: finishingtouchesgroup.com 18 July, Acoustic Wave Therapy, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com 20 July, CPR & Anaphylaxis Update (am), Wigmore Medical, London W: wigmoremedical.com 20-21 July, Radio Frequency, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com 22-23 July, Ultrasonic Lipo-Cavitation, Academy of Advanced Aesthetics, Sutton, Cambridgeshire

2 September, Microdermabrasion, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com 7-8 September, Advanced Skin Restoration, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com 15-16 September, Ultrasonic Lipo-Cavitation, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com 17-18 September, Radio Frequency, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com 23 September, Advanced Facial, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com 25-27 September, Ultrasonic Lipo-Cavitation, Academy of Advanced Aesthetics, Guildford, Surrey W: academyofadvancedaesthetics.com 25-27 September, Radio Frequency, Academy of Advanced Aesthetics, Guildford, Surrey W: academyofadvancedaesthetics.com 25-27 September, Pressotherapy, Academy of Advanced Aesthetics, Guildford, Surrey If you would like to submit details for medical aesthetic training courses (lasers, injectables, skincare, equipment) to be featured in Body Language Journal and online, contact arabella@face-ltd.com

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SKINCARE We offer a handpicked collection to suit all applications and benefit your practice

EQUIPMENT We provide a wide range of equipment to ensure practitioners stay ahead of the competition

INJECTABLES Our extensive range allows practitioners to tailor order products to best suit their patient

PHARMACY For the last 30 years we have supplied medical equipment and drugs to practitioners UK wide

TRAINING Unique courses combine leading expertise, intimate group sizes and hands-on training

Wigmore Medical The aesthetic industry’s preferred partner 23 WIGMORE STREET, LONDON, W1G 0EB I E: CUSTOMERSERVICES@WIGMOREMEDICAL.COM I W: WIGMOREMEDICAL.COM I T: 020 7491 0150

OUTSIDE BACK Not all HA dermal fillers are created equal.

Cohesive Polydensified Matrix® (CPM®) Technology1,2

OPTIMAL

TISSUE

Optimal tissue integration1,2

INTEGRATION

Intelligent rheology design

Injectable Product of the Year

BEL202/0315/LD Date of preparation: March 2015

Contact Merz Aesthetics NOW and ask for Belotero

NEW

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

The filler you’ll love 1. BEL-DOF3-001_1. Belotero® technology, March 2014. 2. Tran C et al. in vivo bio-integration of three Hyaluronic Acid fillers in human skin: a histological study.

Dermatology DOI: 10.1159/000354384.

www.belotero.co.uk