Body Language Journal #73 by Body Language Journal

july/aug

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

ADVICE ON NAVIGATING YOUR WAY THROUGH THE COMPLEX WORLD OF SOCIAL MEDIA

Q-SWITCH

ONLINE REVIEWS

INJECTABLES

The quest for a clearer complexion and reduction in pigmentation

Make the most from online customers and how to approach internet reviews

How to avoid nerve damage when using toxins and fillers

novacutis

body language I CONTENTS 3

contents 07 NEWS

35 MEDICAL AESTHETICS

OBSERVATIONS

Q SWITCH LASER

Reports and comments

Mukta Sachdev explores the use of the Q-switch in skin of colour

15 DERMATOLOGY SUPER-SATURATED OXYGEN EMULSIONS

41 PRODUCTS

Dr Mark Rubin talks about driving oxygen to the surface of the skin using cutagenesis

The latest anti-ageing and medical aesthetic products and services

21 INJECTABLES

44 MARKETING

EARLOBE REJUVENATION

SOCIAL MEDIA

Dr Kathryn Taylor-Barnes discusses why the aesthetic industry may see an increase in earlobe plumping using dermal fillers

Wendy Lewis simplifies the complex world of social media

24 DEVICES TURN ON, TUNE IN, TIGHTEN UP Martin Coady looks at the uses of combining ultrasound and radiofrequency as an effective treatment for skin tightening

30 EVIDENCE

ON THE MARKET

51 MARKETING ONLINE REVIEWS Rosie Akenhead discusses how to approach the world of online customer reviews

55 INJECTABLES NERVE DAMAGE Mr Riccardo Frati discusses how to avoid nerve damage when using injectibles and fillers

SCIENCE VS HYPE

58 EDUCATION

Prof Syed Haq examines the clinical evidence behind vitamin therapy

TRAINING A comprehensive course calendar for the industry

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.

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

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

EDITOR Helen Unsworth 020 7514 5989 helen@face-ltd.com ASSISTANT EDITOR Lousie Renwick 020 7514 5989 louise@face-ltd.com COMMISSIONING EDITOR David Hicks 020 7514 5989 david@face-ltd.com EDITORIAL ASSISTANT Arabella Tanyel 020 7514 5989 arabella@face-ltd.com SALES EXECUTIVE Monty Serutla 020 7514 5976 monty@face-ltd.com PUBLISHER Raffi Eghiayan 020 7514 5101 raffi@face-ltd.com

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.

CONTRIBUTORS Dr Mark Rubin, Dr Kathryn Taylor-Barnes, Mr Martin Coady, Professor Syed Haq, Dr Mukta Sachdev, Wendy Lewis, Rosie Akenhead, Mr Riccardo Frati

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.

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

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body language I NEWS 7

observations

NON-SURGICAL TREATMENT ENQUIRIES RISE BY MORE THAN HALF IN SIX MONTHS Demand for dermal fillers, mole removal and thread lifts top the list, as patients opt for alternatives to surgical procedures Private healthcare search engine WhatClinic.com has revealed its mid-year round up of ‘medical aesthetic’ trends, showing the most popular and fastest growing nonsurgical cosmetic procedures of the last six months. The report shows demand for dermal fillers remains top of the list, with the highest number of enquiries across all treatments in 2014, and so far in 2015. The treatment commonly used for lip augmentation—the third most popular procedure of the past six months—has been top of many celebrity wish lists after Kylie Jenner admitted to having her lips enhanced earlier this year. Mole removal was in second

place as the most popular procedure of the past six months, while looking at emerging trends, thread lifts—hailed as the non-surgical alternative to a facelift—are the fastest growing treatment of 2015, with enquiries up 240%*. Enquiries for the treatment skyrocketed last year by 1165% which, when comparing total enquiries in 2013 with 2014, shows the biggest increase in demand of any non-surgical procedure for UK patients in that period. Injection treatment Macrolane is the second fastest growing nonsurgical treatment, seeing a 139% increase in enquiries in just the past six months. Macrolane is used to enhance body contours, and is

commonly used as a non-surgical treatment for buttock augmentation. By contrast, demand for surgical buttock augmentation procedures have dropped. Emily Ross, director of WhatClinic.com, comments, “While the UK’s appetite for surgical procedures has by no means waned, there is also been a significant boost in non-surgical alternatives, with new and exciting treatments to the market reflected in the boost in demand that we have seen for medical aesthetics across the board.” *Data based on the number of enquiries to UK clinics made through WhatClinic.com in the past six months, compared to the same period last year.

MASSIVE WEIGHT LOSS FUELS GROWTH IN PLASTIC SURGERY Increase in bariatric procedures may be linked In 2014, nearly 45,000 patients who experienced massive weight loss also opted to undergo plastic surgery to reshape their bodies—the biggest single-year increase in nearly a half decade. An increase in the number of weight loss surgeries in the US is beginning to have a ripple effect in plastic surgery, according to data from the American Society of Plastic Surgeons (ASPS). Procedures associated with massive weight loss, including tummy tucks, thigh lifts, breast lifts and upper arm lifts, grew at their fastest rate in four years in 2014, according to the report, mirroring a similar increase in the growth of bariatric surgeries. “We think there is a correlation between the two types of procedures, and we expect that trend to continue,” says ASPS President Dr Scot Glasberg, a private-practice plastic surgeon based in New York. “Post-massive weight loss patients are the number one growth area I have seen in my practice, and I’m sure that’s the case in many doctor’s offices across the country.” In 2013, 179,000 Americans underwent weight loss surgery, averaging nearly 500 procedures every day. The American Society of Metabolic and Bariatric Surgery, says that’s the most since 2009 and the third highest number on record. Since then, plastic surgeries related to weight loss have also increased across the board.

8 NEWS I body language

COMMUNICATION TOOL COULD REDUCE SURGICAL MORTALITY BY TWO THIRDS SBAR technique shown to reduce patient mortality and is recommended by the Royal College of Physicians The Royal College of Surgeons Edinburgh has highlighted a communication tool first created for the nuclear submarine industry and later more widely used by the military and aviation sectors as an effective technique to avoid adverse events and improve patient safety—cutting mortality by as much as two thirds. SBAR, which stands for Situation, Background, Assessment and Recommendation, is a mnemonic system for prompt communication first developed by the US Navy and eventually adopted by medical ‘rapid response teams’ to promote a short, predictable flow of critical information. As part of a competition, the RCS invited trainee surgeons to submit videos showcasing communication techniques across a variety of circumstances encountered in their daily work. The winners—a team of female junior doctors in Sheffield—submitted a video on utilising the SBAR technique to avoid errors and delays when escalating a concern to a consultant outside the hospital, for example when a patient might be deteriorating. A 2013 study in journal Resuscitation evaluated close to 40,000 patient admissions across 16 hospital wards, and the implementation of

SBAR in nurse-doctor communication alone cut unexpected deaths by a staggering 66%. In 2014 a study in the British Medical Journal (BMJ) also showed that using SBAR within a number of anaesthetic clinics reduced the number of ‘serious incidents due to communication errors’ from 31% to 11% (-65%). SBAR is recognised as a useful tool in nursing, and the Royal College of Physicians recommends its use in shift handovers. According to competition winner and trainee surgeon (CT1 level) Anna Watts: “SBAR is a great way of ensuring that a clear picture of what is happening is created and that no information is missed. “We chose to focus on SBAR because communicating over the telephone is part of our daily practice yet little emphasis is put on making sure you can do correctly. It’s a really clear method of communicating that can be used by all members of the multidisciplinary team.” A 2013 study in BMJ Palliative Care showed that poor communication, particularly with cancer patients, is associated with worse clinical outcomes, including worse pain control, worse adherence to treatment, confusion over prognosis and dissatisfaction at not being involved in decision making.

events 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 18-19 SEPTEMBER, AMWC Eastern Europe 2015, Moscow, Russia W: euromedicom.com/amwc-easterneurope-2015/index.html 25-26 SEPTEMBER, Face 2 f@ce 2015 & Annual Meeting of the European Academy of Facial Plastic Surgery (EAFPS), Cannes, France W: face2facecongress.com 7-11 OCTOBER, Annual Congress of the European Academy of Dermatology and Venereology (EADV), Copenhagen, Denmark W: eadv.org 8 OCTOBER, 4th National Aesthetic Nursing Conference, Olympia, London W: aestheticnursingconference.co.uk 15-18 OCTOBER, Annual Meeting of the American Society for Dermatologic Surgery (ASDS), Chicago, Illinois, USA W: asds.net/_EducationPage. aspx?id=1628 16-20 OCTOBER, Plastic surgery 2015 The meeting of the American Society of Plastic Surgery (ASPS), Boston, USA W: plasticsurgery.org 22-25 OCTOBER, Annual Conference of the Australasian Society of Aesthetic Plastic Surgery (ASAPS), Sydney, Australia W: asapsevents.org 23-24 OCTOBER, 3rd Anti-aging Medicine European Congress, Paris, France W: euromedicom.com/amec-2015/ index.html 4-8 NOVEMBER, 4th Annual DASIL Congress, Ho Chi Minh City, Vietnam W: thedasil.org

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body language I NEWS 11

second brief

RISING CASES OF ‘MORTON’S NEUROMA’ Prolonged high heel wear can cause the condition

TATTOO REGRET In response to the launch of PicoWay, Syneron-Candela carried out a survey of 2,000 men and women in the UK to find out what consumers regretted most about their tattoos.

39% of adults regret having their tattoo done 12% of women and 8% of men have had a tattoo removed One quarter of people have considered removal 31%

believe their tattoo is tacky and dated

73% have tried to hide or remove a tattoo of an ex-partner’s name Partner’s names were cited as the most regrettable choice of tattoo by

61%

50% of people regret having one of their tattoos done Six in ten said a visible facial tattoo is drastically off-putting Over half of those surveyed believed that

18 is the most regrettable age to get a tattoo

70% do not find people with tattoos more attractive or sexy Source: Syneron-Candela

Research has shown a 115% rise in incidence of Morton’s Neuroma, also known as interdigital neuroma; a painful condition that leads to over half of sufferers to require surgery. Morton’s Neuroma affects the nerve that runs between the toes, where fibrous tissue develops, becomes compressed and causes varying degrees of pain. A study of the last decade, presented at The Royal College of Surgeons in Edinburgh, shows that the condition, thought to be linked with years of wearing high-heeled or ill-fitting shoes, is a rising complaint. According to the American Academy of Orthopaedic Surgeons, the condition is 8–10 more times likely in women than men, and heels over 5cm are the most problematic. A study was conducted by Andrew Craig, an orthopedic research fellow at Bradford Teaching Hospitals NHS Foundation Trust, entitled “The Role and Efficacy of Conservative Management in the Treatment of Morton’s Neuroma”. The author aimed to ascertain the success rates of different types of treatment, reviewed patient admissions and treatment for Morton’s, a complaint he says is widely misunderstood. Forty cases were studied over five years, 80% of which were female, with an average age of 47 years. Over half of cases required surgery to resolve their painful symptoms. Treatment can include specially designed insoles and steroid injections, but there is no guarantee of success and in some cases surgery is the only option—a procedure to decompress the nerve through an incision between the affected toes. If complete nerve removal is necessary the patient is left with no feeling between the affected toes.

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body language I NEWS 13

3D IMAGING OFFERS ACCURATE RECORD OF WRINKLE REDUCTION Technique could improve clinical efficacy evaluating cosmetic outcomes

BOTOX CAN INCREASE SKIN PLIABILITY AND ELASTICITY Study shows effect of onabotulinum toxin injections similar to a radiofrequency procedure Skin pliability and elasticity improved for up to four months after treatment with onabotulinum toxin (Botox) for mild facial wrinkles, according to a report published online by JAMA Facial Plastic Surgery. Human skin has three biomechanical features: strength, pliability (the ability to stretch) and elasticity (the ability to recoil). As people age, these properties change and the loss of skin elasticity appears to be the most prominent. Physicians use a variety of methods to reverse the signs of ageing and onabotulinum toxin A injections are among them. Dr James Bonaparte of the University of Ottawa and Dr David Ellis of the University of Toronto, studied the effect of onabotulinum toxin A on the skin in 48 women treated at a private cosmetic surgery clinic for mild wrinkles of the forehead and around the eyes. Onabotulinum A injections in the facial skin resulted in increased pliability and elastic recoil—biomechanical changes which mimic those of more youthful skin. The mechanism for this skin change is unclear but the effect of the onabotulinum A injections is similar to a radiofrequency skin tightening procedure. However,

after four months these improvements returned to how the skin was pre-treatment. “The changes occurring in patients’ skin appear to be the opposite of those associated with the aging process and UV radiation exposure and inflammation. This study also suggests that the duration of effect of these changes mimics the duration of effect of the medication and that future studies are required to determine and quantify the histologic changes that are occurring. Dr Catherine Winslow, of the Indiana University School of Medicine, says the team’s findings “add credence” to existing research showing an association between botox and improved pliability and elasticity of skin. “Piecing together this research with continued studies on elasticity and collagen content of injected skin will further the ability of facial plastic surgeons to refine their strategy for long-term planning of anti-aging strategies with patients and educate them as to the importance of nonsurgical therapies for maintenance, in addition to opening new fields of potential treatment options for difficult scars and skin conditions,” she adds.

A new imaging technique called three-dimensional speckle tracking photogrammetry is described in the May issue of Plastic and Reconstructive Surgery as having the potential to measure the efficacy of injection treatments for both cosmetic purposes and to reduce facial paralysis arising from stroke and Bell’s palsy. Photogrammetry—the use of photography to measure distances between objects—can be used to measure dynamic facial wrinkles and their subsequent reduction following injection. Results are presented as a colour-coded heat map. Comparisons of heat maps of patients before and after, can allow physicians to objectively evaluate wrinkle reduction and such other variables such as optimal dosage for obtaining maximum aesthetic benefit. Senior author Dr Ivona Percec says: “With more people turning to injectable fillers, it is important to have evidence-based ways of improving cosmetic and reconstructive surgical results.” Current attempts at measuring wrinkle reduction mostly rely on static photographs and subjective visual assessments. The study evaluated 14 subjects using a dual camera system and three-dimensional optical analysis. White foundation and black speckle makeup were randomly applied to each patient before and two weeks after injection of 20 units of filler in the area between the eyebrows. Movement of the speckles was tracked by the digital camera for analysis. Wrinkles in treated areas were analysed, resulting in before- and after-treatment heat maps. “As new therapies and expanded applications become available for anti-aging and the treatment of neuromuscular disorders, this method may make it possible to quantify clinical efficacy and establish precise therapeutic regimens,” Percec says. “Though future studies will need to explore the use of digital image correlation in larger groups, our results are the first to show the modality can be applied to study a range of challenges in plastic surgery.”

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body language I DERMATOLOGY 15

Super-saturated oxygen emulsions DR MARK RUBIN talks about driving oxygen to the surface of the skin using cutagenesis

y taking a deep breath, we know that oxygen is good for us. From even the most basic understanding of biology we learn that oxygen is a necessity for our body. Those of us interested in tissue growth and new collagen production, are also aware that oxygen is one of the essential ingredients needed for cell growth. Oxygen enhances collagen synthesis and also has a very profound antimicrobial effect on wounds. It’s essential in order to be able to create ATP, and it is one of the rate limiting factors when it comes to re-epithelialisation. Oxygen in the skin Some oxygen enters the skin through blood, but research also shows that the uppermost 250-400 microns of your skin gets most of its oxygen supply from the atmosphere. Oxygen diffuses into the dermis—the upper 400 microns of

your skin, rather than coming through your bloodstream. In many treatment modalities such as microneedling, that’s as deep as you reach, so if you’re trying to heal those areas, the oxygen that’s going to help healing is atmospheric oxygen; it’s the oxygen around you rather than in your blood supply. Healthy skin has a mechanism for absorbing oxygen, but damaged or ageing tissue doesn’t function quite as well and the skin’s oxygen level decreases every year as we get older. Cutagenesis Using Cutagenesis, a super-saturated oxygen emulsion, it’s possible to drive oxygen through the surface of the skin and promote healing. The science is based on the idea of using perfluorodecalin—a material that has a very high affinity for oxygen. Perfluorodecalin has been used by the military over the years as a blood substitute. It’s been used in

Fig.1 showing oxygen transfer across a 1mm thick skin specimen using tcpO2 measurement, showing a 300% increase in oxygen within 20 minutes

trials in the United States for postmyocardial infection to try and oxygenate ischemic areas of the heart and save the heart muscle. It’s possible to put a huge

16 DERMATOLOGY I body language

60 50 40 30

Tissue oxygen level

70 Moisture content

Fig.2 Percentage increase in skin oxygen content following 6 weeks’ treatment with CutaVive

20 10 0

Wrinkle reduction after six weeks’ use of CutaVive (above) and four weeks after treatment cessation in a male smoker (below)

amount of oxygen under pressure into a container of perfluorodecalin. Applying this to the skin allows very slow outgassing into the tissue over several hours. Research has shown that if you create a well, fill it with oxygen emulsion, then lay a 1mm thick piece of tissue over the well, and measure the oxygen that passes through the tissue, that oxygen will increase over the following 20 minutes and stay elevated for several hours (see Figs.1 and 2). This particular research shows a starting reading of 160mm of mercury, and within 20 minutes it goes up to almost 500, illustrating that oxygen can diffuse through a 1mm thick piece of tissue within 20 minutes, and stay elevated over the course of several hours. There is a multitude of products on the market that claim to include oxygen, but the technology used

for the pressurised oxygen in perfluorodecalin is unique. No other topical oxygen product has the same amount of oxygen, nor can they outgas it over the course of several hours. In fact, measuring the amount of oxygen in all these products reveals an oxygen content no higher than atmospheric oxygen at 160mm of mercury. Instilling large amounts of oxygen in a product is impossible if it’s not pressurised. Research and benefits A study carried out in the 1990s tested different moisturisers with non-pressurised oxygen in them, and found that higher levels of oxygen within a product gave more profound reductions in wrinkles over the course of a month. The technology that we have now, allowing pressurised oxygen, delivers over 100 times more oxygen than what they were capable of doing in the 1990s. In a trial of 20 patients with photodamage, using the perfluorodecalin super-saturated oxygen emulsion product CutaVive, patients applied the product twice a day over the course of six weeks. Skin oxygen content was measured using a radiometer and skin moisture content using a corneometer. A biopsy was taken from the face of several of the patients before the study and after six weeks to see what the difference was histologi-

cally. The skin’s oxygen levels naturally reduce as we age—it’s much lower in middle aged skin than when we were 20 years old. CutaVive usage twice a day for 6 weeks created a rise in the resting oxygen level—the partial pressure of oxygen in their skin from them using the product twice a day. The results showed around a 17% increase in moisture content, while the tissue’s oxygen levels increased by over 70%. Patients were asked to rate the improvements in their skin at three weeks and then again at six weeks, considering elements ranging from colour, wrinkle improvement, blotchiness, dryness, pore size and firmness. The results showed some improvement in all of these parameters within three weeks, The response in smokers is a little faster and more profound since they start with lower oxygen levels than non smokers When asked to rate themselves, 76% of the patients rated that they had at least a moderate improvement in their skin overall. Improvement Looking at the images below, in the first set we can see fine wrinkling in the periorbital area in this female patient after six weeks showing the degree of improvement, which is fairly significant. The second patient is a smoker who used the product for six weeks in the trial, and then stopped the product; we waited four more weeks, and then photographed him. We can see an overall improvement in the quality of skin and in wrinkling and he’s also maintained the improvement a month after stopping use of CutaVive. It’s important to realise that wrinkle improvement here is not because of increased moisturisation. Many products for wrinkle reduction work well because they hydrate the skin, and when the skin is hydrated it looks better. However a 17% increase in moisturisation or hydration isn’t enough to give people the significant results in wrinkle reduction

body language I DERMATOLOGY 17

that this trial demonstrated. We can see changes if we look histologically at biopsies in the preauricular area of patients (see opposite page), where facial skin was treated with the topical product for six weeks. There is new collagen production and there are new elastic tissues. The before and after reticular stain shows all these new reticulin fibres at the end of six weeks. A trichrome stain reveals fairly profound new collagen deposition, in the upper dermis and some thickening of the epidermis from the before and the after that goes along. Oxygen is food for cellular growth. If we look at elastic tissue stains before and after CutaVive use, the dark material is all new elastic tissue which has grown at the end of six weeks. We see improvements in the appearance of the skin because there are histologic changes in the skin. New collagen and new elastic tissue, doesn’t die afer a month, so you’d expect that those results are going to be ones that were maintained over time. Now, in real life, obviously, the presumption is people are going to continue to use the product long term, but it’s important to realise that the persistence of the improvement that you see is not an artefact, but due to tissue changes. Other uses for supersaturated oxygen Super-saturated oxygen used after CO2 laser resurfacing, has shown to create improvement in healing and a reduction in complications. Photodynamic therapy, (PDT) for actinic keratoses, or for superficial basal cells, as a therapy can cause some significant tissue reactions. In a recent study, ten patients with multiple actinic keratoses were treated with PDT, following a traditional PDT protocol. After cleaning the skin with alcohol and acetone, topical aminolevulinic acid (ALA) was applied, left to incubate for two hours, and then subjects were put under blue light for 16 minutes to

Reticulin stain Stains reticular fibres type III collagen—arrows show newly deposited collagen fibres. Biopsy taken from the preauricular area before study and after 6 weeks of CutaVive use twice a day.

Trichrome stain Bright blue material shows new collagen deposition in the upper dermis following 6 weeks’ CutaVive use

Elastic stain Staining shows increased papillary dermal elastic tissue—dark staining material in upper dermis. Biopsy taken from the pre-auricular area before study and after 6 weeks of CutaVive use twice a day.

activate the ALA. Immediately afterwards, Cutagenix was applied on one side of the face, and Aquaphor, which is a petrolatum-based product with chamomile in it, on the other half of the face. This was done three times a day for a week. Almost all treated patients reported immediate relief in pain and stinging when they put the

hyper-oxygenated product on that side of their face. They had significantly less swelling and redness on the side treated with the supersaturated oxygen emulsion every day until they were completely healed at days five to seven. At the end of six months, examination of the patients showed that there was no reduction in efficacy

18 DERMATOLOGY I body language

FROM TOP: 1. Vascular occlusion incident from dermal filler injection into lower forehead., showing before, three and seven days after Cutagenix treatment; 2. Radiation DermatitisProgressive improvement using Cutagenix over three weeks; 3. Malignant parotid tumor requiring six weeks of radiation. Cutagenix used twice daily for seven days with marked resolution of radiation dermatitis; 4. Treatment following a hot liquid burn, showing rapid re-epithelialisation and improvement in the quality of the skin 5. Wound healing of burn wounds treated versus Silvadene

of the PDT therapy from the use of the oxygen product compared to the use of the petrolatum based product. This patient in image 1 was injected with Restylane in the glabellar complex, and presented three days after the injection with necrosis in the forehead. We began treatment with the Cutagenix product four times a day. This is a photograph of him three days later, and a photograph four days after that. You can see he has healed rapidly and has no evidence of full thickness necrosis in that area. This was done with just the topical superstaurated oxygen emulsion without the need for hyperbaric oxygen therapy in a chamber. The patient in image 2 shows a case of radiation dermatitis. Radiation dermatitis under the microscope is full of microembolic areas and microthrombi. All these superficial vessels are clotted off as part of the reaction to radiation and there are ischemic changes in the skin. It’s very uncomfortable for these patients and their skin breaks down. If you can increase oxygen levels in tissue that has a very low oxygen level you’d expect it to heal well. When you compare the result seven days after the end of the radiation therapy, there is a fairly profound degree of improvement in the radiation dermatitis, and 21 days later really profound improvement with excellent healing. Image 3 shows a radiation dermatitis patient at the start of the topical oxygen therapy and then seven days later very significant changes in the overall quality of the skin as well as in the healing. 5

The Cutegensis product has also shown good results on thermal burns with rapid re-epithelialisation and improvement in the quality of the skin. When trying to heal from a burn, both healing time and final quality of the tissue are important. The results in image 4 show the contrast in two treatment approaches to a thermal burn. One area is treated with Silvadene and the other, with the Cutagenix product. After three days, the area treated with Cutagenix is already healed, and the eschar has fallen off. The area treated with Silvadene has had almost no change. The results in image 5 show fairly significant improvement and rapid healing, very much unlike what you’d expect to see in burn tissue after ten days of traditional therapy. It’s also possible to use this product for other conditions such as gangrene and it’s also been shown to be very effective for rosacea and for some patients with perioral dermatitis. It’s also proved effective in patients who have eczema or rosacea, who are interested in anti-aging therapies but can’t tolerate AHAs, or retinoids, but they can tolerate topical oxygen easily. So, Cutegenesis is a calming therapy, but also stimulates collagen, elastic tissue and healing. Mark G. Rubin, M.D. is a board certified dermatologist in practice at the Lasky Skin Center in Beverly Hills, California. Dr. Rubin’s practice is limited exclusively to cosmetic dermatology, with a specialty in skin resurfacing. He is one of the founding members of Cutagenesis.

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body language I INJECTABLES 21

Earlobe rejuvenation DR KATHRYN TAYLOR-BARNES discusses why the aesthetic industry may see an increase in earlobe plumping using dermal fillers

he posterior face is often forgotten about when carrying out a facial assessment for anti ageing treatment planning. Our industry is looking more and more at plumping up a particular erogenous zone—the earlobes. We have mastered facial injections and have experience with injecting the backs of hands; the earlobes are the next area to develop. Why do earlobes need treatment? When we are looking at somebody face-on, it is like viewing a picture and we should be aware that the ears frame the face. The earlobes get the same skin ageing effects as the face and skin texture can deteriorate in time with a reduction in collagen, elastin and volume. There are environmental factors in ageing such as sunlight and people often forget to put sun protection creams on their ears. This is particularly relevant for men and women with shorter hairstyles. Ear Lobe trauma can also have

a negative impact on appearance. Skin conditions can affect the ears including Otitis Externa or Eczema. Hormone oestrogen depletion and menopause can significantly diminish volume of the skin globally, including the earlobes. There are behavioural influences such as a nervous condition that involves people pulling on their ears or picking at the skin. Although it is rare, it does happen and can cause thinness and elongation of the lobe. In the West, piercing of the ears, including multiple piercings, are very popular. We are seeing more and more of the enlarged hole ear-plug ‘Indie’ trend too. In other cultures like Africa, the Maasai tribe make a big deal about their ears. At the age of seven or eight, the young girls deliberately have an ear piercing of the upper ear lobe. A year later a hole is made in the lower lobe and is packed with bits of wood and leaves to deliberately make the hole in the lobe very large. When stretched, this area is

then dressed with beads and various ornaments as a factor in the girl’s beautification. The larger the hole in the lower lobe, the more beautiful she is. That is the Maasai tribal cultural way. Hence ears can play a big role in other cultures and taking care of them is important. Ear anatomy The area where we inject dermal fillers to rejuvenate the earlobe is inferior to the tragus. There are two ear types—the autosomal recessive attached earlobe and the autosomal dominant—both of which occur equally in the population.

Among Maasai women, a large hole in their earlobe is seen as an important element of beauty

22 INJECTABLES I body language

Dermal fillers are not always suitable for earlobes. Wearing earrings that are too heavy for them can cause unsightly elongation of the ear-piercing hole. As that gets longer it can actually drag downwards, causing discomfort in the ear. Dermal fillers will not diminish the size of that elongated hole. In fact, if that elongation extends it can tear the earlobe and that will need surgical correction but not fillers. With an earring that has split the ear, there is a simple procedure that is now being done more often in aesthetic cosmetic clinics. It is done under local anaesthetic and is basically a repair job with a few sutures. It takes less than half an hour and is fairly low risk. Frank’s sign A particular deep, distinct diagonal crease in the earlobes is very common in the population. This is called Frank’s sign. It extends from the lower tragus diagonally at 45 degrees to the edge of the oracle. “Frank’s sign” has been used to describe this for over 40 years and is a possible predictor of cardiovascular disease. There have been about 35 studies into this. The most recent study was published in April 2015 in the Journal of Angiology by Korkmaz et al. This looked at the incidence of earlobe crease (ELC) and peripheral vascular disease in patients that did not have any overt symptoms of atherosclerotic disease. By measuring the blood pressure ankle brachial indices the findings confirmed a link between low pressures [PVD] and presence of ELC. This means that these earlobe creases, which are usually ignored, may be a good and easy way we can screen for cardiovascular disease in aesthetic clinics and in primary care. Injection technique When injecting dermal filler into the ear lobe there are three preferred entry sites—the anterior approach, the peripheral approach at the side and a posterior approach. Merz, whose products Belotero

and Radiesse are both suitable for the earlobe, advise injecting in a linear threadlike pattern with one insertion point inferior to superior in direction. I decide which technique to use depending on whether I am trying to correct volume loss or plump up a specific crease. If it is volume loss I use a posterior ‘hidden’ entry point from behind the tragus. This means the client can leave the clinic with no visible marks of treatment. The earlobe is about 25% of the whole ear in length and the optimal earlobe is about 1.5-2cm long. It is important to keep these proportions as a guide when injecting so that you do not end up with an over-enhanced and artificial looking result. I find that the earlobe treatment can take as much as 1ml of product per lobe. The injection technique is simple, straightforward and practice makes perfect. Patients are really happy with the results. It is low risk and can generate revenue for your clinic. It’s also something to add to your repertoire as an area you can offer. Side effects Fillers in the earlobes have the usual side effects including immediate bleeding and redness and swelling. The bleedings stops easily with light sustained digital pressure. Delayed effects include mild soreness locally for a few days and puffiness which usually settles in two days with an HA filler and up to five days with a collagen stimulator filler such as Ellanse or Radiesse. You can occasionally get a little lumpiness, which lasts for about a week so this is something to brief your patient on. I usually follow up a week later with a phone call or in person to make sure everything has settled as expected. I advise avoiding wearing earrings for a week afterwards. If you inject the pre auricular area separately to the lobe, then they may need a touch-up two weeks later as this area of skin is thin and swells easily. We may be injecting a lot more patients with creased and sagging

earlobes in the future, due to patient demand. Soon, there may be earlobe-specific dermal fillers that companies market along with skincare ranges for the earlobes. By examining the earlobe in an aesthetic way, we may also be doing our patients a much greater service on the medical front, inadvertently picking up cardiovascular disease and sending them to their GP or specialist to be screened. It’s a golden opportunity to use those medical skills together with our artistic and creative aesthetic talents. Dr Kathryn Taylor-Barnes is a GP in Richmond and an aesthetic practitioner with clinics in Surrey.

Above: An earlobe that has been split by heavy earrings will need a minor surgical procedure rather than fillers. Below: Frank’s sign presents as a deep diagonal crease in the earlobe and can be a predictor of cardiovascular disease

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24 DEVICES I body language

Turn on,

Tune in,

Tighten up

MARTIN COADY looks at the uses of combining ultrasound and radiofrequency as an effective treatment for skin tightening

lients are drawn to us for skin tightening treatment to address more than just age-related changes —environmental factors also play a major role in long-term skin damage. It’s not just one layer of the skin that’s affected, this is a multilayer phenomenon that we can’t expect to treat with just one device or methodology. Although surgery is the gold standard for face lifts, many patients are just not appropriate for it. Some won’t contemplate surgery, many are too early for surgery, and some patients require treatment post-surgical enhancement or adjustment. Ultrasound and radiofrequency provide an effective treatment option. Beginning To start, we need to restore the mechanical properties of the soft tissues—the elastin and collagen that have been damaged by time and environmental factors. As this is a multi-level phenomenon, daily use of cosmeceuticals is very important, and skin resurfacing will get rid of a lot of photo-damage. Collagen can be stimulated by either mechanically, or thermally stimulating the skin inducing it to re-model. A whole gamut of non-invasive techniques are available at the moment, and we haven’t quite reached the ‘holy grail’, which would offer

permanent skin tightening, reduce fatty tissue, be completely noninvasive with minimal discomfort and no complications. In the non-surgical re-contouring field we also have to address fat reduction, because we cannot achieve shape change and skin contraction without volume change. White fat cells—non-metabolic fat adipocytes—contained within lobules of fat are further locked up inside compartments of fibrous septae. Targeting them and unlocking the breakdown products of fat is quite a task. There are a few current non-surgical treatment options: cavitation using ultrasound; injection lipolysis, cryolipolysis, and radiofrequency heating. When addressing a fat cell, you either have to mechanically disrupt it to release the contents, or induce it to die and then lyse. What we’re talking about is the difference between a fat cell necrosing, or undergoing ‘programmed death’, the process known as apoptosis. To achieve that requires sustaining fatty tissue at a temperature of above about 44/45° for 6–10 minutes. With these parameters there is good evidence that sixty percent of fat cells will probably undergo apoptosis. Collagen The skin contains mainly type one collagen that becomes mechanically degraded and disorganised with

time. Along with similar changes in the elastin, this contributes to loss of dermal thickness, elasticity and therefore skin ageing. To help restore mechanical properties we need to produce regenerated collagen. New collagen production used to be thought of

body language I DEVICES 25

as scar tissue, but we’ve determined that there is a different type of collagen production when tissues are injured in a particular way, and that seems to be a renewal rather than repair per se. We know that we can rejuvenate collagen by mechanically injuring it. This can be done by needling it with derma-rollers or similar, and by laser thermolysis. Essentially we’re punching lots of holes in it to induce inflammation and the rejuvenation. However, you can also produce the same effect by injuring it thermally—not enough to cause necrosis, but enough to denature and produce the micro-inflammatory changes which will stimulate fibroblasts to produce new collagen. You can see immediate dermal shrinkage effects when you apply radiofrequency energy. However, that effect disappears after 24 hours. After two to three treatment sessions, beneficial collagen rejuvenation occurs over three months. It’s vital that clients are aware that

they’re not going to see an instant, maintained result and that they really must wait for that length of time. Radiofrequency energy Radiofrequency energy produces an oscillating electrical current, which by movement of molecules, and particularly water within that tissue, heats it. Radiofrequency energy is converted to heat by resistance dependent upon how resistive the particular tissue you’re targeting is. Fat is quite resistive to the electrical current and will heat up a lot more than the other tissues, so you can differentially heat it. Bipolar radiofrequency energy is of limited use for inducing skin collagen rejuvenation and no use for treating fat. This is because you can produce heating to a depth of half the width of the distance between the two electrodes. To get a decent depth of treatment with bi-polar radiofrequency you’re going to have to have electrodes quite a long way apart. Trip-

Clients need to be aware that they won’t see an instant, maintained result with radiofrequency 99

olar radiofrequency devices are also available, but really don’t have any effect below the very superficial layer. Mono-polar radiofrequency energy is much more useful because of its superior depth penetration, and that normally depends on having the charge passed through the patient to a grounding pad, in a similar fashion to diathermy in theatre. Mono-polar radiofrequency energy can be delivered in either static or dynamic form. Static usually involves putting the treatment electrode on, triggering it, then moving to the next site. Dynamic monopolar involves constantly moving the treatment probe around over the skin. Animal studies have conclusively demonstrated that you can get a decent depth of heat penetration using dynamic mono-polar energy, delivered with a handheld radiofrequency probe. However, new-generation devices now permit intelligent “static/ dynamic” radiofrequency energy, with the patient lying under a non-contact electrode. This still achieves the same effect on the fatty tissue, but not the skin. Indeed it still creates a fair amount of uncomfortable skin heating. Cooling It’s a challenge to raise the temperature of the tissues high enough and long enough without causing a burn and without causing great discomfort. Treating skin does not need quite the temperatures that cause problems, however, treating fat effectively certainly can. It now possible to treat the fat layers effectively whilst simultaneously cooling skin. If you cool the skin, this effectively drives resistive heating deeper into the tissues. So, by adjusting the amount of superficial cooling, and thus the depth

26 DEVICES I body language

Using RF and ultrasound in combination can induce microvibrations and increase fat cell permeability

Peltier cooling uses a solid-state cooling probe to drive heating energy deeper into the skin

of that cooling, you can selectively focus the radiofrequency energy at various deeper levels. This doesn’t mean complicated cooling loops of water or refrigerant. Peltier Cooling is a clever technique using a solid-state cooling probe, applied to the skin at the same time as the therapy. This cools the skin and prevents pain or burns. If you are cooling down to 10°, you can drive the heating energy deeper into the tissues, or if you use no heating at all, then you’ve got an effective modality for heating and rejuvenating the dermis. Studies on pigs have shown that by treating in this way, normal fat did not become necrotic, but did after three months show evidence of having undergone apoptosis. Radiofrequency is a potentially risky technology. Despite any cool-

ing, if you’re not careful, the electrical charge that’s being passed from the hand-piece through the skin has the potential to burn, particularly so when you accidentally, or deliberately lift the hand-piece off the skin. This potentially creates a spark to the patient, who then gets a small burn or blister. There isn’t any technology that completely avoids that, but the ideal device will monitor resistance in the tissues underneath, dynamically changing energy levels so that they do not suddenly peaks, and having some feedback mechanism which detects if you are lifting the handpiece off within nanoseconds. Ultrasound Ultrasound is completely different energy delivery modality, but at the frequencies used for treating fat, it also relies on tissue water content.

OFF

25°

20°

15°

10° COOLING

Skin

1cm

Fibrous septae 2.5cm

Subcutaneous tissue

Muscle

So, whether using RF, or ultrasound, the patient must be wellhydrated before treatment. Ultrasound essentially has two modes of use—mechanical and thermal. Most of the time ultrasound within the skin and the immediate subcutis relies on thermal properties. If you’ve got highly focused ultrasound at the rate of a 1,000 watts and two megahertz frequency, you’re creating a thermal effect, a thermal heating. At lower frequencies and intensities of 200 kilohertz, you’re talking about a cavitation effect, which is the ultrasound generating bubbles within the tissue and those bubbles explode or collapsing and then disrupting the cell. Combining radiofrequency and ultrasound So what does combining radiofrequency with ultrasound do? Well, at certain frequencies, it should provide a thermal and a mechanical delivery system for the device, affecting the cell membrane, and fibrous tissue septae, thus permitting better thermal penetration of the radiofrequency. Inducing microvibrations, it probably increases fat cell permeability as well, and enhances the clearance of that fat once you’ve got

body language I DEVICES 27

the breakdown products into free fatty acids and triglycerides. I use the Exilis Elite, a device that combines radiofrequency, ultrasound and skin cooling. It has both a facial skin tightening, and fat reduction/skin tightening body contouring handpieces. The radiofrequency current and power is dynamic, monopolar. The ultrasound energy used, is quite a high frequency but a very low power. So it’s not really cavitational, and it’s not really heating at all. It’s designed to induce micro-vibrations without heating and without disrupting tissue in order to facilitate the radiofrequency current. We believe, from animal studies, that it induces vasodilatation and hyperaemia. That’s important because it then makes adipocytes more accessible to the bloodstream and to anything that’s going round it, and there’s greater elimination of any breakdown products that you produce. We also believe that it induces some “defibrotisation”—separation of linkages in the collagen of the fibrous septae that separate fat lobules, and induces a beneficial weakening of those. It also induces neo-vascularisation, producing new blood vessels, in a long-term effect, which then increases the metabolism of hard to get to, nonmetabolic white fat cells. It’s possible that this is why it makes the Exilis device quite useful for cellulite treatments, inducing the micro-vibrations in the fibrous septae and loosening them and possibly even stretching them. My ideal non-invasive skin tightening and body contouring device would combine dynamic mono-polar frequency, augmented with ultrasound and a variable skin cooling—and the Exilis does all that in one unit. There are laboratory, clinical, and international multi-centre trials that backup its efficacy. The animal trials were done in the Czech Republic, in Prague, where the device originates. There they did a lot of work looking at the temperature profile created by the device at various levels in the subcutaneous tissues.

To treat fat, you need to get subcutaneous tissues up to 7° hotter than the surface temperature. To get any effect in the skin at all, in the collagen, you’ve got to heat collagen to between 40° and 42° and since burning only occurs following contact with the skin at 44° for a very extended period, you’re probably safe from that point of view. However, studies conclusively demonstrated, that the subcutaneous tissues and fat were heated to a significantly greater degree than the cooled skin over time. You then have to sustain those temperatures for about six to ten minutes to induce apoptosis in fat, or any changes in the dermal collagen as well. So we have to question whether it really causing fat apoptosis, or necrosis and the evidence seems to suggest, that the amount of apoptotic cells skyrocketed. Some human trials were report-

ed in The Czechoslovak Association of Anti-aging Medicine, that quite conclusively demonstrated using 3D imaging techniques that with body contouring at least, you can get an effective reduction in the subcutaneous fat using this combined technology. Dr Weiss, a dermatologist in Baltimore, did some studies looking at the upper arm and the ultrasound thickness before and afterwards and got some really quite interesting changes. So it clearly works—but a multi-device trial would be required to determine whether it works better than single modality treatments. Exilis is really only indicated for mild to moderate deposits of localised, stubborn fat and treating mild wrinkles or skin laxity for maintenance of the skin, somebody who’s had other treatments, or even surgery and wants to maintain the tightness of their skin.

Pre- and post-treatment with Exilis, after three sessions (top) and following five treatments (centre and bottom)

28 DEVICES I body language

It is also useful after surgery. If you get any little bits of hanging tissue, skin, even fat deposits, after liposuction you can iron those out to some extent by using this device afterwards. Treatment protocols There are obvious contraindications to radiofrequency treatment if you’re going to pass a current through a patient—pacemakers, pregnancy and implants being the main ones. Hydration is key and you’ve got to have a patient who will tolerate the maximum power

Exilis can be used for a range of indications, including stubborn fat deposits, gynaecomastia and facial ageing

that you can put into them. Treatment is divided up into zones. You really need between two and four sessions to rejuvenate the skin and depending on how much you’re doing it can be 20 minutes or 90. In two sessions you’ll notice a difference, four sessions probably more and at intervals of seven to ten days, maximally. For skin tightening, we divide up the face into various zones and regions. The hand-piece on the Exilis elite device is very ergonomic— it combines ultrasound and radiofrequency in that small hand-piece as well, but there’s no cooling on this one so you have got to be quite careful to maintain what is tolerable for the patient. There appears to be some variability in the response. For body contouring, you have got to choose the correct degree of cooling, and to get the subcutaneous tissues up to the correct temperature as fast as you can, and then maintain them there. It’s very useful having an infrared thermometer on the hand-piece that gives you constant feedback of what you’re doing. Using the correct power settings, you try to maintain skin temperature at 40°, knowing that the temperature in the underlying fat is about 7 degrees higher. You can then step down the power to keep the temperature constant. It’s a bit like boiling an egg or boiling a pan of fluid, you turn up the heat to get it to boiling, and then you simmer it by turning the power down. Using feedback from the patient, with a little bit of cooling on, you can affect the hypodermis quite nicely and get some shrinkage of the immediate subcutaneous fat, which helps with the skin shrinkage as well, in my opinion. With more cooling you get effective fat reduction down to about 4cm depth. Lifting other areas As well as re-contouring the most common areas in the lower abdomen and hips, you can also achieve effects anywhere there is a problem, for instance knee-lifting. I

had a client who hated her knees (see image top left), the medial fat deposits, and the wrinkling. I was intending on giving her four treatments, but after two she wore a dress for the first time in years and felt she was a lot better. The treatment also seems good for acne scarring. It produces useful shrinkage and dermal thickening in the facial skin akin to microneedling. I treated a lady who had had a laser resurfacing many years ago. She had old style CO2 treatment, so she’s got very pale cheeks, but she liked the first Exilis treatment course so much that she’s going to come back and have some more as maintenance. Conclusion If your client doesn’t really have an indication for a facelift but thinks their tissues and skin are starting to show ageing changes with early wrinkling, then this treatment will return a lustre to the skin, with useful moderate thickening and rejuvenation as well. If a patient is not suitable for liposuction or abdominoplasty, but has stubborn mild to moderate deposits of fat, it will effectively recountour those areas non-surgically. Combining monopolar radiofrequency energy, ultrasound and cooling modalities is therefore a viable technology, which enhances the effects we know these energies have individually. Ultrasound is synergistic with radiofrequency energy, particularly for fat and cellulite. Complications are minimal to zero, inconsequential when they occur and the Exilis device is low on consumables. The future of non-surgical skin tightening and body contouring is here. Martin Coady is the first plastic surgeon in the UK to offer the Exilis Elite—skin tightening and fat reduction treatment. His clinical interests are in non-invasive radiofrequency medical treatments, developing strategies for preventing diabetic complications in feet, peripheral nerve surgery and chronic wound management

30 EVIDENCE I body language

The evidence behind vitamin therapy— science or hype? PROFESSOR SYED HAQ examines the clinical research behind intravenous vitamin therapy, which has been popularised in recent years by celebrity endorsements

he use of intravenous vitamin infusions over several decades has been reported as having significant clinical benefit. Many of these reports have emanated from the United States. A number of articles have been published on the use of intravenous magnesium and ascorbic acid in a variety of clinical conditions. The addition of nutritional supplements as part of a formula for intravenous therapy was most notably pioneered by the late Dr John Myers of Baltimore. Here Dr Myers modified the original intravenous vitamin and mineral formulation first introduced by the double Nobel Laureate Linus Pauling by increasing the amount of vitamin C, calcium, B vitamins

and magnesium in the “cocktail”. The modified Myers’ cocktail when used was reported to be effective against a variety of conditions ranging from acute asthma attacks, migraines, fatigue, chronic fatigue syndrome, fibromyalgia, acute muscle spasm, upper respiratory tract infections, chronic sinusitis, seasonal allergic rhinitis, cardiovascular disease, hyperthyroidism, dysmenorrhea and a variety of other disorders. Following the death of Dr Myers in 1984 saw a number of protocols introduced whereby monthly, weekly or twice weekly intravenous injections where used to treat patients with a broad spectrum of conditions. Interestingly many relatively healthy patients chose to

body language I EVIDENCE 31

receive periodic injections of vitamins because as they stated, “it enhanced their overall well-being” for periods lasting from between a week to several months at a time. In the last 16 years many thousands of physicians and naturopaths in the United States, in particular, have been using the Myers cocktail as a form of medical intervention. Many hundreds of thousands of patients have been treated in this way. However despite the many positive anecdotal reports there are only a small amount of published research trials and studies using this type of treatment modality. Theory The theoretical basis for intravenous vitamin-nutrition therapy focuses on the premise of restoring depleted serum concentrations of essential nutrients to either normal or supranormal levels which ultimately restore normal homoeostatic function and anti-oxidant potential in the body. It should be noted however that oral, or intramuscular administration of nutrients can provide adequate levels of nutritional support. Advocates of intravenous therapy however suggest that IV administration is the only way to significantly increase levels of such nutrients as vitamin C or magnesium two or three fold higher than that when using oral supplementation alone. This “optimisation of nutritional balance” through IV administration has been described as creating a more potent pharmacological effect either locally or systemically. This has been exemplified by attaining an anti-viral effect with vitamin C at a concentration of 10 to 15 mg/dL. A level observed with IV but not oral therapy. In addition high-dose vitamin C has been shown to significantly reduce levels of histamine in solution when administered at a dose of 80 mg/dL in vitro. Such an effect may have important implications in treating various forms of allergic conditions.

32 EVIDENCE I body language

Popularisation The use of intravenous vitamin injections have been popularised by celebrities and described as cutting-edge medical therapies. This type of sweeping claim can have serious repercussions, particularly when unproven therapies are being touted as helping prevent illness or targeting patients with life-threatening illnesses like cancer. Effects There is no question that intravenous vitamin treatment can have benefits. The mere administration of an isotonic solution with no other added supplements will rehydrate a patient or may induce a placebo response. Either way the patients can see some benefit. However the line is crossed when practitioners and naturopaths try to endorse the practice of administration of such treatments as a panacea for the prevention or treatment of conditions that include cancer. A systematic review of the literature failed to reveal a single double blind placebo clinical trial whereby intravenous vitamin therapy was seen to be efficacious over and above placebo. Clinical studies A study by Chen et al. 2005 in which pharmacologic ascorbic acid concentrations was shown to selectively kill cancer cells implicating a pro-drug to deliver hydrogen peroxide to tissues. The data indicated that ascorbate, at concentrations achieved only by IV administration, may act as a pro-drug for formation of H2O2, and that blood could be a delivery system of the pro-drug to tissues. The findings gave plausibility to IV ascorbic acid in cancer treatment, and unexpected implications for treatment of infections using H2O2. It should be remembered however that since its publication, this preliminary finding has not been substantiated in human studies. Importantly, the study by Hoffer et al. 2008 where a Phase I clinical trial of IV ascorbic acid in advanced malignancy showed that high-dose IV ascorbic acid was well tolerated but failed to demonstrate

anti-cancer activity when administered to patients with previously treated advanced malignancies. The trial failed to show any significant promise as a stand alone therapy. Three case reports examining the efficacy of intravenously administered vitamin C as cancer therapy by Padayatty et al., 2006 certainly provided increase plausibility for use of the therapy in oncology, but critically did not provide conclusive evidence. Mikirova et al. 2012 examined the effect of high-dose intravenous vitamin C on inflammation in cancer patients. Administration of high dose intravenous ascorbic acid therapy affected C-reactive protein levels and pro-inflammation cytokines in cancer patients. The study, found that modulation of inflammation by IV vitamin C correlated with decreases in tumour marker levels. Unfortunately on further scrutiny the unblinded study was not properly designed and failed to measure relevant clinical outcomes. Finally Vollbracht et 2011. investigated the role of vitamin C in fatigue in breast cancer. Is it any surprise the patients who accepted vitamin C felt better subjectively? Using unblinded and uncontrolled trials cannot be reported as providing an evidenced based appraisal of whether a treatment is efficacious or not. Notably, two clinical trials (NCT00441207 and NCT00626444) have concluded in the past few years but have still not reported any results, suggesting the results were negative. Risks The risks of using intravenous vitamin infusions cannot be underestimated. Poor aseptic technique can lead to a small risk of infection. Anaphylaxis has been reported in patients, and critically osmotic fluid shifts, increased rates of nephrolithiasis and drug-drug interactions raise significant concerns. Coupled to this is the lack of regulation which is an extremely worrying trend. It should not be forgotten making any addition to a bag of intravenous fluids and then administering this to a patient

represents the use a “specials drug”. The UK’s Medicines and Healthcare products Regulatory Agency (MHRA) guidance note 14, provide specific direction for those who want to manufacture import distribute or supply unlicenced medicines for use also known as “specials”. “Specials” are products which are specially manufactured and imported for the treatment of an individual patient after being ordered by a doctor, dentist, nurse independent prescriber, pharmacist independent prescriber or supplementary prescriber. To be able to provide this form of treatment therefore requires pre-authorisation by the MHRA and any individual therapist having a licence to dispense such “specials” medication and of course to be an independent prescriber. Failure to comply with this directive constitutes a criminal offence. The lack of clinical evidence, efficacy and the mine field of issues associated with special drug provision must be addressed as vitamin infusions cannot be simply used a “quick” fix in the afternoon but properly monitored and regulated. Ultimately there is no replacement for proper clinical trials which will ultimately determine whether this form of therapy is accepted in mainstream medicine or not. Professor Syed Haq is a Consultant Physician and Founder of The London Preventative Medicine Centre References 1. Chen et al. (2005). Pharmacologic ascorbic acid concentrations selectively kill cancer cells: Action as a pro-drug to deliver hydrogen peroxide to tissues. Proc Natl Acad Sci U S A. 20; 102(38): 13604–13609. 2. Hoffer et al. (2008). Phase I clinical trial of i.v. ascorbic acid in advanced malignancy Ann Oncol. 19 (11): 1969-1974. 3. Padayatty et al. 2006. Intravenously administered vitamin C as cancer therapy: three cases CMAJ 174 (7): 937-942. 4. Mikirova et al. 2012. Effect of high-dose intravenous vitamin C on inflammation in cancer patients. J. Transl Med. (10) 1479-5876-10-189. 5. Vollbracht et al., 2011. Intravenous Vitamin C Administration Improves Quality of Life in Breast Cancer Patients during Chemo-/Radiotherapy and Aftercare: Results of a Retrospective, Multicentre, Epidemiological Cohort Study in Germany. In vivo (25): 983-990.

Save the Date!

Sat 7th November 2015 At the 5 Star InterContinental Hotel, London Park Lane The prestigious MyFaceMyBody Awards are back for the fourth year after the hugely successful 2014 event which was attended by the best in the industry and lots of celebrities. Feedback from the industry “It was the most prestigious event of the year.” “An awards that gives brands so much credibility and exposure.” “A glittering night in a fabulous setting and a must for everyone in the aesthetics industry.” The MyFaceMyBody Awards have been recognized all over the world with global brands entering their products and professionals travelling to attend the big event. Entries open 1st May 2015.

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body language I MEDICAL AESTHETICS 35

Q Switch Laser DR MUKTA SACHDEV explores the use of the Q-switch in skin of colour

igmentation, whether it be freckles, lentigines or melasma, is a common problem in the universal quest for a clearer uniform complexion. In ageing skin of colour, facial dyschromia is more common than wrinkles as a sign of ageing. This population may have less demand for toxins and fillers, but you will see plenty of pigmentation. How does Q Switch work? The Q-switch laser is increasingly becoming a necessity in a cosmetic dermatology office practice. The principle of the Q-Switch is by a photoacoustic mechanism of action. The laser beam shatters the pigment, which gets dispersed into the surrounding skin and becomes phagocytosed. The process takes approximately two to four weeks, so sessions should be spaced accordingly. A Q-switch pulse is so rapid that extremely small pigments—ten to 100 nanometres—are heated to

fragmentation temperatures before the heat can dissipate into the surrounding area. The threshold for the destruction of skin is between 1.6–5.0 joules per centimetre squared, which means that pigment destruction can take place without the ablation of skin. The modality is both selectively targeting pigmented structures and non-ablative because it’s below the photoacoustic threshold. The theory of SSP SSP or sub-cellular selective thermolysis theory means that sub-thermolytic Q-switch uses light that is selective on a sub-cellular level, because it breaks apart pigments only and not cells. Therefore, theoretically it should be safer. This was a theory that the mechanism of action may also involve bio-stimulation. There is some degree of damage that accompanies this sub-thermolytic Qswitch treatment, but it’s less than a thermolytic treat-

36 MEDICAL AESTHETICS I body language

Make sure you know what you’re treating. Hyperpigmentation may be of varied aetiology and the correct diagnosis is essential for proper management 99

Hypopigmentation is highly undesirable because the social stigma of vitiligo is much higher than anything else

ment or an ablative treatment. So although it may not be 100% safe, it is much safer and there is no recovery period from the treatment. When you’re using low-fluence Q-switch, patients may have a little bit of erythema, but otherwise you won’t be able to see anything. Compared with traditional high-fluence therapies, the treatment is relatively side effect-free, although some side effects may include erythema and slight oedema. Fitzpatrick’s skin type five can develop mottled hyperpigmentation and also hypopigmentation. Facial pigmentation is the most common problem in clinical and cosmetic practice. Post-inflammatory hyperpigmentation (PIH) can be disease- or drug-induced,

post-procedural, traumatic and self-induced; for example with acne and PIH. Clinical diagnosis It is important to make the correct diagnosis—clinically and using the necessary instruments and investigative procedures. Use of a dermascope, patch testing and skin biopsies are important for diagnosis. You need to make sure you know what you’re treating. Always consider a differential—hyperpigmentation may be of varied aetiology and the correct diagnosis is essential for proper management. Patch testing is another important diagnostic modality. It may be a basic procedure or test, but if you do it you’ll know what patients are sensitive to. More often than not, Asian women show a sensitivity to PPD; paraphenylene diamine from using hair colour. Hori’s Nevus of Ota-like macules of pigmentation, also known as ABNOM—a dermal pigmentation seen in 0.8% to 1% of the Asian population—is often misdiagnosed as melasma. A correct diagnosis is vital to inform your

choice of treatment. If you use a Q-switch laser for this kind of pigmentation, you will get a good result. Melasma Melasma is one of the common facial melanosis, commonly seen in Asians. Standard protocol topical treatment of melasma would be first line with Kligmans formula. Chemical peeling is an adjuvant therapy depending on the type of melasma you’ve got—epidermal, dermal or mixed. For laser treatments of melasma, the fractional Q-switch laser is now being considered adjuvant therapy, not curative. Many laser physicians are starting to use lowfluence fractional Q-switch for the treatment of melasma. Another diagnostic tool is an Antera. It is a camera like instrument that can help in diagnosis and can be used to determine whether a client presents with erythema or melasma. The instrument photographs the pigmentation so you can determine whether it is a vascular or a melanin aetiology. If it is vascular, you can look at a vascular laser, but if it is melanin

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38 MEDICAL AESTHETICS I body language

Before and after treatment for lichen planus pigmentosis on the neck

I would consider a low-fluence Qswitch. Resurfacing with Q-Switch Q-Switch is becoming very common for skin rejuvenation and the treatment of various skin imperfections including melasma. It’s a very popular treatment modality in Asian skin for people wanting

full-face low-fluence treatments, referred to as skin toning. When treating with low-fluence Q-switch lasers, patients must be counseled on the risk of recurrence and of mottled hypopigmentation. Many Asians are on a quest for fairer skin. Hypopigmentation is highly undesirable because the social stigma of vitiligo is much higher than anything else. Always document the treatment response and measure your pigmentation with a Mexameter, a chromometer, a DermaSpectrometer. If you can, pick up an Antera or look at a dermascope. Always take clinical photographs. The procedure when you’re doing a Q-Switch, is under topical anaesthetic. There is slight burning, but usually ice and painkillers are enough. I use it for freckles and lentigines, which usually require one to three treatment sessions. Deeper pigmented lesions like a Hori’s nevus require seven to ten treatments, usually about two months apart. Another indication for Q-switch is lichen planus. I’ve had success treating clients with PIH from lichen planus and also some work with amyloidosis. Fractional Q-switch The most recent Q-Switch is a fractional Q-Switch, with which we are veering towards much safer treatments. Fractional lasers work on the principle of leaving normal skin. When there is some intact skin

Q&A Q: What percentage of your melasmas don’t respond? I don’t treat all melasmas with laser. It’s very individual. I would say realistically about 50%. Q: Would you use them in combination therapy? Of course. I never use anything alone for melasma. I will use topical therapy including broad spectrum sunscreens and also consider combination adjuvant treatment with laser and possibly chemical peels. Q: With the advent of the new pico lasers, where do you see the use of the Q-switch going? Do you

and a target tissue, the healing is much faster. I work with the new fractional Q-Switch by Alma, which allows you to change the tip and get different levels of depth of penetration. A very specific level can be targeted and I think this is possibly the future for darker skins. I treated one woman who had a lichen planus pigmentosis on the neck (see images above). We did five sessions and she developed a hypo patch. We treated her with topical tacrolimus. We treated her with a topical UVB handpiece and it repigmented, but after four sessions it’s a bit of a danger territory and after five you’re getting into areas where you might not be able to predict the response. From a darker skin standpoint, fractional Q-switch is definitely the way to go. If you can control the depth of pigment, I think that is really something that I would consider, though you must be aware of the PIH and the hypo and hyperpigmentation. Dr. Mukta is one of the leading practicing dermatologists in India. With two decades of clinical experience in medical, aesthetic & cosmetic dermatology, she has extensive experience in lasers & devices. Presently, she is a senior consultant & professor of the department of Dermatology at Manipal Hospital, Bangalore & has been head of the department of dermatology from 2011 to 2013.

see the picos superseding it? I’ve had some discussions with the Pico laser manufacturing companies. I don’t have much experience using it in darker skin and we are now working with it. They also have very limited experience with darker skin ands once we have documented experience with the Q-switch and the fractional Q-switch, there will be comparative data soon with the Pico lasers. In my mind I need to be well versed with what I have, whilst also gaining experience with newer technologies. As shown to you the Q-switch laser can also have unpredictable results in darker skin and caution is recommended in with any laser technology.

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40 PROMOTION I body language

A Guide to Advanced Lip Care Cosmetic doctor DR SARAH TONKS answers questions on SkinCeuticals’ new AOX Lip Complex

Q: Why do lips need specialised treatments to tackle everyday challenges of environmental damage and ageing? It’s important to understand the anatomy of the lips and how this presents specific challenges when it comes to environmental damage and premature ageing. Lips have a much thinner stratum corneum than the rest of the face, with only 3–5 cellular layers compared to around 16 layers in facial skin. This, combined with the fact that lips have no sebaceous glands means that they readily lose hydration, resulting in damage such as chapping and cracking. The lack of melanin in lip tissue renders it vulnerable to UV damage, which can impact collagen stability—leading to a loss of lip volume and density, as well as the appearance of fine lines and sun spots. It is therefore vital to include a specialised antioxidant and moisturising treatment for the lips within your daily facial routine, in order to protect against these effects and guard against future damage. Q: What is AOX Lip Complex and how does it address these concerns? The AOX Lip Complex from SkinCeuticals is an advanced, powerful lip treatment specifically designed to treat damaged or ageing lips. It has a unique combination of the potent antioxidants Vitamin E and Silymarin, as well as a complex of humectants and emollients made up of hyaluronic acid, hydroxyethyl urea and glycerine. These help attract and retain water to rejuvenate, reshape, and replenish lip tissue. I will be recommending AOX Lip Complex to my patients as part of their daily care and protect regime. In addition, it offers a more in-depth treatment

for those patients who have signs of premature lip ageing, like fine barcode lines round the lips and a blurred vermillion border. Q: How do you recommend incorporating AOX Lip Complex into a daily skincare routine? Because AOX Lip Complex is such a versatile treatment, I will incorporate it across a broad range of my patients, as it addresses multiple clinical needs. For example, I will start by educating my patients on the need for specific lip protection and care, and encourage them to use AOX as part of their daily moisturising routine. For those who are more concerned about premature ageing, I will recommend it as an intense overnight treatment and ensure they are applying it prior to outdoor activities, to protect against dehydration and UV damage. Finally, some of my patients suffer from cheilitis due to drying prescription therapies such as oral isotretinoins, so the AOX Lip Complex will help provide them with long-lasting relief and smooth, protected lips. Q: How can AOX Lip Complex enhance care pre- and post- lip augmentation procedures? Lip augmentation procedures are booming and as clinicians we want to ensure that our patients receive the best possible outcomes. To ensure that the lips are in optimal condition prior to an injectable procedure, I will recommend that my patients use AOX for a few weeks before treatment. The botanical emollients

in this special formulation hydrate and heal dehydrated lips, restoring smoothness to the lip tissue. Common post-procedure sideeffects include dryness, tightness, swelling, itching and peeling— again, the unique combination of active ingredients in AOX will help to assist the healing process and ease dryness and tightness by boosting tissue moisture retention. Q: How does AOX Lip Complex deliver value for you and your patients? For me, this will be a valuable tool for building patient retention and loyalty. AOX Lip Complex delivers great results and lasts for about three months, so I will expect to see a regular flow of patients coming back for skincare advice alongside purchasing their top-ups—so a great opportunity for cross-selling and expansion of existing skincare regimes. In addition, I will be able to recommend it for a broad range of patients, whether they are looking for a ‘step-up’ to enhance their skincare routine, or perhaps as an alternative to lip augmentation for those patients who aren’t yet ready for this procedure. With my lip augmentation patients alone, I can give them a product which works pre-and post-procedure which is tailored to their needs and delivers great results. I’m going to keep one in every handbag! AOX Lip Complex from SkinCeuticals is available from July 2015 Cost: £35 / €40 SkinCeuticals Stockist Enquiries: www.skinceuticals.co.uk

body language I PRODUCTS 41

on the market The latest anti-ageing and medical aesthetic products and services  ReCell Device Cambridge-based Avita Medical has launched a new device that is said to increase the skin treatment size by up to six times, offering much greater flexibility and a cheaper cost for clinics and hospitals where the device is used for burns and reconstructive procedures. The ReCell device is designed for clinicians to be able to rapidly create a Regenerative Epithelial Suspension (RES) – the active element in Avita’s products – by using just a small sample of the patient’s skin. Avita Medical say it can be used alone or in conjunction with conventional treatments for burns and the technology provides epithelial cells and their associated wound healing factors to the treatment area. Treatments which include the use of ReCell are said to achieve early definitive closure and superior outcomes with less donor skin. Furthermore, the regenerated skin is said to have a superior appearance compared with meshed autograft alone, as RES regenerates skin in the mesh interstices (very small spaces), blending the mesh pattern across the graft. W: recell.info

 iS Clinical Youth Serum iS CLINICAL launch their new Youth Serum, a pharma grade, botanical based formula. Designed to instantly smooth and tighten skin, rebuild collagen, repair and protect DNA and dramatically reduce fine lines and wrinkles, this new youth serum benefits from bio-identical growth factors, intelligent proteins and enzymes and patented extremeozyme technology. Youth Serum is said to outperform the market leading growth factor formulations, is proven to improve collagen synthesis and is able to produce this level of improved collagen synthesis in aged fibroblasts, which have an impaired ability to produce collagen. iS Clinical point out that the serum also illustrates superior anti-ageing performance can be achieved safely and effectively using non-human growth factor technology. W: isclinical.co.uk  Surface Fillers Range Surface-Paris, a French maturing aesthetic brand, has three types of hyaluronic acid fillers that are said to cover different facial needs in a very delicate way, from the filling of small lines to the treatment of deeper wrinkles or volumising cheekbones. Surface offers dermal fillers that are designed to both treat and rejuvenate the skin. This includes Surface Style, which treats lip contours, frontal sulcus, teardrops and superficial wrinkles. Its light concentration of hyaluronic acid is designed to allow a discrete but effective application. Surface Ultra is a light volumising hyaluronic acid that is designed to correct skin ptosis, and fill nasolabial folds. And finally, Surface Volume is the brand’s newest filler, which is designed to help recovering volume in areas such as cheeks, jawlines and temples. By creating volume in targeted areas, this cross-linked filler is said to reshape and redefine facial contour. W: surface-paris.com

 Medihoney Comvita have launched a new range that uses medical grade Manuka honey to help eczema sufferers. Medihoney medical grade Manuka honey, is not just your everyday edible Manuka honey. The active ingredient medical grade Manuka honey has been scientifically researched to support the healing of skin and wound infections. Comvita’s NEW range of Medihoney is specifically designed to target broken, infected and intact skin and uses the same key ingredient used by professionals and hospitals in treating wounds. With their key ingredient, Medihoney medical grade Manuka honey alongside oat extract, aloe vera, chamomile and plant butters, Comvita’s new Derma Range will help eczema sufferers take control of their skin. W: comvita.co.uk

 Facial Sun Cream SPF30 Green People’s newly launched SPF30 Facial Sun Cream is said to be a gentle yet effective natural and organic sunscreen, benefiting from the soothing and skin softening ingredients of chamomile and marshmallow and vitamins A, C and E from avocado. Designed for people who struggle with greasy sun lotions which can lead to blocked pores and skin irritations, this lotion is said to be naturally non-pore clogging, scentfree, naturally free from chemical nasties and suitable for all skin types even those prone to eczema and skin allergies. Green People say that the new SPF30 Facial Sun Cream contains a synergistic blend of antioxidant-rich plants including Edelweiss, Green Tea and Rosemary which work together to support the skin’s natural immune system, interrupt free radical damage and ultimately protect the living skin cells. By neutralising free radical activity these antioxidants are designed to protect and maintain collagen and elastin in the skin, which in turn preserves the skin’s supporting framework, helping to delay the signs of ageing. W: greenpeople.co.uk

42 PRODUCTS I body language

 DMK Super Serum DMK have just launched a new super serum combining two of their signature serums Beta Gel and Direct Delivery Vitamin C. The serum is said to be beneficial for all skin conditions, particularly Acne, poor immune response, hyperpigmentation and premature ageing. DMK say it is packed with potent betaglucan, which stimulates the skin’s inbuilt immune system and works as a powerful antioxidant against destructive free radicals, which cause premature ageing. The combination of Betaglucan & Vitamin C is said to have optimum healing properties for skin, with the Vitamin C stimulating collagen synthesis and cell regeneration. In addition to this, the Betaglucan is said to directly stimulate the Langerhan cells (skin’s immune system), activating the white blood cells within the skin, which release compounds that stimulate the fibroblast cells to produce collagen and elastin. W: dmk-uk.com

 SkinCeuticals Antioxidant (AOX) Lip Complex Skinceuticals announce the launch of the AOX Lip Complex, the latest addition to their ‘Correct’ product range. Designed to treat damaged or ageing lips, the Lip Complex consists of a combination of pure antioxidants Vitamin E and Silymarin and active ingredients. This restorative treatment offers three key benefits: To restore hydration to the lip to improve volume, to refine and smooth the appearance of the lip tissue and to protect against environmental damage in order to prevent premature wrinkling of the lips and surrounding vermillion border. The formulation of the pure antioxidant ingredients of AOX Lip Complex are said to counteract environmental damage by neutralising free radicals, helping to prevent premature lip tissue wrinkling. In addition, a complex of active ingredients including hyaluronic acid, hydroxyethyl urea and glycerin, are said to help attract and retain water to rejuvenate, reshape, and replenish lip tissue. Skinceuticals say that the AOX Lip Complex is a versatile treatment, able to be incorporated as part of a daily care routine, or as an intense overnight treatment. In addition, it is said to offer significant benefits when offered as part of pre- and post-procedure care following dermal filler lip augmentation procedures, in order to prime the lips ahead of treatment by restoring lip tissue and for relieving common after-effects such as dryness, tightness and swelling. W: skinceuticals.co.uk

 Noel Asmar Collection International beautywear brand, Noel Asmar, has been brought to the UK by uniform supplier, Grahame Gardner Ltd, to offer spa managers and therapists a working wardrobe for their business. Grahame Gardner Ltd have joined SPA UK and are offering 15% off for all members. The collection encompasses tunics and trousers and is said to be ideal for spas seeking to cultivate a luxurious identity for their employees. The garments within the Noel Asmar collection are said to capitalise on luxurious fabrics and so are therefore soft to the touch and pleasing to wear. With a selection of over thirty tops and complementary trousers and skirts, the collection is said to offer a range of flattering and stylish workwear solutions ideal for the spa environment. W: grahamegardner.co.uk

 Optilight All Over Spot Minimizer SPF 25 Exuviance launch their new triple-action OptiLight All-Over Dark Spot Minimizer for fighting the effects of photoageing and reveal youthful skin. Designed to correct and prevent dark spots brought on by ageing and environmental aggressors, Exuviance OptiLight All-Over Dark Spot Minimizer SPF 25 is said to be a comprehensive, all-over facial treatment that creates a more uniform and healthy looking complexion. Exuviance say that first, the patented NeoGlucosamine enhances cell power to exfoliate and break up existing dark spots. A combination of two powerful brighteners, B-Resorcinol and Turmeric, are said to help visibly reduce the appearance of hyperpigmentation and prevent the formation of new dark spots by blocking the trigger that leads to the development of melanin. Then, Exuviance say, Vitamin E and grape seed extract strengthen the skin’s resistance to environmental stressors to prevent new signs of photoageing. It is also said that SPF 25 ensures essential broad-spectrum protection against pigment-inducing UV exposure for a clear, bright complexion. Designed for use on the face, neck, décolletage and anywhere dark spots are a concern, Exuviance OptiLight All-Over Dark Spot Minimizer SPF 25 is fragrance-free, paraben-free and oil-free as well as non-acnegenic and non-comedogenic. W: exuviance.co.uk

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Social Media WENDY LEWIS simplifies the complex world of social media

Social media can be overwhelming so start by figuring out which platforms your patients use

o why do you need to be on social media? First and foremost, the numbers of people you can connect with via social media are huge. On YouTube, owned by Google, and the most important video platform, there are over a billion users. As of 2015, Facebook has 1.4 billion users globally. The UK has the largest percentage of the population of the country using Facebook; more than one third. There are 24 million daily active Facebook users in the UK, in a country where the population is 60 million—that’s almost half. India’s also a huge user and for many countries that are really big users of social platforms, it tends to be with younger populations. Turkey is a huge user, Brazil is a huge user, and so are Philippines

and Indonesia. You don’t have to be on every platform unless you have a huge marketing machine behind you— and at that point you are definitely going to have to outsource and probably have an SEO company doing part of that for you in terms of optimisation. How to get started If you want to get more active than you already are, you need to figure out where your patients are. 73% of people aged 35–44 have a social media account. Numbers increase as you go down, but 58% of people aged 45 to 54 have a profile on a social network—and that’s facelift territory, that’s fillers and toxins, laser resurfacing; that’s most of what you do in your clinic. Around 29% of those aged 65 plus have a profile on at least one

social network. In most cases if they’re going to have a profile it’s Facebook, but that’s changing. Many doctors will concern themselves with the fact that they have an older population and of course you’re in the anti-ageing business, but even older populations aged 50+ are on these platforms. If nothing else, grandmas want to see their grandchildren, so they are on these platforms in a bigger way than you may realise. Start by figuring out the platforms that your patients are on, your specific patients, and expand from there. Looking at social media becomes overwhelming, so we want to dissect it and bring it to a level that you’re comfortable with and that is manageable in-house to start with. Perhaps you then graduate to outsourcing it, depending on your

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budget and the way your practice is run. Create multiple touch points Promoting yourself is no longer only about having a pretty brochure or having a fairly good website; you need to be in other places where your patients are and the most important thing today is now being on mobile devices, because so much social media activity is going to come from a smartphone or a tablet. It doesn’t have to cost a fortune to convert your website to a mobile friendly version, but if you’re starting a new website that ought to be mandatory at this point. Create shareable content I see a lot of really good content and I see a lot of content that misses the mark. Part of it is that being in medicine restricts you from how colloquial you can get on these platforms and I recognise that. You’re not selling lipsticks, you’re not selling shoes, and your clinic is not a pizza restaurant. You really have to keep your physician or practitioner hat on and think a little differently than a service business that reaches a

much wider net. You’re looking for a very specific, niche market; a target audience. Targeting is essential. The more you target, the more effective you’re going to be and the less money it will cost you in the end. Look at the platforms that are going to be most relevant to your patient population. In most cases it’s probably going to be Facebook, Twitter, maybe Pinterest. It may be Instagram if you have a younger population. Figure that out and then start with tier one, see how you do, and expand as you need to. You can forget LinkedIn in this context, because despite merits that we will look at later, I don’t think it’s a place to look for patients. Employ a professional PR If you don’t have an in-house expert, outsource to someone who knows what he or she is doing—a PR or marketing person is ideal. What you put out has to have the right tone and that’s very important because even if you’re very active, if what you’re posting isn’t the right kind of content, you’re wasting your time and defeating your purpose. Social is not all about SEO, but it definitely helps

66 Targeting is essential. The more you target, the more effective you’re going to be and the less money it will cost you. 99 SEO and enhances your greater marketing efforts online. People are 44% more likely to engage with content that contains visuals. That means anything, including photos, graphics, video; even links would fall into that category. Video is big, photographs are big. It could be a line drawing but it’s got to be something that is more engaging than just straight text. If you really must just do text, then at least break it up with a hashtag or two, so it looks a little more consumer friendly and there’s something of interest in it rather than just words. Tailor your content to different platforms Each platform has a specific type of user. Everyone’s going to have their own favourite platforms that they’re going to want to spend more time on and they consume content in a very different way. The format is completely different in every one of these platforms, so you can’t just put a Facebook post up and call it a day. You have to figure out how that’s going to look on Twitter if you have it automated and on any other platform if you plan to share it. Of course content can be reformatted. You can use the same basic content and just repackage it in a way that’s going to fit that other platform, and thumb-friendly content is good on a mobile platform. The following guidelines may help distinguish some of differences between content on these platforms. Instagram: How gorge is Jane after skin laser?! Note the difference in tone, note the exclamation point; much more

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colloquial, much more conversational, a lot younger as well because a younger demographic is on Instagram now but that is expanding. In fact, many milennials have shut down their Facebook profiles in favour of Instagram. YouTube: watch me doing a laser treatment. Factual and professional. LinkedIn: My skills include expert laser resurfacing. Totally different tone here. You’re talking to each other—colleagues, vendors, business partners—you’re not talking to consumers. Pinterest: Jane has flawless skin after a laser treatment. Very personal, very feminine, very relatable content that is more inspirational. Google+: join my circle to learn about what lasers can do. Google+ is still a mystery but a very important platform and not one you can afford to overlook because Google owns it. A word on LinkedIn LinkedIn is a business-to-business networking platform. It is not for reaching consumers. In fact, I would discourage you from trying to use it to reach consumers. I see sometimes that doctors have their SEO people putting consumer blog posts in groups on LinkedIn. Frankly, that’s a good way to get thrown out of a group. I would not delegate LinkedIn to anyone other than someone in your staff. This is about your business and I believe it needs to be done by someone who represents your business internally, especially

66 In terms of content, pictures of faces capture a lot of attention because they’re nice to look at and provide eye contact 99

Beware of lifting content

Be very careful about lifting stock photography from Google images. If you see a pretty picture you want to use, you must go and license that from the stock photography platform that owns the rights to it. If you’re merely lifting it from someone who bought it for one use and you’re putting it on your Facebook page, it’s not licenced for that so you could be sued.

if you are a public company. 79% of users on LinkedIn are over 35. These are serious people. Users are twice as confident in the information found on LinkedIn because it’s not a social site in the very essense of the word. It’s not a community in the way Facebook is, but it’s so good for information. In my opinion, the way to use LinkedIn is to put in weekly updates—it doesn’t need to be time consuming. What I mean by an update is you share some content you read online about a workshop you saw at this meeting. It can be something that came up in the news. LinkedIn is also a great way to hire staff. It’s really good for job hunters, if you’re looking to replace or you’re looking to bring someone else new in. Facebook One in every seven people on earth is on Facebook. It’s just too big to go away, but Facebook wants your business so they’ve really improved things. Their customer service isn’t good, however their didactics and their insights and the features they offer are excellent and well thought out, and they make it very user friendly because they don’t want you ever to call them. Their ads have become cheaper and offer you more options, so the more you can target your ads, the better you’re going to get a result and it’s very easy to track. I don’t know how many doctors who are using Facebook ads, but I think Facebook is a good place to advertise and in my experience, it can

be extremely effective if done efficiently. If you’re not very active on Facebook yet, it’s important to keep profiles separate from business, because a lot of doctors can really get into trouble with this. If a patient reaches out to you to try to friend you personally on Facebook, my advice would be to send them a note back—thank you so much for your interest, please like our Facebook page, Dr Smith’s Clinic—so you’re not ignoring them and not accepting them which may tick them off. What makes good content? Pictures of faces, especially eyes and lips, capture a lot of attention just because they’re nice to look at and it’s eye contact. I try not to use more than three hashtags. I really like branded content for Facebook. It’s very hard to get practices to do this unless you have someone who has really good Photoshop skills but it isn’t that difficult. If you’re working with a social media firm I would urge you to try to get them to do that because it looks so much better. There are also some hurdles to overcome relating to upload sizes, which an expert will be able to overcome much quicker. Content should be light, it should be friendly and have a positive tone. If you’re trying to market a medical spa or a clinic, you need to lose the technical language. Keep it professional, in that you’re talking to prospective patients and media, but avoid any kind of big words that require lengthy explanations, words that are hard to spell, complicated words or phrases that are not going to be picked up a search engine. You can write about almost anything except religion. Politics is probably a bad thing too. Sex, you have to be a little careful because you’re practitioners. I would do nothing off-colour and nothing that could be misconceived or that someone could potentially take offence to. However, Facebook does allow you can go back and edit the post if needed. Facebook gives you a lot more

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room to work with as opposed to Twitter where you have 140 characters, and Instagram which you basically can only do a caption. However, if you don’t capture your reader in the first sentence they’re not going to read any more, so too long is not good because they’re never going to click on that. Three or four lines at the most is ideal, and the most important things—as when you are writing a press release—need to go upfront. I start all my Facebook posts with a hashtag because I link all my Facebook pages directly to Twitter—so then that will go to Twitter and the Tweet will start also with a hashtag. I’m very conscious of how the post will look when it becomes shortened to a tweet at 140 characters followed by a Facebook link. Plain text doesn’t look great on Facebook. Try to make it look as magazine like as possible. Obviously we’re not Condé Nast, but try to make it pretty and appealing and visually interesting; a lot of different types of content and not repetitive content. If you post something on Monday don’t post something similar on Tuesday—keep it different. We use #ThrowbackThursday because it’s fun and people smile, they like it. My office hates me for this because it’s so not me, but inspirational quotes get unbelievable amounts of likes and shares. Boosting a post Because of the way Facebook

works, a lot of the content you put up is not going to be seen by that many people. It may be seen by the people who are your friends, but it gets weeded out very quickly. However, it is possible for you to boost a post so more of your target audience see it in their newsfeeds—for example, women in the UK aged 25 to 45 who like beauty, cosmetics, Botox or lasers. This may cost you £30–50, or you can spend thousands if you want. But Facebook will show you right away when you’re putting those analytics in, exactly how many people you could be reaching. So if you’re spending £50, you’re maybe reaching 3,000 to 20,000 people that fall within that target audience. The more targeted you can be the better. You can target by geographical area and also by gender, level of education and marital status amongst others. It’s a small investment but in my experience it really works. Hashtags Hashtags are a very important part of social media marketing now. A Hashtag is a hashtag symbol (#) with a phrase and the phrase is searchable. There are four platforms at least that I know of where you can use hashtags, which would be Facebook, Instagram, Pinterest and Twitter. If you go on Twitter and you want to search for Beauty Secrets, enter #BeautySecrets and you’ll see all the listings where that

hashtag was used in tweets. Try not to create lots of random hashtags because they will not be searchable. It’s fine to create your own branded ones—though they don’t have to be branded. Sometimes you’re better off if they’re not branded because more people will pick them up and then you get some traction. Twitter Twitter is fun but it is time consuming, so if you don’t want to spend a lot of time on Twitter, you could consider automating it. I like putting Facebook to Twitter. Never put Twitter to Facebook. I think twice daily is a good benchmark for number of posts. The whole idea of a doctor tweeting while he’s in surgery is ridiculous, and in my view, it de-medicalises what you do. You see a lot of this online. I don’t think that’s the doctor you want to be. Pinterest Pinterest is pretty and clever, and highly addictive. It skews very heavily female—68% in fact. So if you are operating on, or injecting or lasering women in some way, you probably want to be on Pinterest. It also skews younger. However, it is extremely time consuming, so the last thing you want to do is have your receptionist, who should be answering the phone and taking care of patients to pay the bills, pinning in the middle of the day.

Each social platform has a specific type of user but you can reformat content and repackage between platforms

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You start on Pinterest by creating boards. And one thing you should not do is create boards that are named Rhinoplasty, Rhytidectomy, etc. Look for Health and Beauty themes. Before and afters of the 65 year old woman who had a neck lift does not belong on Pinterest. This doesn’t even belong on Google ads. An after picture of an attractive patient who had a great result is okay for Pinterest. Nothing clinical, ugly or unappealing, nothing bloody or too intense will work. A picture of a laser is not interesting at all. It’s the absolute opposite of what Pinterest is all about. Pinterest is about celebration and inspiration. Eyes, lips and legs are really popular. Fashion is always good. Celebrities are always good. You should have a caption on every pin that you put up because otherwise it has no identity and that’s not really recognisable. The goal of successful engagement is to get re-pinned or shared; it’s not necessarily followers. Never re-pin something without giving credit. Just doing a screenshot and posting it on your page, is bad etiquette. With Pinterest you should re-pin it because that person who you’ve re-pinned is much more likely to re-pin your stuff too. Instagram Instagram is fun, and it’s owned by Facebook so it’s not going anywhere, but it takes up a lot of time. Instagram can be a great plat-

You can hire a videographer to spend a day documenting staff, patients, procedures or consultations, and upload to YouTube

form but you’ve got to have something to take a picture of, so you have to be a little creative. If you have ugly or amateurish, poorly taken pictures on Instagram they will never be shared and people will unfollow you. The people who are good on Instagram have beautiful taste and know how to manipulate images. They have very high standards because some of the images on Instagram are amazing. Instagram requires a fair amount of upkeep. You want to include a caption and you want to include a few hashtags. Three is a good number, but I think four, five or six becomes silly. A lot of the content that you create for Pinterest can be recycled on Instagram. If you sell products in your practice, that’s a perfect thing to put on Instagram, but you’ve got to have something to work with—a picture of a syringe is not the answer. A syringe going in is definitely not the answer. A product in a beautiful setting, or a lovely smooth forehead on the other hand would be fine. Instagram is on fire, so it is definitely a platform to keep tabs on and consider being on for your clinic. YouTube Google-owned YouTube has a billion users. Original video content is required, so this is another example of when you can’t really recycle content very easily. However, the content you create for YouTube does not have to be professional

SEO versus PR

Some people think these are the same thing, when in fact they’re diametrically opposed. The person who is good at SEO is very analytical, very results oriented, numbers oriented and it’s probably someone you don’t want to have dinner with. Let’s be honest, PRs are friendly and outgoing and smiling because that’s their job. It’s relationship building. SEO is link building. It’s completely different. So to have SEO friends do all your social content, I think you’re missing the mark.

quality and it’s perfectly fine and common to do it with your iPhone. Another option is to hire a videographer who could spend a day, or half a day at your practice doing videos of the staff, patients if they’ll allow it, doing a procedure, doing a consultation. One video is not going to be cost effective but to do five, six, ten videos in one day, then it’s going to be worth your while. Testimonials are the new word of mouth, and because today we’re so unfortunately skewed by reviews and ratings, having videos from real patients talking about their experience in your clinic is the most compelling. You often see on websites, patient letters and cards that are handwritten. It’s charming, but they’re hard to read once you’ve blacked out the patient’s name, the doctors name, what they had done.

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It’s fine to do a mix, but there’s nothing more compelling than a real video. We know how important ratings and reviews are, and what other patients are saying about your clinic, so this is a good way to counterbalance some of the ratings and reviews. It’s something you have control over, but these must be legitimate real patients, it cannot be an actor, it cannot be a member of your staff, it cannot be your sister in law, it really has to be a legitimate patient. Think transparency. People want to hear from other real people who are relatable. Also bear in mind that what you post should mirror the target audience you’re going after to some degree. A patient doing the talking is word of mouth at its best. I’m very conservative about these things and I ensure there’s an exit strategy, so if the patient decides they don’t want it on your site anymore, they should be able to call you and you should be able to take it down.

I don’t think you’re putting the fire out, you could be inadvertently adding fuel to the fire in a way. So I would be careful about that. Try to answer in a very positive open way. Apologise, ask how you can help. Get them off that forum and try to get them to either email, direct message you, or call the office or clinic. This also shows your other fans and followers that you’re interested and engaged and not just leaving that out there. Be every careful about acknowledging any doctor-patient relation-

ship in an open forum. On Twitter you have no control at all, so if you see a negative tweet it’s generally best to leave it alone. The risk of responding can be worse than leaving it because Twitter is real time and it’s gone in a second. If you don’t respond in three minutes it’s out there and that’s it, unless it goes viral, but this is highly unlikely if you do nothing. You can send a direct message to the Twitter account, but these may be overlooked.

Six Rules of Social Media

Google Plus With Google Plus you create circles and invite people to join your circles. When I first started on Google Plus I couldn’t find anybody to invite because nobody I knew was on Google Plus. Minimum post is probably daily, and there are lots of things you can do. In my view, G+ is most helpful for SEO value.

1. Outsource what you cannot do effectively and consistently. Even if you’ve got somebody

Dealing with negative posts A negative post is really not as bad as it sounds. On Facebook you can take it down in a second. However, I would urge you to think twice before you do that. Of course, if it’s really abusive or it’s fake, then you take it down and you ban the user, but if it’s something about pricing or results—which is actually quite unlikely to come up on Facebook—I would urge you to try to address it, because when you get rid of it you just make someone mad. If you get rid of it on Facebook, which is the only platform you can really do that on easily, the same person who may be now even more ticked off at you, can post it on Yelp, or create a new account and post it again on Facebook.

to your target audience. If you don’t know who your target audiences are you need to do that first before you start spending money. It can be more than one target –you have a main target, then you have sub targets, then maybe you want to go even further and do a deeper dive. Start by knowing who you want to attract and what you want to do more of for your practice. Figure out if you want to do more lasers, more fillers, or more liposuction patients.

great on staff who can do it well, if she doesn’t have the time to do it consistently you’ve got a disconnect. So take that person and let them manage some of the outsource. Interns, grad students or medical students are great because they understand what you do and they’ve got time, they need the money and it’s something they can do from their laptop.

2. Track each tactic and measure success and ROI (return on investment), to figure out whether things are working or you need a change of focus or increase in investment or time, resources, or staff.

3. Know your target market. Don’t waste your money and effort on tactics that are not going

4. Invest in technology. Give your team members the right technology to be efficient, if you are doing your social media in-house. I am partial to Apple because their products lend themselves well to these activities. The more integrated your technology can be, the easier it will be for your staff to succeed. For example, if you are serious about social media marketing, at a minimum use a third party platform to schedule and optimise your content and posting, such as HootSuite or any other like that.

5. Make it easy for patients to follow you. Make it easy for patients to engage with you. Include social links on all clinic signage – “Like us on Facebook for special offers,” on ALL marketing materials, and above the fold on your website landing page.

6. Consistency and clarity are key. You won’t get results from doing something once. Create a social media marketing plan for 12 months, start by creating content one month at a time, and use consistent themes, images, hashtags that speak to your clinic brand.

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66 Budget for social media; it’s not free. It has to be done strategically and by someone who really enjoys doing it 99 Best times to post I like 11 o’clock in the morning and mid-afternoon, but it can go both ways. It depends on who you’re reaching. If you’re in the city and you’re getting secretaries and office people coming in to see you during their lunch hour maybe lunch hour makes more sense. The only way to really know is to change times and see where you get more engagement, then you figure out a strategy to that degree. Another mistake is people forgetting that the week has seven days. Just because your clinic isn’t open Sunday doesn’t mean people aren’t on Facebook on Sundays. National holidays are a great time to post because there’s so much more you can say. You can’t talk about your clinic every single day, people don’t want to hear it. If you toot your own horn every day of every week, people will stop listening and stop paying attention. This isn’t what social is about. It’s about a dialogue and sharing. The secret to me is that it has to be attractive, appealing, not over the edge, not low class or anything that can be considered off colour. Social budget Everybody thinks social is free and it’s not. That’s a fallacy about social media. It’s not something that you just throw at whoever’s not busy at that moment in the office. It’s got to be done strategically and it’s got to be done by someone who really likes doing it, because if you don’t like it, it will show. And everything today is about transparency. Consumers are acutely aware of where this is coming from and it’s got to sound real. So, I would urge

you to get someone to do this for you—unless you’re female and you really like doing it. To start with, I would suggest you make a list of everything you need to do social well. Someone has to set these things up for you. Yes you can do it yourself, but I promise you it will not look good or function well. There are some things that require a programmer and, short of going to programming school, you need someone who actually knows how to do this. You need them to put tabs on a Facebook page and ultimately that really needs to be done by a programmer. Hootsuite and Tweet Deck are popular ways of managing, automating and giving you analytics on your social media, but you do have to pay for them. Video is another cost—someone’s got to shoot the video unless you’re going to do it yourself. And don’t forget about staff time, because even if you hire a social media agency they don’t know what you do, so someone on your staff has to be able to direct them, manage them and make sure that what they’re posting about is accurate and not getting into trouble. Check out exactly what you need and get it in writing before you commit to any contracts. Be very careful as it can be a very sleazy business sometimes. Don’t sign a contract without a lawyer looking at it and make sure that your rights are protected. You should always own your URL. You can’t let somebody own your Facebook page URL either, so you should really make sure that that’s been done properly. Figure out the frequency of what you need, how many ads you want to do, how many boosted posts, then figure out what it’s going to cost you and really sit down and decide how much you can spend on it and go from there. Measuring results This is critical, and there are many ways to do it but all of them are time consuming. Facebook insights are really easy to use and it creates reports, which you can

print, download and compare. They’re really good, you can go back years, months, it will allow you to track best times of day, engagement, figure out what the best measurement is for the strategy that you’ve put in place, and those are the numbers you want to pay the most attention to because there are a lot of different ways to approach this. Social media presents many challenges for aesthetic clinics. However, the rewards are there for those who are serious about this new form of marketing. Social is here to stay and the sooner you accept it as a vital component of promoting your clinic’s services and products, the faster you will be able to grow a fan and follower base. Don’t just jump in because you think you have to. It is always best to have a strategy that is developed to address your goals over time, the right people on the team, and a reasonable budget to see results. And don’t get discouraged because you don’t have thousands of Facebook fans in a month. Like SEO and any other marketing tactic, it takes time to move the needle. These are some of the most important social media trends for 2015, according to a recent survey conducted by TrustRadius:  60% of people report that measuring the ROI of social media is their biggest challenge.  Respondents reported that their primary challenges include: aligning goals, demonstrating value, and deriving insights from data.  80% indicated that engagement (likes, shares, comments, followers) is the MOST important metric.  32% said leads or new clients are important; 28% said revenue is a key metric. Wendy Lewis is president of Wendy Lewis & Co Ltd, Global Aesthetics Consultancy. Lewis is a frequent presenter at international conferences. In 2008, she founded Beautyinthebag.com and has served as Editor in Chief. The author of 11 books, her next, Aesthetic Clinic Marketing in the Digital Age (CRC Press) will be published Winter 2015.

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Online reviews ROSIE AKENHEAD discusses how to approach the world of online customer reviews

or any service that is beauty or surgery related, “online reviews” might be a daunting phrase. The world wide web is vast and many businesses want to know what people are saying about them online and how they can control it. An online review is really no different from an email, a phone call or a customer standing across your desk and talking to you directly. Yet, how you handle an online review can sometimes be even more important than how you handle customer feedback face to face, because it can be seen by so many other people browsing the net. Consumer interactions In the digital age, the information landscape has changed hugely since the first paper Yellow Pages style listings were created. People now use Google, YouTube, Gumtree and Craig’s List in the same way they once used encyclopaedias and local papers. Often, now when people search for businesses they turn to sites like Yelp to get the information they need, rather than paper directories. Yelp gives consumers basic business information, plus gives people a platform to interact and respond to businesses – through reviews, photos and discussions. Like many sites, Yelp has taken what naturally occurs – word of mouth – and moved it to an online platform. Around 60% of searches come from Yelp mobile. That means people are browsing and looking for services and finding out what’s around them while they’re on the move, ready to make that purchase. Searching on devices is on the up and a partnership between Yelp and Apple Maps only enhances that process. Yelp doesn’t just cover beauty salons or surgeons, it covers things like bars, restaurants, shops and anything you might find in your local high street or town. Reviews are written in many different areas, but when you’re in the beauty, health or fitness industry, people tend to have quite a personal experience with you which can certainly lead to individuals writing reviews online. We discovered in 2014 that 82% of people who come to Yelp are looking to buy a prod-

uct or service. This is important because it means that when someone is looking on your business page, they are likely about to make a purchase, so you want your page to look as attractive as possible. In general we found that as a result of their search, people were purchasing from a business they found on Yelp within a week. Search trends According to the 2013 British Association of Aesthetic Plastic Surgeons (BAAPS) report, there were 50,000 cosmetic procedures performed within the UK in 2013 – a rise of 17% from 2012. One million Botox procedures were undertaken in 2010 and that figure continues to rise year on year. This is a sector that’s really booming, with non-surgical procedures currently accounting for about nine out of ten treatments. The Minotaur Consumer Study showed that 19 million people in the UK would like to have a cosmetic procedure. That’s a big percentage of the UK population who would like these kinds of services, and people are frequently searching online for opportunities and clinics where they can get these procedures done. Around one in three people using Yelp have searched for Health or Medical and two in three people have searched for Beauty & Spa. Given that Beauty & Spa is not an every day activity, unlike going for a coffee, it shows that people are turning to online review sites to get

Yelp Yelp’s goal is to do one thing – and one thing only – and that’s connect people with great local businesses. Yelp was founded in 2004 by CEO Jeremy Stoppelman, after a personal experience of being ill in Seattle. Unable to find recommendations or any impartial information about specific, local doctors and frustrated by finding merely listing information, Yelp was born. It’s now used by an average 135 million unique monthly visitors in 29 countries across the globe.

52 MARKETING I body language

Misconceptions about online reviewing  Reviewers are all anonymous On Yelp that’s not the case. People build out their profiles so you can see what kind of person they are. Every single person writing reviews provides their real name and an email address. You can also see what things they like, whether they’ve written reviews and what sort of ratings they give. This can give consumers and businesses a good idea of how trustworthy someone is.  Reviewers are all students Actually on average, the people writing reviews are in their mid-thirties. These are generally people with a disposable income and they are often college or university educated – that’s a prime target market for the cosmetic industry.  All reviews are negative Not only is this not true, but on Yelp, 78% of reviews are three to five star, which means good to excellent.  Online reviews aren’t reliable We work really hard at Yelp to make sure that we’re showcasing the most useful and reliable content to consumers. We have an automated system that looks out for those reviews that might be fake or biased. By doing this, we help to keep consumers safe, keep content relevant and protect businesses from dubious competitor activity.

the latest tips on where to choose. As you know, this is a very personal industry. Every interaction with every single consumer, from getting waxing done on the high street to having full-blown cosmetic procedures, is a potential review. The number of reviews on Yelp

for these categories actually reflects that. 9% all of Yelp reviews are Beauty & Fitness and 6% are Health. How to make the most of customers online One of the easiest ways to make your business listing more attractive is by adding pictures and ensuring your business information is both accurate and useful. Once you have some reviews, you will want to interact more with your customers online and learn how to handle online reviewing. On Yelp, businesses list for free so you can set up a business account easily and get statistics about your Yelp page. You can check how many people visit your Yelp page, how many are looking at your website and how many are checking your business map. You also get free tools, such as ones that encourage people to ‘check in’ on Yelp when they are at your location in return from a small incentive. It’s free to do and means that people are aware you are on Yelp and actively engaging people online. If someone has had a good experience they can get a little nudge afterwards to write a review. Responding to online reviews If you get a review, good or bad, it’s good practice to respond. Whether it’s thanking someone for a great review or responding to negative

Q&A Q: If a business posts an owner reply and then regrets the response, can the manager remove it? RA: Yes, in a situation where you think you haven’t reacted or responded in the way you want to, you can take it down. However other people are still likely to see it before you do, so I advise people to wait 24 hours before responding to reviews, so they can be more objective in their response. Also get a friend or colleague to read it over before posting. Q: What recourse does Yelp have for slanderous reviews? RA: There are strict content guidelines for reviews on

feedback on Yelp, Facebook, Twitter, or anywhere else you have a presence – it serves a purpose, just as any verbal feedback does. On Yelp you have the option to send a private message or to add a public comment. A private message is essentially an email; so feel free to get more information about a negative experience via this medium. If you don’t hear back you can add a public comment but there needs to be more caution with what’s said, of course. If, for instance, someone says they had a Botox treatment that went wrong, you can say something about your guidelines and procedures. This means the public are aware not only that you’re responding, but that you also do have guidelines and procedures that outline any risks. Customer service doesn’t end when they leave you, it continues online so if you pride yourself on being friendly, make sure that’s reflected online also. You can always ask customers if they had great experience and whether they mind writing a testimonial, but things like stickers in windows and Yelp widgets on your website are helpful ways to remind consumers that they have an option to review your business. Rosie Ackenhead is the Manager of Business Outreach for Yelp in the UK and Ireland.

Yelp. If someone was to name one of your staff by full name, behave in a very rude way or be slanderous, you can flag a review. You can also flag a review if you believe a competitor may have written it, it is written about the wrong business, or it is particularly unjust. This then gets sent to a specific team in our headquarters so we can look at every single factor and decide whether it should stay up or come down. Q: Do businesses advertise with you? RA: Our revenue model is a mixture of display and local advertising. Here is a natural search ranking (which you can’t buy) but we then sell small adverts at the top of the page of each search term, so you can bid on search terms like “botox” or “facelift” for example.

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body language I INJECTABLES 55

Nerve damage RICCARDO FRATI discusses how to avoid nerve damage when using injectibles and fillers

n facial procedures we can use different fillers in the dermis and middermis, some non-permanent and some semi-permanent. Because the needles aren’t going to go under the dermis where the nerves are in the deeper layer, we tend to think that we’re not going to have any potential injury. However, it’s important to understand that nerve damage isn’t necessarily caused by a direct injury, it can also have an indirect cause. If we develop an early complication like an early infection or a skin necrosis, this is going to spread around and is going to affect any underlying nerves. Even worse, late complications such

as granulomas or even late infection, can involve the nerves which are underlying. Procedure It’s key to inject the right filler at the right level in the right patient at the right time. But the first step is to do a proper sepsis. I’ve heard of some patients treated without any alcohol wipes or any prep prior to the filler—and that really must be the first step. Next, is proper analgesia, using either EMLA Cream or dental block. We also need to ensure a comfortable setting for the patient, to put the patient at ease. That’s key, because while we’re using the

filler, any movement might cause injury. It’s also important to do very accurate, preoperative markings where we can identify any potential danger zones, areas where obviously we need to avoid. Once we know which filler we are going to use and whether it’s going to be a volumiser, or something else, we need to consider our technique: will it be a constant technique, a thread technique or a serial injection? Many studies have been carried out of the facial nerves, which give bi-dimensional guidelines to us as clinicians. Twelve years ago at Miami University with the Department of Neurosurgery we

Administering Fillers: Seven Facial Danger Zones

Supplied by the great auricular nerves. This is of low concern because we wouldn’t treat that area behind the ear.

Supplied by the temporal branch of the facial nerve, which goes across that zygomatic arch. Potentially, an injury on that level could be devastating because it’s going to affect the forehead and involve the eyebrow and eye ptosis.

The area supplied by the mandibular branch or the marginal branch. All these areas are under this mass so they’re deep and we wouldn’t target them.

Defined by a triangle between the malar and zygomatic eminence, the oral commissure and the posterior border of the mandibular angle. Although we wouldn’t inject that area we need to think about if something happens, then we’re going to involve the nerves. And the consequences obviously are going to affect the upper lip area and cheek and the nose.

It is the area on the Superior Orbital Rim above midpupil line. It is supplied by the supraorbital and supratrochlear nerve. Signal of injury are: Numbness of forehead, upper eyelid, nasal, dorsum, anterior scalp

We’re not interested in the supraorbital rim and supratrochlear nerves because, again, we wouldn’t inject that area. Something that we really need to spot is the infraorbital nerve. Consequences are long term and chronic pain to the infraorbital nerve.

The mental nerve. The pre-jowl area is becoming more popular area for fillers and this is a very vulnerable nerve and becomes more superficial. The consequences are numbness of half or lower lip/chin with some difficulties while biting.

56 INJECTABLES I body language

below the tragus, a line going to 2cm above the lateral eyebrow, but it doesn’t give a three-dimensional view. It’s important that we understand the different layers, from the superficial temporal fascia—the nominate fascia which is very important while we are on that zygomatic arch, because we can identify a specific fat pad during our facelift dissection.

We need to be careful not to injure the infraorbital nerve, which lies 1cm below the orbital rim

did a very interesting study to define the different layers of the facial nerve with specific reference to the frontal temporal branch. We wanted to achieve a threedimensional understanding of the nerve, rather than a bi-dimensional position. We now have a three-dimensional redefinition of the different anatomy layers, especially on the temporal area. To give a quick overview of the different layers—we have skin, subcutaneous tissue, SMAS which can be called galea, superficial temporal fascia. We recognised the importance of the loose tissue separating the SMAS and the periosteum. From bi-dimensional guidelines we know we need to avoid, for example, the temporal branch of the facial nerve. In 1966 Pitanguy identified the Pitanguy line, 0.5cm

Danger zones As we identify in zone two in the diagram on the previous page, we need to pay attention on the temporal branch because when we do cheek augmentation or a zygomatic arch augmentation, we are deep into the dermis and potentially we can injure if we are not careful on the zygomatic arch because it’s a very thin layer. We can potentially damage the frontal temporal branch of the facial nerve. The danger zone number three is one supplied by the mandible branch or the marginal branch. The location is quite simple to identify. It’s like a circle, which is a probably 1.5–2cm radius between the oral commissure and the midmandible. The mandible branch, while it goes after the pre-jowl lines, the top of the chin becomes more superficial, going to innervate the depressor labii inferioris muscle and the depressor angularis oris muscle. Sometimes this area is quite common for fillers. Often we don’t realise that while we go medially here, the facial nerve terminal branches become more superficial and we could cause an injury. Another important area is in the triangle defined by the malar eminence, the oral commissure, the posterior border of the mandibular angle. The cheek area, the nasal labial fold area, is probably the most common area for fillers. This is supplied by the zygomatic and buccal branch of the facial nerve, which I don’t think is a very fragile branch. There are a lot of nerves at terminal branches, but potentially if there is an infection or a granuloma, then obviously the nerve lies

there and the consequences are extremely devastating. There is a crossover innervation all around the area with the zygomatic major, zygomatic minor; so you must mark this area carefully when treating. In number five, I don’t think we need to talk about the supraorbital or the supratrochlear nerve which is an area where mainly we do Botox and there’s not going to be any issue with that; there won’t be any fillers on the forehead area. Infraorbital nerve Zone six is 1cm inferior to the orbital rim, below the midpupillary line. We’ve got the infraorbital nerve and most of the time when we need to provide a dental block or to inject local anaesthetic, we really need to be careful not to injure the nerves. This is one of the most common problems while injecting local anaesthetic. And as a result, we can have numbness to the upper nose, cheek and upper lip. This is a very important landmark—1cm below the infraorbital rim with a radius of 1.5cm. This is all the area supplied by the infraorbital nerve (see image opposite). Lastly we should consider the mental nerve, which is very easy to identify. It’s in the mid-mandible, below the second premolar. This is an area where if we do any dental block just to make the lower lip numb, again we need to be careful not to cause any trauma to the mental nerve. Fillers in the pre-jowl area are becoming popular and we need to take into consideration that these nerves become more superficial while exiting from the foramen. This is all the area supplied by the nerves and the most dramatic complication is obviously that while the patient will lose the sensation, he may bite the lip itself. Mr Frati is a specialist in plastic and cosmetic surgery. He attained his Clinical Fellowship in Cosmetic Surgery with Professor Gasparotti, a pioneer of the modern liposuction techniques and now practices at London’s Highgate Hospital.

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2 Sculptra* FB 1 Sculptra* 4 ZO Medical Basic 3 Microsclerotherapy* 8 Whitebox Mesotherapy 5 Microsclerotherapy* 5 ZO Medical Interm. 9 Advanced Fillers-TT* (am) 10 Mini-Thread Lift & Dermal Filler* FB 11 Mini-Thread Lift & Dermal Filler* 6 ZO Medical Adv. 9 Advanced Fillers-F* (pm) 11 Advanced Toxins* (am) FB 12 Advanced Fillers-TT* (am) 7 Advanced Fillers-TT* (am) 10 Mini-Thread Lift & Dermal Filler* FB 11 Advanced Fillers-TT* (pm) 12 Advanced Fillers-CH* (pm) 7 Advanced Toxins* (pm) 12 Dracula PRP* 12 Intro to Fillers* 14 Dracula PRP* 8 Mini-Thread Lift & Dermal Filler* FB 15 Core of Knowledge—Lasers/IPL 13 Dracula PRP* 12 Core of Knowledge—Lasers/IPL 21 CPR & Anaphylaxis Update (am) 18 Mini-Thread Lift & Dermal Filler* 13 ZO Medical Basic (Dublin) 21 Skinrölla Dermal Roller (pm) 13 Neostrata by Aesthetic Source 20 Skincare & Peels 14 ZO Medical Interm. (Dublin) 22 Skincare & Peels 18 Skincare & Peels 20 ZO Medical Basic (Dublin) 20 CPR & Anaphylaxis Update (am) 22 ZO Medical Basic (Dublin) 19 Intro to Toxins* 21 ZO Medical Adv. (Dublin) 20 Skinrölla Dermal Roller (pm) 23 ZO Medical Interm. (Dublin) 20 Intro to Fillers* 21 Intro to Toxins* 21 Skincare & Peels 23 Intro to Toxins* 22 Intro to Fillers* 22 Intro to Toxins* 24 Intro to Fillers* 26 ZO Medical Basic 23 Intro to Fillers* 25 Mini-Thread Lift & Dermal Filler* 27 ZO Medical Interm. 25 Microsclerotherapy* 28 ZO Medical Basic 28 ZO Medical Adv. 29 ZO Medical Interm.

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

58 EDUCATION I body language

training TF

TOXINS AND FILLERS

10 July, Bespoke Botox & Dermal Filler Training, Cosmetic Courses, Bucks W: cosmeticcourses.co.uk

13 July, Dracula PRP, Wigmore Medical, London W: wigmoremedical.com 13 July, Microsclerotherapy Training, Cosmetic Courses, Bucks W: cosmeticcourses.co.uk

11 July, Advanced Botulinum Toxins (am) and Advanced Fillers – Tear Troughs (pm), Wigmore Medical, London W: wigmoremedical.com

20 July, Platelet Rich Plasma Training, Cosmetic Courses, Bucks W: cosmeticcourses.co.uk

11 July, Foundation Botox & Dermal Filler Training, Cosmetic Courses, Bucks W: cosmeticcourses.co.uk

25 July, Microsclerotherapy, Wigmore Medical, London W: wigmoremedical.com

12 July, Introduction to Fillers, Wigmore Medical, London W: wigmoremedical.com

8 August, Mini-Thread Lift & Dermal Filler, Wigmore Medical, London W: wigmoremedical.com

15 July, Advanced Dermal Filler Training—Lips, Peri Oral Cheeks, Honey Fizz Training, Newport W: honeyfizz.co.uk

1 September, Sculptra, Wigmore Medical, London W: wigmoremedical.com

16 July, Bespoke Botox & Dermal Filler Training, Cosmetic Courses, Bucks W: cosmeticcourses.co.uk 17 July, Bespoke Botox & Dermal Filler Training, Cosmetic Courses, Bucks W: cosmeticcourses.co.uk 18 July, Foundation Botox & Dermal Filler Training, Cosmetic Courses, Birmingham W: cosmeticcourses.co.uk 22-23 July, Introduction to Toxins and Fillers, Wigmore Medical, London W: wigmoremedical.com 3 August, Foundation Botox & Dermal Filler Training, Cosmetic Courses, Leeds W: cosmeticcourses.co.uk 7 August, Advanced Fillers - Tear Troughs (am) and Advanced Toxins (pm), Wigmore Medical W: wigmoremedical.com 15 August, Combined Botulinum Toxin and Dermal Filler Training Day, Honey Fizz, Newport W: honeyfizz.co.uk 19-20 August, Intro to Toxins and Fillers, Wigmore Medical, London W: wigmoremedical.com 24 August, Foundation Botox & Dermal Filler Training, Cosmetic Courses, London W: cosmeticcourses.co.uk 5 September, Combined Basic Training – Dermal Filler and Botulinum Toxin, Honey Fizz, Newport W: honeyfizz.co.uk 12 September, Advanced Fillers—Tear toughs (am) and Cheeks and Mid Face (pm), Wigmore Medical, London W: wigmoremedical.com

5 September, Microsclerotherapy, Wigmore Medical, London W: wigmoremedical.com 11 September, Mini Thread Lift, Wigmore Medical, London W: wigmoremedical.com 14 September, PRP, Wigmore Medical, London W: wigmoremedical.com 25 September, Mini Thread Lift, Wigmore Medical, London W: wigmoremedical.com

SKINCARE

9 July, Dermaroller Training, Cosmetic Courses, Bucks W: cosmeticcourses.co.uk 10 July, Neostrata Chemical Peel Training, Cosmetic Courses, Bucks W: cosmeticcourses.co.uk 10-12 July, Advanced Skin Restoration, Academy of Advanced Aesthetics, Guildford, Surrey W: academyofadvancedaesthetics.com 13 July, Advanced Facial, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com 13-14 July, ZO Medical Basic and Intermediate, Wigmore Medical, Dublin W: wigmoremedical.com 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

14 September, Botox Training Course, Cosmetic Courses, Bucks W: cosmeticcourses.co.uk

25-26 July, Advanced Skin Restoration, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com

14 September, Foundation Botox & Dermal Filler Training, Cosmetic Courses, Leeds W: cosmeticcourses.co.uk

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

8 July, Whitebox Mesotherapy, Wigmore Medical W: wigmoremedical.com 10 July, Mini-Thread Lift & Dermal Filler, Wigmore Medical, London W: wigmoremedical.com

7-8 August, Radio Frequency, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com

21 September, Skinrölla Dermal Roller (pm), Wigmore Medical, London W: wigmoremedical.com

12 August, Cryotherapy Induced Lipolysis, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com

22 September, Skincare & Chemical Peels, Wigmore Medical, London W: wigmoremedical.com 28-29 September, ZO Basic and Intermediate, Wigmore Medical, London W: wigmoremedical.com

14-15 August, Advanced Skin Restoration, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com

LASERS/RF/ULTRASOUND

16 July, Low Level Laser Therapy, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com 1-3 August, Low Level Laser Therapy, Academy of Advanced Aesthetics, Guildford, Surrey W: academyofadvancedaesthetics.com 11 August, Low Level Laser Therapy, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com 12 August, Core of Knowledge – Lasers/IPL, Wigmore Medical, London W: wigmoremedical.com

12 September, Foundation Botox & Dermal Filler Training, Cosmetic Courses, Birmingham W: cosmeticcourses.co.uk

OTHER INJECTABLES

18 August, Skincare & Chemical Peels, Wigmore Medical, London W: wigmoremedical.com

OTHER TRAINING

10-12 July, Ultrasound for Skin Rejuvenation, Academy of Advanced Aesthetics, Guildford W: academyofadvancedaesthetics.com 13-14 July, Areola Masterclass, Finishing Touches, West Sussex W: finishingtouchesgroup.com 17 July, Cryotherapy Induced Lipolysis, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.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 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

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 27 August, Ultrasound for Skin Rejuvenation, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com 1 September, Infrared, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com 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 21 September, CPR & Anaphylaxis Update (am), Wigmore Medical, London W: wigmoremedical.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 W: academyofadvancedaesthetics.com 28 September, Low Level Laser Therapy, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com

30 July, Non-Surgical Facelift Training, Cosmetic Courses, Bucks W: cosmeticcourses.co.uk

29 September, Cryotherapy Induced Lipolysis, Academy of Advanced Aesthetics, Sutton, Cambridgeshire W: academyofadvancedaesthetics.com

1-3 August, Acoustic Wave Therapy, Academy of Advanced Aesthetics, Guildford, Surrey W: academyofadvancedaesthetics.com

30 September, Acoustic Wave Therapy, Academy of Advanced Aesthetics, Sutton, Cambridgeshire 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

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