Body Language #84

october

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

CONSULTING

WENDY LEWIS EXPLAINS THE NEW RULES FOR PATIENT INTERACTION DURING COSMETIC CONSULTATION

HAIR REMOVAL

MARKETING

MALE BEAUTY

The available laser treatment options for ethnic skin

How to introduce sexual wellness treatments into your practice

Dr Sebastian Torres gives his perspective on male aesthetics

NOW APPROVED FOR

UPPER FACIAL LINES The first and only aesthetic neurotoxin approved for combination treatment of Upper Facial Lines including: • Horizontal Forehead Lines • Crow’s Feet Lines • Glabellar Frown Lines

CONFIDENCE IN MY CHOICE

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Botulinum toxin type A free from complexing proteins Bocouture® (incobotulinumtoxinA) 50 units Prescribing Information M-BOC-UK-0007 Please refer to the Summary of Product Characteristics (SmPC) before prescribing. Presentation: 50 units of Botulinum toxin type A (150 kD), free from complexing proteins as a powder for solution for injection. Indications: Temporary improvement in the appearance of moderate to severe upper facial lines (glabellar frown lines, crow’s feet lines, horizontal forehead lines) in adults below 65 years when the severity of these lines has an important psychological impact for the patient. Dosage and administration: Unit doses recommended for Bocouture are not interchangeable with those for other preparations of Botulinum toxin. Reconstitute with 0.9% sodium chloride. Horizontal Forehead Lines: Intramuscular injection, the recommended total dose range is 10 to 20 units, a total injection volume of 0.25 ml (10 units) to 0.5 ml (20 units) is injected into the frontalis muscle in five horizontally aligned injection sites at least 2 cm above the orbital rim. An injection volume of 0.05 ml (2 units), 0.075 ml (3 units) or 0.1 ml (4 units) is applied per injection point, respectively. Glabellar Frown Lines: Intramuscular injection (50 units/1.25 ml). Total recommended standard dose is 20 units. 0.1ml (4 units) into 5 injection sites (2 injections in each corrugator muscle and 1 injection in the procerus muscle). May be increased to up to 30 units. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. Crow’s Feet lines: Intramuscular injection (50 units/1.25mL). Total recommended standard dosing is 12 units per side (overall total dose: 24 units); 0.1mL (4 units) injected bilaterally into each of the 3 injection sites. Injections too close to the Zygomaticus major muscle should be avoided to prevent lip ptosis. Not recommended for use in patients over 65 years or under 18 years. Contraindications: Hypersensitivity to the active substance or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, Lambert-Eaton syndrome).

Infection or inflammation at the proposed injection site. Special warnings and precautions: It should be taken into consideration that horizontal forehead lines may not only be dynamic, but may also result from the loss of dermal elasticity (e.g. associated with aging or photodamage). In this case, patients may not respond to Botulinum toxin products. Should not be injected into a blood vessel. Not recommended for patients with a history of dysphagia

and aspiration. Caution in patients with amyotrophic lateral sclerosis, peripheral neuromuscular dysfunction, or in targeted muscles displaying pronounced weakness or atrophy. Bocouture should be used with caution in patients receiving therapy that could have an anticoagulant effect, or if bleeding disorders of any type occur. Too frequent or too high dosing of Botulinum toxin type A may increase the risk of antibodies forming. Should not be used during pregnancy unless clearly necessary. Should not be used during breastfeeding. Interactions: Concomitant use with aminoglycosides or spectinomycin requires special care. Peripheral muscle relaxants should be used with caution. 4-aminoquinolines may reduce the effect. Undesirable effects: Usually, undesirable effects are observed within the first week after treatment and are temporary in nature. Undesirable effects independent of indication include; application related undesirable effects (localised pain, inflammation, swelling), class related undesirable effects (localised muscle weakness, blepharoptosis), and toxin spread (very rare exaggerated muscle weakness, dysphagia, aspiration pneumonia).

Frequency of adverse reactions by indication is defined as follows: very common (≥ 1/10); common (≥ 1/100, < 1/10); uncommon (≥ 1/1000, < 1/100); rare (≥ 1/10,000, < 1/1000); very rare (< 1/10,000). Upper Facial Lines: Very common: Headache.

Common: Hypoaesthesia, injection site haematoma, application site pain, eyelid ptosis, dry eye, facial asymmetry, sensation of heaviness, nausea. Glabellar Frown Lines: Common: Headache, Muscle disorders (elevation of eyebrow). Crow’s Feet Lines: Common: Eyelid oedema, dry eye, injection site haematoma.

For a full list of adverse reactions, please consult the SmPC. Overdose May result in pronounced neuromuscular paralysis distant from the injection site. Symptoms are not immediately apparent post-injection. Bocouture® may only be used by physicians with suitable qualifications and proven experience in the application of Botulinum toxin. Legal Category: POM. List Price 50 U/vial £72.00 Product Licence Number: PL 29978/0002 Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer Landstraße 100,60318 Frankfurt/Main, Germany.

Date of Preparation: July 2016. Further information available from: Merz Pharma UK Ltd., 260 Centennial Park, Elstree Hill South, Elstree, Hertfordshire WD6 3SR.Tel: +44 (0) 333 200 4143

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

Adverse events should also be reported to Merz Pharma UK Ltd at the address above or by email to UKdrugsafety@merz.com or on +44 (0) 333 200 4143.

1. Bocouture® 50U Summary of Product Characteristics (SPC).

April 2016. Available from: https:/www.medicines.org.uk/emc/ medicine/23251 2. Carruthers A et al. Multicentre, Randomized, Phase III Study of a Single Dose of IncobotulinumtoxinA, Free from Complexing proteins, in the Treatment of Glabellar Frown Lines. Dermatol Surg. 2013:1-8 3. Prager W, et al. Comparison of Two Botulinum Toxin Type A Preparations for Treating Crow’s Feet: a Split-Face, DoubleBlind, Proof-of-Concept Study. Dermatol Surg. 2010 Dec; 36 Suppl 4:2155-60 4. Kerscher M, et al. Efficacy and Safety of IncobotulinumtoxinA in the Treatment of Upper Facial Lines: Results From a Randomised, Double-Blind, Placebo-Controlled, Phase III study. Dermatol Surg 2015;41:1149-1157 5. BOC-DOF-012 Bocouture® Convenient to Use, August 2015 BOCOUTURE® is a registered trademark of Merz Pharma GmbH & Co, KGaA. M-BOC--0002

Date of Preparation August 2016

PURIFIED1• EFFECTIVE2, 3,4 • CONVENIENT5

Botulinum toxin type A free from complexing proteins

body language I CONTENTS 3

07

49

contents 07 NEWS OBSERVATIONS Reports and comments

18 MEDICAL AESTHETICS COSMETIC CONSULTATION Wendy Lewis discusses the new rules of interacting with patients

25 DERMATOLOGY YOUR AESTHETIC PATIENT'S PERFECT PARTNER Offer your patients Radara—an at-home micro-channelling treatment to compliment all in-clinic procedures

26 EQUIPMENT LASER HAIR REMOVAL Dr Rahul Pillai discusses the various treatment options for ethnic skin

35 PRODUCTS ON THE MARKET The latest products and services in medical aesthetics and anti-ageing

37 EQUIPMENT NEW LASER TECHNOLOGIES 18

Professor Mukta Sachdev speaks about the Alma Soprano

Platinum 3D hair removal technology

40 BUSINESS MARKETING TREATMENTS FOR INTIMATE AREAS Caitlin Farrell discusses how to introduce women’s sexual wellness into your practice, and build a strong foundation for long-term success

47 AESTHETICS EYELASH GROWTH SERUM Xxtralash is a nutrient rich eyelash serum designed to stimulate new lash growth, repair weak and damaged eyelashes and prevent lash loss

49 MEDICAL AESTHETICS MALE BEAUTY Dr Sebastian Torres gives his perspective on male aesthetics

53 THREADS BIO-RESORBABLE TENSOR THREADS Dr Catherine De Goursac clears up some of the controversy over the use of bio-resorbable tensor threads as a medical alternative to a light surgical facelift

4 CONTENTS I body language

PRODUCTION 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 PUBLISHER Raffi Eghiayan 020 7514 5101 raffi@face-ltd.com CONTRIBUTORS Wendy Lewis, Dr Rahul Pillai, Professor Mukta Sachdev, Caitlin Farrell, Dr Sebastian Torres, Dr Catherine De Goursac ISSN 1475-665X The Body Language® journal is published ten times a year by AYA Productions. All editorial content, unless otherwise stated or agreed to, is © AYA Productions 2016 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

Dear Body Language Reader, Welcome to the October edition of Body Language.

As the changes begin within this Journal we hope that you are all able to use Body Language as a guide to identify the next course of action for your practice regarding treatments, products and concepts in our ever changing world of aesthetics. Our aim is to continue to support your professional development as we endeavour to become your closest partner in aesthetics.

Body Language has always maintained the high calibre of scientific content, featuring editorial from international figureheads in aesthetics. Alongside this ethos, we are incorporating the other side of the industry—featuring the manufacturers and service providers. They are the backbone within the aesthetic community and for the first time Body Language will not only tell the story from the clinic table, but from the teams that make it all possible. Scientific content mixed with up-to-date product news and concepts will keep you abreast of everything aesthetic. If you have done some research or are in the process of reviewing a treatment with your colleagues and you would like to see your finding published please do get in touch.

Raffi Eghiayan, Publisher, Body Language

26

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Radiant Skin, Radiant Patients Restylane® Skinboosters™ are clinically proven to deliver progressive, long-lasting improvements to the skin condition of your patients.

The visible improvements provide high levels of patient satisfaction and the progressive treatment approach provides the opportunity to guide your patients in a consultative partnership helping to deliver attentive, personalised care and long-lasting results.

Kelly’s Story

A Restylane Skinboosters patient shares her experience Forehead area

“Before trying Restylane Skinboosters, I had never done an injectable treatment of this type – but I had been told what the treatment could do and was very hopeful that I would see some of these results for myself!

My practitioner explained that the results would appear over time, and that I would continue to see improvement even after my third treatment. I couldn’t wait to get started.

The procedure itself was better than I expected. It wasn’t too painful; I felt just a few small pinpricks, and my practitioner was very gentle.

I loved that I could go back to my normal, everyday activities right after treatment.

I really started to notice a difference after my second treatment. My skin started to glow, and felt so much fresher. I could feel that the structure of my skin had improved as well, and my face felt softer. I also had fewer fine lines around my cheeks and mouth.

I am so pleased with the results of my Restylane Skinboosters treatment that I would recommend it to any of my friends. The results are subtle and natural-looking but everyone tells me I look refreshed and that my skin is radiant. I can see and feel the same effects myself, and I feel younger! The treatment has even made a difference to me on the inside - I feel happier, and I feel good about myself.

Crow’s feet Cheek area Smile lines

Peri-oral lines

Neck area

Hands

Décolletage

All thanks to Restylane Skinboosters!”

A versatile treatment suitable for a wide range of age groups and skin types

www.restylane.co.uk RES/041/0516 Date of preparation May 2016

HENTIC AUT Micro-Focused Ultrasound with Visualisation

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An evolution in aesthetics treatment1 • Scientifically proven*1-4 • Lift that can last for over a year3,5 • Treatment takes between 60-90 minutes6

ULT/180/2016/MAY/2016/SS Date of preparation May 2016

• No patient downtime2,3,5

Contact Merz Aesthetics NOW and ask for Ultherapy® Tel: +44 (0) 333 200 4140 Email: customerservices@merz.com

The only noninvasive lift US FDA cleared7

EU CE mark certified8

Before

After

Before and after imagery: all patients have had their Ultherapy® treatment line counts tailored to their individual needs by their practitioner. These line counts may differ from those recommended in the Instructions For Use.

*stimulates new collagen and elastin which can reverse the signs of ageing References: 1. Ulthera System Instructions for Use, 1001393IFU Rev H 2. Sasaki GH & Tevez A. JCDSA. 2012; 2: 108-116 3. Alam M, et al. J Am Acad Dermatol. 2010;62:262-269 4. Lee HS, et al. Dermatol Surg. 2011;1-8 5. Brobst RW, et al. Facial Plast Surg Clin N Am. 2014;22:191-202 6. ULT-DOF-003 Ultherapy Treatment Duration. Merz - July 2015 7. http://www.accessdata.fda.gov/cdrh_docs/pdf13/k134032.pdf Accessed May 2016 8. CE Certificate 3808396CE01, DEKRA April 2012 Adverse incidents must be reported. Reporting forms & information can be found at www.mhra.gov.uk/yellowcard. Adverse incidents must also be reported to Merz Pharma UK Ltd by email to ukdrugsafety@merz.com or on +44 (0) 333 200 4143

www.ultherapy.co.uk

body language I NEWS 7

observations

MEDITERRANEAN DIET REDUCES CARDIOVASCULAR DEATHS Evidence stacks up to support the benefits of the Mediterranean diet More evidence that the Mediterranean diet is associated with good health—reducing the risk of death in patients with a history of cardiovascular disease—has been presented at ESC Congress 2016 by the observational Moli-sani.

"The Mediterranean diet is widely recognised as one of the healthier nutrition habits in the world," said Professor Giovanni de Gaetano, head of the Department of Epidemiology and Prevention at the IRCCS. Neuromed Institute in Pozzilli, Italy.

"In fact, many scientific studies have shown that a traditional Mediterranean lifestyle is associated with a lower risk of various chronic diseases and, more importantly, of death from any cause."

"But so far research has focused on the general population, which is mainly composed of healthy people," he added. "What happens to people who have already suffered from cardiovascular disease? Is the Mediterranean diet optimal for them too?"

The answer is yes, according to the Moli-sani study of patients with a history of cardiovascular disease, such as coronary artery disease and stroke.

The patients were enrolled into a prospective epidemiological study that randomly recruited around 25 000 adults living in Molise, Italy.

"Among the participants, we identified 1197 people who reported a history of cardiovascular disease at the time of enrolment into Moli-sani," said Dr Marialaura Bonaccio, lead author of the research.

Food intake was recorded using the European Prospective Investigation into Cancer (EPIC) food frequency questionnaire. Adherence to the Mediterranean diet was assessed with a 9-point Mediterranean diet score (MDS). All-cause death was assessed by connection with data from the office of vital statistics in Molise.

During a median follow up of 7.3 years there were 208 deaths.

A 2-point increase in the MDS was associated with a 21% reduced risk of death after control-

ling for age, sex, energy intake, egg and potato intake, education, leisure-time physical activity, waist to hip ratio, smoking, hypertension, hypercholesterolaemia, diabetes and cancer at baseline.

When considered as a 3-level categorical variable, the top category (score 6-9) of adherence to the Mediterranean diet was associated with 37% lower risk of death compared to the bottom category (0-3).

Professor de Gaetano said: "We found that among those with a higher adherence to the Mediterranean diet, death from any cause was reduced by 37% in comparison to those who poorly adhered to this dietary regime."

The researchers expanded their investiga-

tion by looking at the role played by specific foods that make up Mediterranean diet. "The major contributors to mortality risk reduction were a higher consumption of vegetables, fish, fruits, nuts and monounsaturated fatty acids - that means olive oil," said Dr Bonaccio.

De Gaetano concluded, "These results prompt us to investigate the mechanism(s) through which the Mediterranean diet may protect against death. This was an observational study so we cannot say that the effect is causal.

We expect that dietary effects on mediators common to chronic diseases such as inflammation might result in the reduction of mortality from any cause but further research is needed."

8 NEWS I body language

MICROBEADS TO BE BANNED IN UK BY 2017 UK government announces plans to ban use in cosmetics and cleaning products Warnings from environmentalists over the dangers of microbeads—the small pieces of plastic commonly found in toothpaste and exfoliating scrubs—are finally being listened to the UK. After a number of cosmetic companies made voluntary commitments to phase out the use of microbeads by 2020, the UK government has announced plans to ban microbeads used in cosmetics and cleaning products by 2017.

With growing concerns over the amount of plastic building up in oceans and entering the food chain, the House of Commons Environmental Audit Committee said in August that the government needed to step in, to protect the environment as soon as is practicable, after it was revealed a single shower can result in 100,000 plastic particles entering the ocean.

With environmental campaigners like Greenpeace pushing hard for a ban on the plastic beads several cosmetics companies including Johnson & Johnson and Proctor and Gamble have already made promises to stop using microbeads by the end of next year. Asda, Waitrose, Avon, Tesco, the Bodyshop, L’Oreal and Boots are many other big brands are pledging to stop use in their own brand products— but they may still currently stock other

products containing microbeads.

The US recently became the first country to announce it would ban microbead use in cosmetics and the European Commission is also currently developing proposals to ban them in cosmetics across the EU, following calls from a number of member states.

It’s not always easy to identify whether plastic particles are concealed within a product. Microbeads are often disguised behind the words polyethylene, polypropylene and polymethylmethacrylate—the chemical names for plastics. Nylon may also be listed as well as the abbreviations PET, PTFE and PMMA.

WHY THE LONG FACE? First equine-based collagen boosting anti-ageing treatment We could be saying goodbye to toxins for good, claim the makers of Nithya, a next generation collagen boosting treatment sourced from horses. The pain-free, skin rejuvenation injectable made from equine-sourced protein is designed to holistically improve the production of new collagen, helping to ease fine lines around the eyes, improve facial volume in areas such as the cheeks, and décolletage.

The revitalising protein, which is derived from the tendons of horses, is a first for UK aesthetic clinics keen to offer a more natural-looking anti-ageing option. Results are long-lasting, and unlike wrinkle reduction treatments like Botox which paralyse the muscles and dermal fillers which can leave the face looking overfilled, Nithya works in harmony with natural tissue structure.

This Class III medical device is a heterologous Type I collagen powder which stimulates the production of new fibroblasts to create native Type III collagen, a process that is fundamental

in cosmetic medicine and anti-aging treatments. In the form of a lyophilised collagen patch, this product has been used for almost 30 years and is still successfully used today to affect the healing of skin ulcers, open wounds, scars and bedsores.

“This exceptional collagen-boosting product is proven to be safe, has had no reported side effects, is hypoallergenic and gives excellent results. We truly believe this could rival the results of established but overused anti-ageing cosmetic treatments,” said Eddy Emilio, Director of Vida Aesthetics, who is pioneering the unique equine protein treatment in the UK. “This is the only commercially available Type I collagen intended for aesthetic use in the country, and we’re already getting rave reviews from cosmetic doctors thanks to its excellent results and numerous areas it can improve the appearance of. The idea of using protein sourced from horses may seem quirky, but we’re certain this is the future of anti-ageing”.

Invasix present InMode, the unique multi-disciplinary machine that offers everything from radio frequency for facial and body contouring, IPL for skin rejuvenation to laser hair removal.

With five non-invasive options available, this machine allows practitioners to offer their patients multiple in-demand aesthetic treatments in just one machine.

BE INNOVATIVE • • BE INMODE | PLUS

/ Mini

For more information contact: Neil Wolfenden: E: neilw@invasix.com T: +44 (0) 7876 597763

THE COMPLETE BODY MAKEOVER

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

W: WIGMOREMEDICAL.COM/EVENTS I

TRAINING

DATES

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

FB - FULLY BOOKED All courses in London unless otherwise specified.

E: TRAINING@WIGMOREMEDICAL.COM

I T: +44(0)20 7514 5979

OCTOBER

NOVEMBER

DECEMBER

1 Microsclerotherapy* 2 Core of Knowledge (pm) 3 Dracula PRP* 4 ZO Medical Basic (London) 5 ZO Medical Interm. (London) 6 ZO Medical Adv. (London) 9 Adv. Toxins and Fillers* FB 10 CPR & Anaphylaxis Update 12 ZO Medical Basic (Dublin) 13 Sculptra* 13 ZO Medical Interm. (Dublin) 18 Skincare with NeoStrata 19 Intro to Fillers* FB 20 Intro to Toxins* FB 21 Adv. Fillers* 22 Mini-Thread Lift* FB 28 Algeness*

1 CPR & Anaphylaxis Update 1 Skinrölla Microneedling (pm) 2 Mini-Thread Lift* 2 glo therapeutics 5 Microsclerotherapy* 6 Adv. Toxins and Fillers* 7 Dracula PRP* 8 ZO Medical Basic (London) 9 ZO Medical Interm. (London) 10 Sculptra* 10 ZO Medical Basic (Manchester) 11 ZO Medical Interm. (Manchester) 11 Non-Surgical Rhinoplasty* 12 Algeness* 15 ZO Medical Basic (Dublin) 16 ZO Medical Adv. (Dublin) 22 Skincare with NeoStrata 23 Intro to Toxins* 24 Intro to Fillers* 25 Adv. Toxins* 26 Mini-Thread Lift* 30 CPR & Anaphylaxis Update

1 Adv. Toxins and Fillers* 2 Dracula PRP* 3 Microsclerotherapy* 6 ZO Medical Basic (London) 7 ZO Medical Interm. (London) 8 ZO Medical Adv. (London) 9 Core of Knowledge (pm) 13 ZO Medical Basic (Dublin) 13 Skincare with NeoStrata 14 Intro to Toxins* 14 ZO Medical Interm. (Dublin) 15 Intro to Fillers* 16 Adv. Fillers* 17 Mini-Thread Lift* 19 Algeness*

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

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

body language I NEWS 11

REGENERATIVE MEDICINE THE NEXT FRONTIER IN FACIAL PLASTIC AND RECONSTRUCTIVE SURGERY? Unlocking regenerative potential of allografts and flaps

DEATH OF WOMAN WHO MADE TRANSPLANT HISTORY The Frenchwoman who received the world’s first face transplant in 2005, has died of cancer At the age of 38, Dinoire received a triangularshaped graft of the nose tip, mouth and jaw from a brain-dead donor, to replace parts of her face that had been mauled by her pet dog, Tanya.

Since the transplant, Ms Dinoire’s immune system degenerated and had twice rejected the skin transplanted to her. Le Figaro newspaper reported that Ms Dinoire was suffering from 2 types of cancer at the time of her death this April—suggesting it was a consequence of heavy anti-rejection medication.

Although the face transplant operation was presented as a medical success, it became clear that alongside the physical scars of acquiring the face of another woman and in her latter days losing the use of her lips, Ms Dinoire also suffered mentally.

She described her torment over her mutilated face and the new one in Le Baiser d’Isabelle—Isabelle’s Kiss—a diary published in 2007.

“When I think about my face, without looking at it, it’s just what’s in front of me,” she wrote. “But the face of the donor will exist until the end of my life. She’s my saviour, like a twin sister. I will never be like I was before. I dream of myself with my old face, not with the one I have today.”

The operation was carried out by Professor Jean-Michel Dubernard, who in 1998 carried out the first hand transplant, and by Professor Bernard Devauchelle. Since 2005, more than 30 face transplants have been carried out around the world.

The future of regenerative medicine isn't rebuilding missing tissue like they do in "Star Trek" movies, it is about unlocking the regenerative potential of allografts and flaps, which are the foundation of surgical reconstruction, writes Matthew Q. Miller, M.D., of the University of Virginia, Charlottesville, and coauthors in a recent review article published online

by JAMA Facial Plastic Surgery.

In the article, the authors review regenerative medicine techniques in facial plastic and reconstructive surgery, including stem cells, growth factors and synthetic scaffolds; examine platelet-rich plasma; and suggest directions for future studies.

"Regenerative medicine is an exciting field with the potential to change standards of care in FPRS [facial plastic and reconstructive surgery]. This review discusses soft-tissue, cartilaginous and bony regeneration in facial plastic surgery using stem cells, growth factors, PRP [platelet-rich plasma] and/or synthetic scaffolds. Our subspecialty has to continue to clinically investigate these techniques to show whether the new frontiers of regenerative medicine improve outcomes and cost-effectiveness in FPRS while not adding to the risks of treatment," the article concludes.

12 NEWS I body language

DANGERS OF TOOTH WHITENING The British Society of Dental Hygiene and Therapy (BSDHT) are reminding consumers of the huge dangers posed by illegal and unsafe whitening treatments Both the cosmetic and dental tooth whitening industry is a major growth area for the UK, yet despite strict measures regulating who can perform tooth whitening, the problems arising from unsafe tooth whitening are numerous.

Research has shown that one in four people (28%) would choose not go to the dentist for their tooth whitening treatment, favouring potentially unsafe home kits, or visits to illegal beauticians and kiosks.

“The public need to be aware that unsafe and illegal tooth whitening can lead to severe chemical burns and the possibility of permanent scarring, hyper-sensitivity, tooth loss and in extreme cases affect the ability to eat

and breathe.” said Michaela ONeill, President of the BSDHT. “We are encouraging the public to be aware of these fake traders which leave them with irreparable damage due to their false safety claims. Their products are often highly dangerous and are not suitable for anyone to use even dental professionals “In the UK tooth whitening is classed as an act of dentistry and therefore procedures can only be carried out by a registered dental professional.

Anybody offering tooth whitening products at consumer shows, as highlighted in the programme, should be actively avoided and reported to the General Dental Council (GDC) and trading standards

immediately.”

Under a European Council directive, tooth whitening products containing or releasing above 0.1% hydrogen peroxide can only be sold to a registered dental professional offering the treatment in their practice.

Tooth whitening requires an initial consultation by a registered dental professional, to assess a patient’s oral condition and age. The first use must be from a dental practitioner, or under their direct supervision by a dental hygienist or dental therapist.

Anybody who is not a registered dental professional and is offering tooth whitening treatment using hydrogen peroxide above 0.1% is breaking the law and liable

for prosecution. Every single case raised by the General Dental Council since the rules came into force has resulted in a successful prosecution.

Michaela continued: “If you do have any doubts about fake dental professionals then you should immediately contact the GDC to ascertain if they are falsely trading and use your gut, if you don’t trust them go somewhere else.”

“The cases where illegal and unsafe tooth whitening is leading to serious damage are increasing. There is no reason to put your health at peril and risk permanent and severe damage in order to emulate the fake smiles you see on TV.”

HOW TO PROMOTE SUN SAFETY Visual communication of sun damage is most effective at promoting sun safe behaviour In a new study published in the Journal Cogent Psychology, researchers from the University of Surrey examined the way sun safe messages are conveyed to young women, and found that visual communication using technology to age participant’s faces and emphasise sun damage and premature ageing was most effective.

The findings from the research concluded that young women are most concerned about the immediate damage to their skin, and that the impact of a visual, personalised message that illustrated immediate skin damage was greater than text-based messages, or damage in the longer term.

Fair skinned young women are the most at risk group for UV attributable malignant melanoma, however, they often don’t realise the extent of the risk. The new research studied the differences between text-based and visual messages and examined whether warning about future appearance has an impact on changing behaviours.

The results showed seeing their own face prematurely sun aged using the technology prompted young women to take double the number of free sun screen samples and three times the number of skin cancer leaflets compared to those women who had read text information about the damaging nature of the sun.

They also showed a 30% lower belief in the skin’s ability to heal.

“Malignant melanoma is on the increase yet young women often don't protect themselves by using sun screen,” said Professor Jane Ogden of the University of Surrey, one of the authors of the study.

“Our study explored the best way of framing messages to change their attitudes and promote healthier behaviour. The results showed that appearance based messages that used imagery to emphasise sun ageing were the most effective. This sun ageing technology could be used more widely to increase sun screen uptake by young women.”

body language I NEWS 13

events 6-7 OCTOBER, CCR Expo, London Olympia, UK W: ccr-expo.com 6-9 OCTOBER, International Society of Plastic & Regenerative Surgeons, Marseille, France W: ispres-congress.org 7 OCTOBER, Breast Cancer Conference, London, UK W: royalmarsden.nhs.uk/breastmeeting 12-14 OCTOBER, Aesthetic Medicine, Saint-Petersburg, Russia W: aestheticmed.ru/ 19-23 OCTOBER, DASIL—Dermatologic Aesthetic Surgery International League, Dubai, United Arab Emirates W: thedasil.org 21-22 OCTOBER, AMEC 2016 - 12th Aesthetic & Anti-aging Medicine European Congress, Paris, France W: congres-medical-congress.com 23 - 27 OCTOBER, 23rd Congress of ISAPS, Kyoto-shi, Japan W: isapscongress.org 3 - 5 NOVEMBER, 3rd AMWC Latin America, Columbia W: euromedicom.com 6-16 NOVEMBER, 11 Days of Plastic Surgery 2016 — 3rd Singapore Advanced Rhinoplasty Fresh Frozen Cadaveric Dissection Course, Singapore W: singaporeentcourses.com.sg 16-19 NOVEMBER, 2nd EPSC 2016—2nd Emirates Plastic Surgery Society Congress 2016, Dubai, United Arab Emirates W: epsc.ae/ 24 - 26 NOVEMBER, ICAD 2016, Bangkok, Thailand W: euromedicom.com 30 NOVEMBER – 3 DECEMBER, Cosmetic Surgery Forum 2016, Las Vegas, USA W: cosmeticsurgeryforum.com/

CLINIC RATINGS Substandard clinics could be named under new government proposals Cosmetic surgery clinics in England which are not up to scratch could be named by the Department of Health, once an eight-week consultation to expand the rating programme—run by the Care Quality Commission (CQC)—is complete in November.

The CQC already offers online ratings for NHS services such as hospitals, walk-in clinics and GP surgeries. These proposed plans would see this extended to 1,000 independent health care providers including up to 100 cosmetic surgery clinics.

The development comes after increasing pressure on the cosmetics surgery industry to improve its safety record after the 2012 PIP breast implant scandal. Centres will be assessed and ratings will be given of outstanding, good, requires improvement or inadequate.

The health secretary Jeremy

Hunt said it would help end the "lottery" of poor practice, saying: "Anyone who chooses to have a cosmetic procedure should have high quality and safe care - and that's why we have a tough regulator in place to help people make an informed decision," "Our proposals to extend the CQC's powers to rate more providers are an important step forward in improving standards and will help to end the lottery of poor practice in parts of the cosmetic industry."

Douglas McGeorge, President of the British Association of Aesthetic Plastic Surgeons, said that the organisation welcomes “as much government scrutiny as is possible” for the industry, while reminding the public that cosmetic surgery clinics are already inspected by the CQC, despite not receiving online ratings.

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WIGMORE OPEN DAY An educational and networking day with a focus on enhancing knowledge of premium brands Wigmore Medical hosted another successful Open Day event at the Royal Society of Medicine on Saturday 3rd September. Led by a faculty of leading doctors and industry professionals, this networking and educational event offered valuable insight into the exciting world of aesthetic medicine.

“The Wigmore Medical Open Days are designed to be an education refresher for our clinics. They are a reintroduction to key brands; unveiling new products, updated techniques and providing workshops and masterclasses with industry experts. This was our second Open Day of the year, giving clinics a post-summer top-up and look at new innovations we are set to unveil for the latter part of 2016. It was a busy day with some great seminars and demonstrations, as well as a fantastic opportunity to network with industry peers.” Alex Bodikian, Head of Marketing, Wigmore Medical With a particular focus on top brands such as ZO Skin Health, glo, Invasix and Ultra V Mini Thread, including new products on the market, business strategies and exclusive tips on how to improve the success of your clinic, this event had something for everyone.

Attending delegates gained practical knowledge and made new connections.

“A very informative event, I learned a lot. Met very nice people and the venue offered high quality facilities, the lectures were innovative and the speakers brilliant” said Ms Kornelia Hauck.

Mrs Joanna Bartholomew added, “The Wigmore staff were very welcoming, knowledgeable and a pleasure to talk to.

Open days are a great way to network and find out about what everyone else is doing”.

Mrs Svetlana Tsankova noted, “ I really enjoyed the day and found it very informative. I was able to attend sessions in both agendas and that was great as I could choose exactly what I needed. I also had useful meetings in the breaks and took one of the brands for my clinic. Dr Kwon is a master and Dr Townshend is always good to meet and presented an informative session as usual.”

Ms Zahid Butt concludes, “It was a thoroughly enjoyable day, I was well looked after

and it was very informative and helpful. An excellent and well organised open day.”

A huge thank you goes out to all the speakers who shared their expertise and experience at the highest level possible and received a lot of positive feedback from attending delegates.

Natalie Ball, the Wigmore Customer Services Manager, explains that the event was a huge success “not just from a business point of view but also in terms of meeting existing and potential clients and establishing a friendly relationship with our fellow industry goers.”

To register for the next Wigmore Medical Open Day, please email events@wigmoremedical.com.

SUCCESS AT STYLIST AND HARPER'S BAZAAR AWARDS Aesthetic Source announce NeoStrata wins for Best Pigment Corrector and Best Antioxidant Serum Stylist, the weekly magazine for women with a circulation of over 400,000 readers has one of the most respected beauty awards in the country—Best Beauty by Stylist. Products are rigorously tested by a panel of judges and readers. This year NeoStrata Enlighten Pigment Controller won Best Pigmentation Corrector.

One of the expert judges, facialist Kate Kerr said she ‘saw a very obvious lightening of dark spots’ when trialing this product.

Director of AestheticSource Lorna Bowes says: “we know that our Pigment Corrector is phenomenal and now we have support from experts in the field and Stylist readers. This is a

wonderful accolade.”

Harper’s Bazaar's annual beauty awards, Best in Beauty, is recognised internationally and is awarded by the editorial team.

Editor-at-large, Sophie Bloomfield awarded NeoStrata Skin Active Antioxidant Defense Serum, Best Antioxidant Serum due to its inclusion of eight powerful types of antioxidant.

Lorna Bowes says: “we are thrilled that NeoStrata Skin Active Antioxidant Defense Serum won Best Antioxidant Serum.

To have recognition that ours is the leading antioxidant serum on the market is just magnificent!"

16 WIGMORE NEWS I body language

CAST YOUR VOTES Wigmore Medical have been nominated for MyFaceMyBody and Aesthetic Awards The fifth MyFaceMyBody Awards will be held on Saturday 12th November at the five-star Hilton Hotel on Park Lane in London and is set to attract the most innovative, popular and cherished brands in the industry.

Wigmore is proud to announce that ZO Skin Health, one of the top cosmeceutical skincare ranges on the market, has been nominated for Best Professional Skincare Range and Best Skin Tightening Treatment with its Controlled Depth Peel. The latest all natural filler, Algeness, which has also proven to be popular amongst both doctors and patients alike, has been nominated for the Most Innovative Treatment award.

In addition, Wigmore is up for Best Training Programme, thanks to their extensive high quality training courses, and one of their top skincare sales representatives and ZO/glo trainer, Kerrie Smythe, has been nominated for Sales

Representative of the Year. Kerrie has been in the beauty arena for the past 22 years as a qualified aesthetician and prides herself in establishing a great rapport with all her account holders and building long lasting relationships with them.

The prestigious Aesthetic Awards bring together the very best in medical aesthetics and leaders in the profession to celebrate the achievement of the past year and will be held on Saturday 3rd December at the Park Plaza Hotel, Westminster Bridge in London.

Wigmore is thrilled to announce that it has once again been nominated for Distributor of the Year, an award that would acknowledge the vital role they play in bringing new, international products and treatments to the UK medical aesthetic market.

Furthermore, the latest take home micro-channelling skincare regime from

Radara has been nominated for Product Innovation of the Year and trainer Kerrie Smythe has once again been nominated for Sales Representative of the Year.

These awards are the perfect opportunity to recognise those who have worked hard to represent the highest standards in product innovation and customer service and have truly excelled in the field of aesthetic medicine.

Many industry goers will be meeting up at these annual events to celebrate the successes of their friends, colleagues and peers all whilst enjoying drinks, a sit down dinner, entertainment, music and dancing late into the night.

To register your vote for the MyFaceMyBody awards, please visit myfacemybody.com/awards/vote and to show your support for the Aesthetic Awards, please visit aestheticsawards.com/voting and register your vote before Monday 31st October.

NEW APPOINTMENTS Becky Brown joins the Wigmore Medical team as a regional sales representative Wigmore Medical are pleased to introduce Becky Brown as their new regional sales representative, responsible for promoting and selling all the top skincare brands distributed in the UK. Having worked in skincare and make-up for nine years, Becky has seen and developed an in-depth understanding of skin within the aesthetics industry. Her passion stems from having seen these products and the technology behind them work so well for every patient.

This is a very exciting time to join as Wigmoreâ&#x20AC;&#x2122;s top skincare brands are really kicking off with an expansive portfolio and a growing popularity within clinics and amongst the general public.

The ZO Skin Health range provides unparalleled formulations for maintaining healthy skin and today includes some of the most widely recognised skincare products and solutions recommended by physicians. glo is also on the rise with its complete beauty solutions, including glo minerals makeup and glo therapeutics skincare products. More and more clients are turning to glo for its personalised skincare regimens to enhance professional treatments and skin nourishing mineral makeup to cover, correct and protect.

Wigmore would like to wish Becky a very warm welcome to their team of passionate sales reps and are looking forward to the benefits she will bring for their continuously growing skincare ranges.

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Cosmetic consultation WENDY LEWIS discusses the new rules of interacting with patients

T

he cosmetic patient's journey has changed.

Not only because consumers have many options, but also because they have less time and sometimes, less money. Even the wealthiest people, who have the most options, are still cautious about how to spend their money.

Increased awareness from the

media and each other via social media translates to increased competition in terms of the array of clinics and practitioners to choose from.

There was a time when Londonâ&#x20AC;&#x2122;s Harley Street was the only location for aesthetic treatments, but now clinics offering botulinum toxins, fillers and lasers can be found in every region, city and village in the UK. Europe is also exploding,

especially Eastern Europe and the Baltics.

Increased awareness has also made the decision-making process a little more challenging for the patient and therefore, a little more challenging for the practitioner. It has become almost necessary to deprogramme a patient who comes into the clinic, in terms of what else they have read, who else they

body language I MEDICAL AESTHETICS 19

also comes with a new set of criteria as it is not reasonable for patients to want to have Kylie’s lips or J Lo’s bottom.

Another huge driver is a life event such as graduation, empty nest syndrome, new job, divorce or big birthday. A partner's influence is another factor that we should be somewhat sensitive to— there’s nothing worse than having a patient who comes into the clinic because their partner thinks they need something done.

Career is another influencer.

People are seeking to keep up appearances in today’s ageist culture.

There’s a lot of pressure in the UK and the US from being in a peer group where people are having toxins and others start to look quite lined even though they're probably about the same age.

have seen, where they have been on line, from chat rooms and forums.

Many come in with a lot of misinformation and false assumptions about what is safe, effective, costs, and recovery time.

Influences on take up The consultation process has taken on a life of its own and in many cases it requires a lot more time, which busy practitioners don't really have.

The key drivers of the journey for patients are still being impacted by celebrities and the new crop of influencers. Unfortunately they have really defined cosmetic medicine in many ways and they aren’t going away. Every B-list reality star, wannabe Kardashian, and pop star is getting on the bandwagon of cosmetic enhancements. This may signal a boom for aesthetics, but it

Patient screening Various approaches are necessary to handle each patient in order to screen them and decide if they are someone you actually want to treat. It may be different in the UK, but in the US market, once you do a treatment you are stuck with them for the statute limitation of two and a half years. The time to decide not treat a patient is during the consultation process, not the second or third consultation—and not after you've already done the treatment.

Screening is important to keep those patients who are absolutely destined to be incredibly unhappy and become the bane of your existence, out of your clinic from the get go.

In my experience it is very difficult to screen patients today compared to 20 years ago when I ran practices and we sat with people for 45 minutes—most of your staff just don't have the same kind of time anymore. We also face the additional present day challenge

of many patients who approach a clinic having done a lot of research and with a firm self-diagnosis of what procedure they need. This also takes time to be dealt with in the consultation process. Another important factor is that there are so many more options in terms of injectables, lasers, surgical procedures, skin care and more on offer that patients can be overwhelmed and come in with a laundry list of questions to be addressed. They also see more practitioners now and get advice from multiple sources.

I have noticed that there tends to be a five-step system in most patient consultations. First is self-evaluation—whether that's happened at a cocktail party, or on the high street—the potential patient has seen someone for the first time in a number of years and this person looks a lot better than they do, or tells them they look tired, and that starts the whole thinking process.

Next they research online, investigating doctors and clinics and checking out reviews and ratings, which are a big factor in our industry that is not going away. You can't afford not to pay attention to it because it is a huge deciding factor in whether that patient who wants to have something done is going to choose you or someone else. A few bad reviews can absolutely negatively impact your waiting room and your reputation in the community and it's getting worse than ever.

Checking out referrals from friends is next—if they are so bold as to ask a friend, which is not always the case. They may ask colleagues, or someone who has talked about having something done, or other doctors, their GP, their gynaecologist, their dentist, beauty experts, the hair salon, a skin specialist and so on.

66 The consultation process has taken on a life of its own and in many cases requires a lot more time 99

20 MEDICAL AESTHETICS I body language

They'll then check out referrals online, so before they ever make it into your clinic, they're going to look at where they're going to go. They'll look at your website, they'll look at your blogs and social media channels and everything they see will have an impact on their decision to have a treatment with one clinic or practitioner over another. It has been well documented that the most heavily visited pages of a clinic website are often the photo gallery. Consumers today are very visual and want to see the quality of results you achieve.

The last step in this process is actually scheduling an appointment for the consultation or a treatment—presuming they get that far. We all know that the negative press about cosmetic treatments on front-page news can often trickle down and have a negative impact on our industry as a whole. But it is important to bring patients into the clinic even if they just fall into the ‘considerers’ bucket. They may be thinking about having one thing done, and then learn about something else while they are in your rooms and switch gears. It is an education process.

Relating to patients A consultation today has evolved into a courtship. It used to be that the doctor was interviewing the patient, to decide whether he or she even wanted to treat this patient, but now it's both. The patient is testing the clinician too in many ways.

A cosmetic consultation could literally take an hour, which really isn’t financially sound business if the surgeon or busy doctor is carrying it out. I believe there are benefits to spreading the consultation out in a clinic. Certainly for a surgeon or aesthetic doctor, it can be helpful for more than one person in the clinic to interact with that pa-

tient on a one-on-one basis.

When I ran a cosmetic surgical practice, the entire staff, the nurses, myself and the physician would meet for at the end of a patient day to go through the entire list of who came in giving feedback on whether they were happy with their procedure, or suitable for operating on, and point out anything important that may not have been shared with the doctor.

Following the patient journey to post treatment, the next question is where is this patient going? Are you going to see her again? Do you want to see her again? If you don't want to see her, then that's the time to cut that cord right there, before there is really a formal doctor-patient relationship established.

If she’s coming for a follow-up consultation, she may have additional questions to be answered and I think that you can reduce a lot of the consultation time via virtual consultation. I think that this is definitely the future and certainly for bigger procedures.

I predict it's going to be the new norm in the next three to five years. There are cloud-based platforms and apps, such as Zwivel. com and Crisalix.com among others, that allow practitioners to connect with patients in a meaningful way without coming into the clinic as a logical first step.

This can be a huge time saver and for larger procedures, provided another way to pre-screen patients.

Patient seminars I also predict a growth in practices offering group seminars for potential patients. There's an excellent plastic surgeon in Banff, Canada who only does breast surgery such as lifts, reductions and augmentations. Her quality of work is exceptional and she has seminars, much like bariatric surgeons do, where ten patients come in and they talk about the procedures. This is a very

66 A consultation today has evolved into a courtship.

It used to be the doctor interviewing the patient— now the patient is testing the clinician too 99

good way to educate patients without having to spend an hour doing a consultation on each. It provides an opportunity for patients to find out more information, like what is involved, costs, recovery, and then decide if it is right for them or find out about alternatives.

Consultation fees I do not believe in free consultations, however there are certain regions in the USA where it's impossible to charge a consultation fee because your waiting room will be empty, since no one else in the market does. Clinical time is valuable and patients don't necessarily respect something they don't have to pay for.

It's a very personal choice, but to charge a consultation fee and apply it to a treatment fee as a credit on the patient's account is a happy medium, especially for surgical consultations. Whether they're going to buy a sunscreen, to have a microdermabrasion treatment, or three sessions of an IPL, it doesn't really matter because the money is still in the clinic’s bank account. A non-refundable deposit for surgery is perfectly reasonable in my mind, because not only is the surgery time booked, this requires an incredible amount of admin time and treatment time that someone else could have used. Patients are very fickle today and cancellations are more common than they were a decade ago because they have so many more choices I don't think there should be a follow-up charge. At second consultation, it's better for you to bring that patient in and get their questions answered before you carry out any treatments. I also believe in pre-consultations with a nurse, aesthetician, office manager, or someone in your practice who knows exactly how you treat patient – this saves a lot of doctor face time. I would reserve valuable MD face time as much as possible for actual procedures or someone who is really ready to book or ready to have the procedure.

Telemedicine Consultations in the digital domain are exploding right now and

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22 MEDICAL AESTHETICS I body language

seem to be the logical next step in the consultation process. On Google or the App Store are literally hundreds of apps, where faced with some kind of aesthetic emergency anywhere in the world—in the absence of a dermatologist, GP, or a skincare professional—I can pay $75 for a face-to-face consultation online with a Board Certified dermatologist, no waiting required.

In the era where, particularly in the UK, medical care is not that accessible, it is taking off. Tele-medicine is here to stay. It's a big trend and I would urge you to consider staying up with new developments for the future.

Virtual consultation doesn't replace the actual doctor face time consultation—it’s impossible to fully evaluation a patient’s skin from an iPhone. However it is definitely suitable for preconsultations, where Skype and FaceTime are becoming really standard procedure.

Dr Jeffery Spiegel, a facial plastic surgeon and chairman at Boston University, has an extremely successful global transgender population of patients. He sees patients from all over the world and he reports that he is doing 15 or more video teleconferences by Skype every week. That's a real sea change in how many surgeons are approaching practice today.

Patient privacy is the main concern in terms of tele-medicine and practice seems to be so far ahead of what the laws are. We can expect to see more legislation on this issue. How you consult online in a private, secure environment is a big question. However, there are some platforms that can be confidential, which of course, is the gold standard.

Social media influence Doctors often report that patients are reaching out to them on social media. I think that's a slippery slope, but it's definitely something that's going to happen and needs a mechanism in place for dealing with it. The best way to manage these queries is to thank them for their interest, and ask them to contact your office manager and provide the clinic phone or email.

Having a dialogue in an open fo-

rum about anything specific to that patient is risky business, especially in the US, the most litigious nation on Earth. The patient journey is still about multiple touch points and engaging patients where they are—and today they're online and they're on social media. They're in forums and they're reading your ratings and reviews and some patients will even be happier to see a bunch of 4.5 star reviews rather than all five stars which they don't really trust.

Dr Hassan Galadari, a prominent dermatologist in the Emirates, is very active and smart in his use of social media. People ask him questions on Instagram and write into his clinic website with legitimate questions. Follow-up has also been virtual which makes good sense if you have an international clientele.

Video vs travel Many patients want to send a video if they're coming from out of town.

When everybody is over-scheduled, geography doesn't necessarily have to be a barrier. People will travel for excellence, someone really good at something they do, someone unique, and something they cannot get where they are. They’ll also travel for privacy to avoid having to walk out of a clinic on the high street where they live, with bruises and swelling or dressings. They will also travel for bigger procedures, but tend to be much less likely to travel for repetitive treatments like microdermabrasion and laser hair removal or IPLs. They will even travel for fillers and toxins, which amazes me because there are so many good people who can do that fairly locally. That is a true sign of patient loyalty.

Video is a very interesting platform that's relatively new to the industry in the US and I think will be open globally at some point. It enables any doctor to do a virtual consultation in an HIPPA (Health Insurance Portability & Accountability) compliant mechanism. Instead of just being able to send an email, which is not HIPPA compliant, this is a HIPPA compliant way to interact with prospective patients before they come into the practice and screen them. You

save your time and your patient’s journey if you consult a potential liposuction client digitally and discover she weighs 300 pounds and isn’t really a candidate for liposuction. You might not be able to treat her immediately but you can invite

Video enables any doctor to do a virtual consulation

body language I MEDICAL AESTHETICS 23

of online screening saves a lot of staff and clinic time. I used to be of the mindset that your goal is to get everybody in the door, but I think practitioners can evaluate how you would like to spend your time. Your time is valuable and you need to account for your time at your standard hourly rate. Time is money.

Cosmetic coordinator role This role has never been as important as it is today, because that individual in a clinic can do a large percentage of the consultation. In my 12 years as a cosmetic coordinator—my role was a lot of prescreening, a lot of hand-holding and managing the doctor's time.

We booked a lot more cases and with more qualified, educated patients—the kind of patients you dream about that are harder to identify today.

This role is vital, if you're serious about doing any kind of cosmetic procedures and you're dedicated to building a successful clinic. It does not have a medically trained individual, or a marketing expert, but think of this role as the concierge of your practice—the face of your practice dealing with patients and the go-to person. Her role is to manage the patient experience from consultation to after care. Even dermatologists and specialists who do not offer surgical procedures are carving out this role in their practices. For example, a CO2 resurfacing procedure or fat reduction treatment still requires instructions and answering patient questions which should be carried out by someone with credibility who is knowledgeable about the nuances of all treatments offered in the clinic.

her to come in and talk to a nutritionist and be put on a weight-loss programme.

I think this is going to be the future and predict that we're going to see more platforms like this emerge. The whole concept

Combatting bad reviews The way to combat bad reviews is to get good reviews by taking better care of patients, screening better and having a professional staff that is switched on and attentive.

If you're notoriously late and people wait for two hours to see you, you're going to get bad reviews. I don't review doctors but I do review hotels, restaurants, any other service industry—it’s just human nature. If you are super-aggressive

with patients and try to sell them hundreds of pounds worth of skincare when they come in for something else, you're going to get a bad review. People love to write bad reviews if you overcharge, miss-bill or mess up their appointments. And most people are more inclined to write bad reviews than good reviews.

Physician reviews are a fact of life and should be closely monitored. It is better to have a healthy amount of 4 or 5 star reviews, than just a few. If you have a lot of 3 star reviews, you are doing something wrong and it should be a warning to step up your game. One negative review can greatly bring down your average. The best way to overcome that is to generate positive reviews and ask patients to do that for you so the negative ones get buried and do not come up on top.

Testimonials Testimonials can make a big difference. I don't like the word testimonial but I use it as a categoriser.

Videos, photos, user-generated content from real patients who are willing to share their experience, cannot be beaten. These are relatable and has become a very important aspect of running a cosmetic practice that absolutely encourages people to come to see you.

Conclusion Practitioners need to evolve to meet what patients want today which means staying up to date digitally.

This field is changing rapidly because the way we consume information, the way we live and where we spend our time has changed so rapidly. You cannot stay in a bubble and hide from the digital world if you're going to run a modern cosmetic clinic because that's where patients are going. Innovate or risk extinction.

Wendy Lewis is President of Wendy Lewis & CO Ltd, a New York based medical marketing and communications boutique founded in 1997.

She is founder and editor in chief of Beautyinthebag.com and the author of 11 books on beauty and over 500 articles in publications and websites in the US and Europe.

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body language I DERMATOLOGY 25

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hen it comes to facial aesthetic treatments, market research has shown that the eye areas are far and away the top priority for patients.

It’s often the first reason a patient will come into the clinic, concerned about those first signs of wrinkles, tiredness and puffiness. Yet no matter what non-surgical procedure your patients are having—their skin quality, skin health and maintenance of results are paramount to your success. Patients are increasingly keen to prolong the results of their aesthetic treatments through at-home regimens, so finding the right partner treatment is vital to getting real patient satisfaction and loyalty.

This is where Radara comes in: it is a true step-change in skin rejuvenation and offers the perfect follow-up and maintenance treatment for every aesthetic patient. Specifically tailored for the periorbital area, Radara is an innovative, targeted and painless approach to skin revitalisation using a new micro-channelling technology. This at-home treatment is a one-month regimen of micro-channelling patches and a high purity, naturally-derived hyaluronic acid serum which delivers an average 35% reduction in lines and wrinkles after just four weeks.

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Unlike traditional microneedling which can require topical anaesthetic and cause erythema, oedema and pain—Radara uses a non-invasive, micro-channelling alternative with minimal disruption of the epidermis. Radara’s ultra-thin, flexible DERMATOLOGICAL TESTS SHOWED • An average 35% reduction in lines and wrinkles after four weeks, with some results seen as early as two weeks • 81% of patients reported skin felt smoother • 88% of patients reported skin felt firmer • Radara patches almost doubled the efficacy of the HA serum • Treatment was well tolerated, with no reported side-effects • Improvements in skin health continued for a further four weeks post-treatment

patches are coated with microscopic plastic structures (similar to needles) less than 0.5mm long. When applied, these painlessly create thousands of tiny micro-channels in the skin. The HA serum then flows through the micro-channels to the deeper layers where it restores and replenishes natural elasticity, hydration and support.

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New Patients • Radara offers a non-invasive treatment and an introduction to aesthetic clinics and the range of other suitable procedures.

• An initial ‘stepping stone’ Needle-phobics / non toxin or filler patients • Radara offers a way to treat their lines without needles, pain or downtime • Allows patients to achieve a ‘natural’ look with no stark contrast • Builds patient’s confidence in treatments and aesthetic clinics Existing toxin / filler patients • Gives an effective at-home maintenance treatment to enhance overall effect of treatment and also address treat static lines • Allows the opportunity to bring the patient back at week 4 and 8 for skin analysis, top ups and to discuss further treatments The innovators • For those looking for the latest new treatment trends and interested in new technologies Step-change in skin rejuvenation Whether your patients are still needing that interim stepping stone to having a full aesthetic treatment, or if they’re experienced innovators looking for the next new skincare trend—Radara offers the perfect solution to deliver great results and complement your ongoing aesthetic treatment programme.

A one month supply (x60 patches, x1 HA serum pump) has a rade price of £99. For stockist enquiries, please contact Wigmore Medical on 020 7491 0150, or visit wigmoremedical.com. For further information on Radara, email info@radara.co.uk, visit radara. co.uk, or tweet @radaraUK

26 EQUIPMENT I body language

Laser hair removal DR RAHUL PILLAI discusses the various treatment options for ethnic skin

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hen it comes to hair removal in ethnic skin, there’s a very narrow spectrum of treatment options. Few laser industry giants in the aesthetic field have developed laser technologies for hair reduction, and over the years these technologies have been modified to treat ethnic skin with more specificity.

Principles of removal The principle behind hair removal is selective photothermolysis— heat is being absorbed by melanin, which eventually heats up the hair shaft, the hair follicle, the surrounding area and the germinating layers in such a way that the mela-

nin helps in destroying the hair.

The chromophore here is melanin, which is competing with other chromophores that are oxyhemoglobin and water.

The spectrum of 600 nm to 1,100 nm wavelength is useful in destroying the hair follicle, but the more specific we are, the lesser chance of complications. This brings us down to a few technologies utilising different wavelength, such as Pulsed Diode, Nd-Yag, Alexandrite and Ruby, which are a little more specific when it comes to heating the melanin which helps in destroying the hair.

The latest statistics on population from the US show that by 2020 ethnic skin will become a far more significant demographic

proportion. European trends are similar—the ethnic skin majority is increasing in number – and that’s one reason why understanding how to treat an ethnic skin will become important in order to maintain a good practice.

Patient selection Different areas of the body respond differently to lasers. A place like upper lip requires multiple numbers of sittings. Promising that you’ll be able to do a permanent hair reduction in six to nine sittings is risky—you’ll probably require more. The rest of the cheeks, or the arms or legs respond better and the back of the body also responds differently.

Ideally, when we look at eth-

body language I EQUIPMENT 27

PERMANENT HAIR REDUCTION The US FDA definition of permanent hair reduction matches with the results that are currently being achieved. Permanent hair reduction is defined as the long-term, stable reduction in the number of hairs re-growing after a treatment regime, which may include several sessions. The number of hairs redrawing must be stable over time greater than the duration of the complete growth cycle of hair follicles, which varies from four to twelve months according to body location. Permanent hair reduction does not necessarily imply the elimination of all hairs in the treatment area. In my practical experience, once a patient has completed about nine to 13 sittings, there is usually very minimal, or no significant hair growth for about three to 10 years—unless there are some hair growth stimulating factors involved like hormone variations or certain drugs.

nic skin, we are looking at a patient who comes with realistic expectations, somebody who’s got normal endocrine activities— so not with polycystic ovarian syndrome, hirsutism or hyperandrogenism. This factors are very important because that will influence the number of sittings

that we are going to do, no matter what technology is used.

An ideal patient has thick, dark hair, but light skin tone. However, this is challenging when it comes to Indian skin because there are huge variations between different people across the states.

The differences from one Indian state to another are probably greater than between Czech and Slovak—yet India is one country.

You may have a patient who’s fair in skin, with dark hair and lightbrown eyes and expect that using a high energy will be safe, but she gets a burn. On the other hand you might have to treat a darker skin tone, which doesn’t respond the same. It’s challenging because you can’t judge an Indian patient or a darker skin Indian simply by looking at them. It’s with experience repeatedly treating such patients that we get an idea of how such skin tones react. Of course we have the option of doing a test dose and deciding our fluence and pulse width—or to be on safer side, always starting with a higher pulse width and lesser fluence.

Considerations Three important parameters to consider when treating are pulse width, the spot size, and fluence.

Pulse Width We all talk about thermal relaxation time, although I’m not convinced this is actually the right term to be used. Thermal containment time is more relevant and more importantly thermal destruction time, because a specific amount of energy is needed within the hair shaft so that it heats up the tissue and the melanin, in such a way that the hair gets destroyed.

That should be ideally with a pulse width not less than 10 ms. In fact a 10 ms would burn the patient and something of 100ms won’t give good results, so we’re looking for something between 10 to 90 ms pulse width and optimal between 15-30 ms.

Thermal destruction time should give a heat sufficient to destroy the primary as well as the secondary germinating layers. The main reason hair returns, is not because the primary germinating

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body language I EQUIPMENT 29

layer is not getting destroyed, but that the secondary germinating layer is not getting destroyed— which is located near the arrector pili muscle. So ideally enough energy should be present to heat up and destroy this layer too, this is why different variations of same technology work, such diode laser which produces single shots of high energy, or in motion technology which gradually heats up the tissue. No particular technology can be called the best technology—all of them can work, provided you know to make them work.

Technologies provided from Alma and Lumenis are contrasting machines, but they both work and give differing explanations for their efficacy, but as a doctor, the physics is an important consideration.

Both machines gradually create heat within the hair shaft, which increases and destroys the primary and secondary germinating layers.

So, it doesn’t matter what technology you use, if you understand the physics, you can make it work.

Spot size A larger spot size creates more dispersion or scattering of energy.

A large hand-piece, for example from Lumenis (22mmx35mm), can do an entire back in 15 minutes, or the entire body in one hour, without any complications and give good results. It is because a large spot size requires smaller fluence, and hence lesser complications and also gives the same results, because the dispersion is more than a small spot size.

Fluence Understanding the implications of this isn’t entirely simple. One should not confuse the terms of fluence, energy, power, or peak intensity of a laser—they’re all different terms.

This diagram shows the older concept of darker skin type if you prefer the Nd:YAG, which has lesser melanin absorption but greater penetration and vice versa when it comes to Ruby. For the fairer, you can use a ruby, alexandrite or a diode.

I have myself used them as synonyms and been corrected, and that’s when I went back to my books and realised that we’re looking at different terms. Fluence is the amount of energy that we are delivering per treated area, in joules per square cm. So fluence is the same as energy density.

A burn happens when the dermal-epidermal junction is being destroyed—so epidermal cooling is important. A burn will never occur if the dermal-epidermal junction remains intact. There are cooling devices, but most lasers have inbuilt cooling systems in the hand piece itself, so that theoretically, if you are cooling the area well enough, using any energy level is safe. That’s true in theory, but must be implemented practically.

Types of technology IPL: IPL’s broad spectrum Intense Pulse Light is very useful when it

66 No particular technology can be called the best technology—all of them can work, provided you know how to make them work 99

comes to fine vellus hair. Since it targets a broad spectrum between 600 -1100nm it is not very specific for hair reduction and never the first go-to machine, but an optional one to have as IPL has high versatility although not much specificity.

Ruby: Ruby, 694 nm, was the first such laser for hair reduction. It was quite effective, but had many complications such as burns and pigmentary changes, so I wouldn’t favour its use in treating ethnic skin.

Alexandrite: Alexandrite was initially very popular because it gave great results, but because of the complications the diode took over.

Alexandrite is now back in fashion again, but I’m not convinced that alexandrite use is the right decision when it comes to ethnic skin.

I won’t favour it, because I think I would rather see a patient for a few more sittings rather than having less with alexandrite and expecting some kind of complications such as pigmentations or burns. Because laser is a voluntary procedure, if it burns, patients simply aren’t going to come back to you. One has to note companies which promote Alexandrite laser are not actually selling an Alexandrite laser but a Diode laser with a wavelength of

30 EQUIPMENT I body language

Alexandrite, 755nm.

Nd:YAG: The Nd:YAG has the longest wavelength, but the melanin absorption is less, making it very safe on darker skin types. Low melanin absorption means it can be used safely with high energy and the penetration is comparatively less, but more energy can be used.

It is safer, but I still prefer the diode when it comes to ethnic skin and I still believe it’s the gold standard when treating this skin type.

Diode: The diode absorption is probably not as good as alexandrite, the penetration is not as much as an Nd:YAG, but somewhere in between, and that makes it ideal for treating ethnic skin. Somewhere between 800 nm to 810 nm would be ideal for treating, and the various lasers that have come into the market right now are modifications of a Diode laser, because that’s what is ideal in darker skin type and selling more in the emerging Asian aesthetic market. The Lu-

menis Infinity with a 1060nm is a Diode laser with wavelength similar to Nd-Yag, hence safer to treat in darker skin types, even Fitzpatrick type 6 skin.

Problems and solutions I don’t believe in applying local anaesthesia. I would want my patient to react and tell me if it burns. If it hurts, I want to know so that I know that I have to increase my pulse width or or reduce my fluence.

Cooling is a must. For example Lumenis lasers are have Sapphire Chilltip, which cools the skin adequately before firing. Even the temperature of a room is very important when it comes to treating ethnic skin and also for the maintenance of laser equipment. Lower energy can be used if patients are feeling any pain, or pulse width can be increased so that the patient feels more comfort—however this may lead to a higher number of sit-

tings being required.

Vacuum suction technology is unique. It’s pretty effective because the skin is pulled closer to the hand-piece, in such a way that lesser energy is going to give better results hence less painful. Using a 5.5 or 6 fluence larger hand piece (22x35 mm) will give the same results as something like 20 or 30 fluence in a smaller handpiece (9x9 mm). When vacuum technology pulls the skin up, the competing chromophores and the oxyhemoglobin move apart. Even the chromophores on the skin are reduced. Also the unique vacuum mechanism activates tactile and pressure skin receptors to inhibit the transmission of pain sensation, hence is less painful. It’s also a mechanism that creates pain in one area to reduce pain in another. Initially when this technology came in, I was a little concerned that the suction would create more pain, but the truth is it’s ideal for a

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32 EQUIPMENT I body language

You can make any technology work as long as you understand the physics behind it

patient who thinks they can’t bear even minimal pain.

For treating thin hair there’s no particular solution, except repeated number of sittings. An IPL is a good option if you have the finest, thinhaired patients or lighter-haired patients. It’s inexpensive, but lowefficiency. Or you can use a Diode laser with very short pulse width and high energy, has its own risk of burning, but is effective. Here an Alexandrite like wavelength maybe useful and many users feel its pretty safe, although risk of burning a darker skin type exists.

When it comes to the handpieces, the large hand-piece can be used for greater body surface areas with low fluence and smaller areas like upper lip with small hand piece and higher fluence.

I’ve noticed that patients generally don’t see the results in the

first or the second sitting with a large handpiece as compared to small hand piece, but by the third or the fourth sitting they find that the results are the same. Hence it doesn’t matter if you are using large piece for larger for larger body areas and small hand piece for lets say facial hair, eventually on a whole body treatments results are the same if you combine both for 6-9 sittings. So, this is one option you can look into when you’re treating ethnic skin.

Lumenis have recently launched the Infinity device which is a diode laser with a 1060 wavelength hand piece making it safe for use in even very dark skin yet with the benefit of a Diode laser. This is a good option as there are various wavelength and handpiece options making it truly versatile. For very dark skin a 1060nm wavelength can be used and after a couple of sittings, once we understand how the skin reacts, shift to a diode laser, 805nm wavelength. Also this gives us a gold standard results for both light and dark skin types.

Using a Diode laser with a NdYAG like wavelength (1060nm) the results are not the same as a Nd-YAG laser (1064 nm) but after a follow-up of six months, 75% reduction was noted in most of the studies as an average.

Alma IN-Motion technology gives good results. Both these companies Lumenis and Alma are good, and again, these are both what sell maximally in Asian countries.

The alexandrite has been reintroduced by Alma in a new platform called Soprano platinum Ice which combines three wavelengths (755, 810 & 1064nm) but coming from the same Diode platform. The results are yet to be understood as its a recent launch but it’s effective when it comes to thinhairs which last at the end, so you treat them with the diode laser, and finally when it comes to the last thin hair, you can treat that with the alexandrite. These are additional luxuries you can have in your clinic if you have the financial capacity and the right kind of patients walking in. I approached Alma with plans to compare both

the new Soprano Ice Platinum and Lumenis Infinity, so that we could come to a conclusion about the efficacy, speed and so on but Alma declined, so I have to be rather one sided when talking about an Alex since my experience is with the previous Soprano XL platform.

When it comes to speed the Lumenis Duet or Desire or Infinity beats any other competitor lasers.

I am a little sceptical about the fact that Alex is popular again, as it didn’t work before, and I see no reason why it should now. The physics is the same, so is the Chromophore, besides its a Diode laser with a Alexandrite like wavelength—for me Diode is still the gold standard and it has been so for more than a decade now.

Summary You can make any technology work as long as you understand the physics behind it. No technology is a bad technology. But understanding the skin is more important and also understanding the technology behind a laser, because you know how this skin is going to react, and you know what to do with the laser. Of course it would be a privilege to have all types of lasers in your clinic if its financially viable and that would make any practise versatile. When it comes to treating darker skin types, Diode laser has been the gold standard and it still remains so.

Dr Rahul Pillai completed his MD in General Medicine from Moscow Medical Academy Russia, and his MD in Dermatology, Venereology and Leprosy, from Pondicherry University, India,where he was the rank holder and gold medallist. Now he is Medical Director of KKRIS Skin Care Centre and Laser Llinic, Kochi.

He is a speaker, trainer and course conductor at various International conferences and workshops and specialises in laser technologies.

References 1. http://nationalequityatlas.org/ data-summaries,PERE-Policy 2. http://www.fda.gov/RadiationEmittingProducts/ResourcesforYouRadiationEmittingProducts

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body language I PRODUCTS 35

on the market The latest anti-ageing and medical aesthetic products and services  LYNTON LASERS Introducing the launch of Lynton Lasers' all new EVO SERIES. Consisting of two high-powered platforms for both laser hair removal and tattoo removal treatments, the EVO series is said to see evolved versions of their highly successful models: The DUETTO MT (Alexandrite 755nm & Nd:YAG 1064nm) and Q-PLUS C (Nd:YAG 1064/532nm & Ruby 694nm) lasers. Lynton Lasers say that the DUETTO MT EVO is the world’s first ‘Mixed Technology’ laser due to its ability to deliver both an Alexandrite and Nd:YAG laser onto the skin simultaneously: this technology is said to allow effective treatment of all skin and hair types.

Lynton also declares that no other laser device will remove more tattoo pigments than their new Q-PLUS EVO. Armed with three individual laser wavelengths, including the Ruby laser at 3Hz, Lynton say that their new Q-PLUS C EVO model is the premier platform for multi-coloured tattoo removal.

W: lynton.co.uk  4T MEDICAL New Polydioxanone (PDO) Thread Cogging Screws have been added to the Honey Derma PDO Thread range. According to UK medical aesthetic product supplier 4T Medical, the PDO Thread Cogging Screws are easy to insert and can be placed more superficial than a standard 3D Cog. They aim to treat a variety of areas including the lower face, mid face, jawline and neck, and can be used for body contouring. They can also be used in combination with 3D cogs to produce a brow lift.

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 NEOSTRATA Award-winning NeoStrata introduces the new Redness Neutralizing Serum to their Restore range. Specifically developed for sensitive skin types to build a stronger barrier function and bring equilibrium back to skin, the Restore range now includes a formulation to tackle one of the most prevalent skin issues in the UK. NeoStrata say that the new Redness Neutralizing Serum targets the underlying causes of skin redness. With a lightly cooling effect, this soothing serum is said to improve skin resiliency and reduce the appearance of flushing, while decreasing the potential for future redness-inducing triggers.

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 SKINCEUTICALS SkinCeuticals are proud to unveil Phyto Corrective Masque—the latest addition to the Correct range and professional mask portfolio. It is said to use high potency botanical extracts and a concentrated calming dipeptide within a hyaluronic acid base to deliver a soothing and restorative result, ideal for post-procedure recovery.

Phyto Corrective Masque has been specifically formulated as the ideal calming and replenishing post-procedure formulation, said to reduce the skin’s surface temperature—restoring hydration, whilst minimising downtime and maximising aesthetic results.

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 NEO ELEGANCE Neo Elegance has introduced their HiDr8 Facial as part of their professional product range. By using the method of Hydrodermabrasion, the treatment works to exfoliate the first layer of skin—the stratum coreum, to effectively eliminate dead skin cells.

The advanced and innovative treatment brightens the skins complexion, unclogs pores and avoids any irritation that the skin may be prone to. The technology from Neo Elegance uses alterable suction power with the infusion of water and a very soft tip to pull out impurities from the pores, remove dead skin cells, but at the same time avoid dryness as the water replenishes lost moisture. There is an option of adding water soluble solutions into the water for a more targeted and tailored treatment to suit each individual. The therapy can be used in a treatment by itself or as part of a more intensive treatment with microdermabrasion and oxygen therapy.

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VANIQA® is licensed for the treatment of Female Facial Hirsutism *Complete or almost complete hair removal was achieved in 93.5% (29/31 subjects) in eflornithine-laser treated sites vs 63.9% (21/31 subjects) in placebo-laser treated sites.1

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Reference: 1. Hamzavi I et al. J Am Acad Dermatol 2007; 57(1): 54-59.

Vaniqa 11.5% Cream eflornithine Prescribing Information. (Please consult the Summary of Product Characteristics (SmPC) before prescribing). Active Ingredient: eflornithine 11.5% (as hydrochloride monohydrate). Indication: Treatment of facial hirsutism in women.

Dosage and Administration: Should be applied to the affected area twice daily, at least eight hours apart. Application should be limited to the face and under the chin. Maximal applied doses used safely in clinical trials were up to 30 grams per month. Improvement in the condition may be noticed within eight weeks and continued treatment may result in further improvement and is necessary to maintain beneficial effects.

Discontinue if no beneficial effects are noticed within four months of commencing therapy. Patients may need to continue to use hair removal methods (e.g. shaving or plucking) in conjunction with Vaniqa. Application of Vaniqa should be no sooner than 5 minutes after use of other hair removal method, as increased stinging or burning may occur. A thin layer of the cream should be applied to clean and dry affected areas. The cream should be rubbed in thoroughly. The medicinal product should be applied such that no visual residual product remains on the treated areas after rub-in. Hands should be washed after applying this medicinal product.

For maximal efficacy, the treated area should not be cleansed within four hours of application. Cosmetics (including sunscreens) can be applied over the treated areas, but no sooner than five minutes after application.

The condition should improve within eight weeks of starting treatment.

Paediatric populations: The safety and efficacy of Vaniqa in children 0-18 years has not been established. Hepatic/renal impairment: caution should be used when prescribing Vaniqa. Consult SmPC for further information. Contraindications, Warnings, etc: Contraindications: Hypersensitivity to eflornithine or to any of the excipients. Warnings & Precautions: Excessive hair growth can result from serious underlying disorders (e.g. polycystic ovary syndrome, androgen secreting neoplasm) or certain active substances (e.g. cyclosporin, glucocorticoids, minoxidil, phenobarbitone, phenytoin, combined oestrogen-androgen hormone replacement therapy). These factors should be considered in the overall medical treatment of patients who might be prescribed Vaniqa. For cutaneous use only. Contact with eyes or mucous membranes (e.g. nose or mouth) should be avoided. Transient stinging may occur if applied to abraded or broken skin. If skin irritation or intolerance develops, the frequency of application should be reduced temporarily to once a day. If irritation continues, treatment should be discontinued and the physician consulted. Contains cetostearyl alcohol and stearyl alcohol which may cause local skin reactions (e.g. contact dermatitis) as well as methyl parahydroxybenzoate and propylparahydroxy-benzoate which may cause allergic reactions (possibly delayed). Interactions: No interaction studies have been performed. Pregnancy and lactation: Women should not use Vaniqa whilst pregnant or breastfeeding. Ability to drive and use machines: Vaniqa has no or negligible effects on

UKEFL3585b(1) Date of preparation: August 2016.

the ability to drive and use machines. Adverse Effects: These are ranked under heading of frequency using the following convention: very common (≥1/10); common (≥1/100 to <1/10); uncommon (≥1/1,000 to <1/100); rare (≥1/10,000 to <1/1,000); very rare (<1/10,000). Very common: acne. Common: pseudofolliculitis barbae, alopecia, stinging skin, burning skin, dry skin, pruritus, erythema, tingling skin, irritated skin, rash, folliculitis. Uncommon: bleeding skin, furunculosis. Rare: rosacea, skin neoplasm, skin cysts, vesiculobullous rash. Consult SmPC in relation to other adverse effects. Legal Category: POM. Marketing Authorisation Number(s): EU/1/01/173/003. NHS Cost: (excluding VAT). Tube containing 60g – £56.87. Marketing Authorisation Holder: Almirall, S.A. Ronda General Mitre, 151 08022 Barcelona, Spain.

Further information is available from: Almirall Limited, 1 The Square, Stockley Park, Uxbridge, Middlesex, UB11 1TD, UK. Tel: (0) 207 160 2500.

Fax: (0) 208 7563 888. Email: almirall@professionalinformation.co.uk.

Date of Revision: 10/2015. Item code: UKEFL3336

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

Adverse events should also be reported to Almirall Ltd.

For more information please go to: www.medicines.org.uk/emc/medicine/21243

body language I EQUIPMENT 37

New laser technologies PROFESSOR MUKTA SACHDEV speaks about the Alma Soprano Platinum 3D hair removal technology

L

aser hair removal is the most common procedure in any cosmetic dermatology office. The safest, most efficient, longest lasting technology is highly sought after, and newer technologies are constantly being evaluated.

Although permanent hair removal is impossible world wide, a reduction of 60% to 80% is possible using laser-assisted hair reduction.

Safety considerations Dealing with unwanted hair is not a case of simply locating hair and removing, or reducing it. It’s imperative to consider not only different skin phenotypes, but characteristics of hair such as hair thickness, hair colour and the depth of the follicle. The AT (anagen:telogen) ratio of the follicle and the anatomical location of the hair must also be considered. Hormonal factors also affect hair, including Cushing’s syndrome, polycystic ovarian syndrome, hormonal medications, testosterone and oestradiol, insulin-like growth factor. Attention should also be paid to gender, photosensitive medications, a history of plucking, waxing

and sun-tanning.

For anyone working with darker skin, safety is paramount and efficacy is secondary. In addition to darker skin safety, safety considerations differ for thin, fine and grey hair. When addressing hair removal, or hair reduction, we have all of these concerns—it’s not just simply the clinician’s skills, the technology and the settings. Paradoxical hypertrichosis—an emerging problem with every single hair removal system on the market, Is it just about hair? Important factors to evaluate when selecting a device include Laser parameters Wavelength Fluence Spot size Pulse width Skin cooling system

38 EQUIPMENT I body language

Diode (1450nm)

ABSORPTION

Nd:YAG (1320nm)

Er:Glass (1540nm)

Nd:YAG (1064nm)

Pulsed Dye

Hemoglobin

KTP

Melanin Water Scatter

300

400

Ultraviolet

500

600

700

800

900

1000

1500 2000

Near Infrared

3000 4000 5000

7500

10000 20000

Mid Infrared

WAVELENGTH (nm) Absorption vs wavelength for various lasers used in aesthetic treatments. Visible light lasers are strongly absorbed by blood (hemoglobin) and pigment (melanin), in contrast to infrared lasers, which are strongly absorbed by water

must also be considered. To address this, research has shown that care must be taken over the machine settings, covering larger areas and that the hormonal status of the patient must be considered.

Safety Efficacy wise, most technologies are similar. In terms of safety, all lasers are safe—it’s the hands of the operator that creates the risk. Safety and burns are largely handler and technique dependent. There is no one perfect device and burns are possible with every single device on the market.

The risk of hypopigmentation is slightly different, but there is enough literature to show that the IN-Motion devices work help to prevent this.

Darker skins Darker skins require specific advice on post-laser skincare, including the importance of protecting from the sun. Acanthosis nigricans and axillary hyperpigmentation of skin of colour must be considered because these are not post-laser pigmentation.

Asian people have pigmentation around the mouth—perioral hyperpigmentation—this is something that’s genetic although many of them return suggesting that the laser did this, when this is not the case.

Diodes IN-Motion Diodes IN-Motion are the latest and safest technology. I began giving laser treatments with an Nd Yag, I then went to the IPLs and onto a diode. I’ve also got a combination and an Alexandrite and I can honestly say that none of them work ‘the best’. I mix and match and use two or three different technologies in the same patient because the coarser, thicker hair responds best to the Nd Yag, but the finer, longer, thinner hair doesn’t. However it does improve with an IPL and also with a diode and I’m also having some very good results with the Alex.

I wouldn’t have touched an Alex ten years ago in a darker skin, but now the newer Alexandrite 755 technologies are safe in darker skins also. If I was new to treating and looking to invest in a laser hair removal system, a device with two, or three technologies in one machine would be my choice.

ICE Platinum This 3D system has three different wavelengths in one laser—an Alex, a diode and a Nd ;YAG laser -1064 nm. This is one of the new kids on the block in the laser device and what’s attractive is having three different technologies in one hand-piece.

This device has clubbed these three together, so that they’ve Laser hair removal is the most common procedure in any cosmetic dermatology office

body language I EQUIPMENT 39

got the Nd Yag which works for the darker skins, the diode which is an IN-Motion technology working well on all skin types and speeding up the process, and the Alex which works on the widest range of skin types and hair colour. It’s a very good mix and all of them are in the desired safety wavelength. They all work, they’re all safe and there’s definitely logic behind the combination technology.

Alex is particularly effective for light-coloured and thin hair, but it is now also safe in darker skins. There is good melanin absorption, high efficacy and no adverse events. The diode is suitable for all skins types, but with the advantage of the diode IN-Motion is that areas can be covered faster. The 1064 nm, which has been around a while, we know works, and if you’re working with darker skins it has been a preferred choice for years for it’s higher safety profile.

When the three are combined, you can reach different areas of the hair follicle structure. Research has found that 1064nm kills the hair follicle and the surrounding tissue. When we consider penetration depth, what goes the deepest is the 1064nm, then the diode, then the Alex. We’re penetrating on three different targets in the hair follicle.

Follicle depth Different technologies work at different depths, different energies and on different aspects of the hair follicle, so the combination of three should ideally give a better result. Follicles are at

different depths over all areas of the body. Usually when looking at hair removal you don’t consider this so much because just one technology is working for you. However in all areas, what you should use should be based on the hair follicle depth.

The overall effect of combining is better results in fewer sittings. Combining 3D, Alex, the 810 and the Nd Yag, provides a full-spectrum for hair removal. When combining two technologies its possible to also treat the thinner, finer hair; ensuring better results. It’s not 100%, but you’re definitely getting a better effect than using one single technology.

ICE Platinum results In my experience ICE Platinum works for men brilliantly—giving great results in just four sessions, compared to 12-16 sessions for women. Men do respond much better and are quite happy with less, rather than no hair—since none of them want to be really hairless.

A laser that works on thinner, finer hair would really a great benefit or a great add-on in my practice, because I’m often telling patients that we can’t go any further and their only options are to go back to waxing and threading.

Combination device hair removal offers a complete range. It’s still not possible however to completely customise the settings to choose an individual wavelength and spot size. This looks like the next step and a definite requirement in the future, since we live in a global world and are all treating different skin types.

Home use lasers The home-use device is something that may be an add-on to our in-office treatments for patients who’ve had treatments with us and then they want to do things at home and don’t want to travel for hair treatments. It’s possible for us to use this to our advantage and consider these devices as adjunctive therapies and there is a significant amount of data showing efficacy for these devices.

Plasmonic therapy Because white hair has no melanin, there is no target, the laser is not effective. There have been studies with a MiraDry device, but the results are inconclusive. Some success has been seen with Plasmonic nanoparticles, which are metal particles that are highly efficient at absorbing and scattering light. There are many devices and studies going on worldwide using targeted plasmonic therapy. This may be a possible treatment for grey hair in the future.

Plasmonic therapy works by applying a nanoshell formulation to the skin, delivered to the pilosebaceous unit. You wipe the shell off and treat with laser tuned to an absorption peak.

This treatment with a non-invasive energy device on the nanoparticle has demonstrated the ability to reduce axillary hair independent of colour.

Conclusion The hair removal device landscape is changing as combination technologies become widely available. This safe and effective Alma Soprano Platinum 3D technology is one such example.

Prof Mukta Sachdev is a Dermatologist and globally recognised skin of colour expert. She has two decades of clinical experience in medical, aesthetic and cosmetic dermatology and runs a niche boutique dermatology clinic in Bangalore.

40 BUSINESS I body language

Marketing treatments for intimate areas CAITLIN FARRELL discusses how to introduce women’s sexual wellness into your practice, and build a strong foundation for long-term success

W

hether you’re a gynecologist or an aesthetic physician, you have patients to see and a business to run so putting together a marketing plan is understandably the last thing on your mind. It may seem especially daunting when it means developing a plan to introduce a new treatment, particularly one that caters to such a private and intimate concern as sexual function.

Neglect usually leads to a marketing plan comprised of a long list of tactics with no long-term strategy. Regardless of the nature of the treatment, building a strong foundation with clear, strategic goals is critical. The good news is that sexual wellness isn’t necessarily more difficult to build a plan around, it’s just different.

obvious, but it’s amazing how often it gets overlooked. Think of your staff, your office and your marketing plan as the foundational pillars that will support your overall success with your current business and your new investment in women’s sexual wellness.

Impulse marketing It’s not difficult to recognise the symptoms of impulse marketing when you see them: the reactionary whim that leads to a highend marketing spending spree.

A national PR campaign, a hefty pay-per-click initiative and giant billboards everywhere! The only thing any of this really guarantees is that the budget for introducing the new treatment will be spent before anyone’s even had a chance to treat a patient. Beyond their high price, these activities can be incredibly time-consuming and Building a strong foundation their success relies heavily on exImagine you’re building a house. perienced, dedicated resources.

You map out your floor plan and It’s also very execution-driven, then construction starts with the which means planning always foundation (framing, concrete, in- takes a backseat. Imagine deciding sulation, etc.) before you move on to run an advertising campaign, to build the second floor. As you but without doing the budget or go, you would have key inspec- monthly plan, or even having put tion points to ensure your house an editorial calendar together. That won’t collapse later on. The same nightmare is impulse marketing. rules apply when you’re introducMany overlook the value of foing a new service to your practice. cusing on their existing patients If you skip the foundational work with an integrated plan comprised and dive right into building your of clear, strategic goals. Take social rooftop pool, you’re bound to have media as an example. There’s a big some issues along the way. It seems difference between updating your

existing social media pages with an interesting announcement about a new treatment and investing in a social media ad campaign across multiple channels, like Facebook and Twitter, as well as some you’ve never considered before. If promotion through Instagram and Pinterest is new to you and your team,

Marketing sexual function treatments can seem a daunting prospect

body language I BUSINESS 41

a new treatment launch is not the time to start getting familiar with the platform.

In general, the cost of acquiring new patients requires a significant investment in time and budget.

The bigger, overriding problem with impulse marketing is that it focuses on acquiring new custom-

ers instead of leveraging relationships with existing patients, whose trust and loyalty you’ve already earned. When it comes to starting a conversation about sexual wellness, trust will play a significant role in whether or not the patient is eager, or even willing, to open up to you.

Strategic marketing As an integral part of building a strong foundation, strategic marketing takes a proactive approach instead of a reactive one. It involves the simultaneous planning and execution of initiatives to reach attainable goals and ensure longterm success. The benefit of stopping to think about your plan is that it won’t really slow you down and you'll actually have better results with less need to clean up any messes later on.

With a strategic approach, you’re thinking about leveraging your existing opportunities.

Within your existing database of patients, lets assume that 70% are women and 50% of these women are good candidates for this new treatment. The first step is making contact with a few of them via phone or email. You can put together a list of 10 - 15 qualified “VIP” patients who you know really well and who are always interested in the latest and greatest treatments you offer. In the short time it took to create this list, you’ll have already completed some of the initial evaluation work—work that would usually require more of your time when dealing with a new patient.

You should also consider if any of those patients would be willing to openly discuss their experience with others. One of the primary ways women are talking about treatments for sexual wellness is with each other. While they’re waiting for their doctor to bring it up, they’re review-searching, interacting with other patients online, or talking to other people they know. Starting with a select group of influential clients who will speak openly about such an intimate subject is a great way to spread awareness about a new treatment for sexual wellness—and best of all, it’s free!

Eventually, once you’ve built your foundation through strategic marketing and preparing your practice, you’re going to expand your reach to new patients through a sensibly planned commercial event that can include local media, or even guest speakers

42 BUSINESS I body language

Make sure your staff are comfortable talking about intimate treatments

who specialise in sexual wellness.

Your time, energy, and money will be wisely spent at this time to secure everything you’ve been working towards.

It’s vital to ensure that all clientfacing parts of the business are in line, and not just on the clinical side but also on the administrative, sales and marketing side.

Staff training Let’s say that the expensive marketing activities worked to gain awareness and attract some new patients.

The phones start ringing off the hook and emails are flooding your inbox from potential patients inquiring about this new treatment.

As a few weeks go by, the traffic starts to slow down a bit and, strangely, not one of those inquiries resulted in an appointment for a treatment. Upon closer evaluation, talking to the staff and asking a few basic questions about patients and the treatment, it quickly becomes obvious where things went wrong.

They clearly weren’t ready to work with sexual wellness patients. In fact, they were barely able to say the word “vagina” without giggling or avoiding eye contact. Whether dealing with medical aesthetics

or sexual wellness, this happens in many clinics where the office hasn’t been sufficiently prepped to talk about a new treatment, and patient-conversion suffers.

To really understand the problem, let’s go back to our homebuilding analogy. In the simplest of terms, this practice jumped right into building the roof before the foundation was set and the structure was slowly caving in on itself. Everyone in the office should take a moment to ask themselves how comfortable they are talking about the intimate details of their own sex lives before they start speaking with patients about theirs. Not because they have to talk about their personal lives, but if they are uncomfortable just thinking about it, it will be very obvious to the patient—a patient who is probably already nervous about the conversation to

begin with. It is worth considering that clinics where the physician and their staff have either had or performed a treatment have had the easiest time integrating sexual wellness into their practice, and have done so with great success.

Your staff know your patients, sometimes better than you do, because they’re talking to them every day on the phone, at the reception desk, in the waiting room and even in the treatment room. With their frequent exposure to your patients and the familiar relationships they create with them, they’re in the best position to start a conversation about a new treatment. You just have to make sure they’re ready to start that conversation, especially when it involves such an intimate and private concern. So in addition to being comfortable with their own intimacy and the treatment they’re representing for you, your staff should also be encouraged to do some research in the broader field of sexual wellness.

Investing in your employees for long-term success means empowering them with all the information they need and making sure that they’re comfortable talking about issues related to sexual wellness with your patients.

Vaginal rejuvenation vs female sexual function and wellness Unfortunately, we have not come very far in regards to women’s health, particularly with matters of sexual sensation and intimacy. Viagra and a long list of other sexual function options for men have been available for some time, but until very recently there hasn’t been much out there for women dealing with loss of sexual sensation due to childbirth or other natural causes.

While vaginal rejuvenation helped to spark interest in women’s health, the treatments have

66 Investing in your employees for long term success means empowering them with all the information they need 99

44 BUSINESS I body language

been mainly focused on cosmetic concerns. At the same time, other treatments have surfaced to address issues with discomfort during sex for postmenopausal women, like atrophy and lubrication. Now we’re seeing the shift into female sexual function, and while it may seem similar to what has already been happening in the market, it’s actually quite different—especially for the patient.

There are a lot of treatments available and this is causing a great deal of confusion among patients and even the media. This is why it’s important that your staff takes the time to familiarise themselves with sexual wellness—not only with the clinical aspects of the treatment you offer, but on what’s happening in the marketplace in general so they know how to discuss it with patients. Your staff should be researching relevant resources in both the professional and the consumer space, making sure they’re up to speed on the current state of sexual wellness. Staying on top of what your patients are talking about and where they’re going to get their information about sexual wellness is critical.

Preparing the clinic As you would with the launch of any other product, it’s important to regularly take an honest look at the current condition of your clinic. I’m sure for the most part it’s clean, and things are up to par, but there may also be little things that you’ve missed when the clinic has been very busy. Knowing that women are coming in for such an intimate treatment, it’s important to really take a look at some things that might make her question whether or not she wants to expose herself to anyone, or anything, in that clinic. Is there any dust in the corner that was overlooked? Is the furniture outdated? Does your office create the appropriate ambiance to make her confortable during treatment?

Placement of marketing materials On the marketing side, consider looking around and thinking about where the promotional materials

are and whether they are visible.

Are they clearly visible? Are they also in a place where she can access and review them privately? Let’s say that in a particular office the only place pamphlets for a vaginal laxity treatment are available is at the reception desk. In this situation a potential patient would have to get up and walk over to the reception desk to pick up a pamphlet—all in front of a room full of strangers.

You might as well just ask her to get up and announce to everyone that she has vaginal laxity. Consider putting marketing material in private areas like the treatment room or the bathroom, where she can read in private.

You can do all the research on the topic, you can know the product in and out, but when it comes to creating awareness about a treatment in your practice it’s really just about using common-sense tactics to guide your approach.

Digital integration This is important, but it doesn’t have to involve a huge spend. Start by updating your website, making sure the new treatment is easy to find from your navigation bar, and then creating a new dedicated page with all of the relevant information about the treatment.

Check to make sure your website is responsive so that patients can easily find you and access your website from their mobile devices. Don’t forget your social media pages, updating any menu of services your have and creating a brief announcement post to introduce the treatment on your page.

Patient tracking Patient tracking is key with these treatments. Unfortunately, happy patients are quiet patients. Quite different from an unhappy patient, if they’re satisfied with their results, a happy patient will go on with their lives and you probably won’t hear from them again until they’re ready for something else. You won’t always have before-and-after photos, and even if you do, your options for where you can promote pictures of a patient’s genitalia may be limited.

Many actually see this as a

benefit to treatments for intimate areas. If you are an aesthetic practice, you’re probably familiar with patients who complain about subtle or gradual results. They quickly forget where they started and sometimes you have to sit down with them to pinpoint their progress on their before and afters. In contrast, a patient who has had a treatment for sexual function, for example, will be able to feel their results. You can’t ask for a better

body language I BUSINESS 45

WELL READ Helping you and your staff feel comfortable having conversations about women’s health—particularly, sexual wellness—is vital to converting potential clients to patients booking a treatment. Sitting together and having regular, open discussions about the topic and treatment procedures is one way to help people feel more relaxed. You can also suggest some reading introductory reading material.  The Physiology of Female Sexual Function and the Pathophysiology of Female Sexual Dysfunction (Committee 13A) Roy J. Levin, Stephanie Both, Janniko Georgiadis, Tuuli Kukkonen, Kwangsung Park, Claire C. Yang. The Journal of Sexual Medicine, Vol. 13, Issue 5, p733–759 Published in issue: May 2016  Risk Factors for Sexual Dysfunction Among Women and Men: A Consensus Statement From the Fourth International Consultation on Sexual Medicine 2015 Marita P. McCabe, Ira D. Sharlip, Ron Lewis, Elham Atalla, Richard Balon, Alessandra D. Fisher, Edward Laumann, Sun Won Lee, Robert T. Segraves. The Journal of Sexual Medicine, Vol. 13, Issue 2, p153–167 Published in issue: February 2016  Association of Reproductive Health Professionals www.arhp.org:  Handbook on Female Sexual Health and Wellness  Sexual Health Fundamentals—Clinician Competencies for Sexual Health  What You Need to Know—Talking to Patients About Sexuality and Sexual Health  Sexual Health Fundamentals—The Top 10 Things You Need to Know About Female Sexuality

testimonial than, “I feel incredible”, or “I haven’t felt like that in a long time!” Happy patients won’t always come running to thank you and share their results with you so you have to make patient tracking an integral part of your patient care process.

Check in with your happy patients at the one-month, threemonth, and six-month mark to see how they’re doing and keep a record of their progress. For cer-

tain devices, there may only be one treatment, and then there’s no need to return for a while, so it’s even more important to make sure you follow up on their progress. By the six month mark, if they are still happy they’ll probably be willing to give you a good review—or even better, they’ll let you record or film their testimonial. It’s the best piece of promotional material you can get at a fraction of the price!

Caitlin Farrell is the Senior Global Director of Business Development for VIVEVE Medical. Ms Farrell helps practices throughout the world initiate and implement the tactics and strategies that empower patients to seek out treatments for intimate areas. With her indepth understanding of marketing strategy, combined with a compassionate approach to patients’ interests, concerns and aspirations, Ms Farrell offers essential guidance designed to expand the reach of medical practices everywhere.

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body language I AESTHETICS 47

Eyelash growth serum Xxtralash is a nutrient rich eyelash serum designed to stimulate new lash growth, repair weak and damaged eyelashes and prevent lash loss

F

alse eye lashes have been ‘the talk of the town’ for many years, after the first artificial lashes appeared in London in 1902, and were then patented in the US in 1911, although there are reports of a Parisian ‘craze’ for sewing hair into the eyelid in the 1880’s. The real growth in false lashes seems to coincide with the glamour of Hollywood. But, most women know that the time it takes to apply them means they are simply not an everyday option. Furthermore, in recent years, the trend has been for a more ‘natural’ looking beauty aesthetic, where women want to enhance what they have rather than apply false lashes; this has seen a huge demand in innovative lash serums.

Proven results Xxtralash is a powerful and clinically proven nutrient-rich eyelash serum, that bestows long and natural lashes on the user. Formulated with vitamins, botanical extracts and ProbBiozyme TriPeptides that enrich eyelashes and enhance their appearance, as well as keeping them in optimum health. Users reported up to an 80% increase of eyelash growth and density in for weeks, with 100% stating their lashes had a; ‘healthier, more beautiful look’.

After years of research and development, the secret to more beautiful eyelashes is finally available without a prescription.

This revolutionary, nutrient-rich serum is clinically and dermatology tested for both its safety and efficacy, it is suitable for all skin types. The gel serum is fragrance free and designed to be used daily, it is brushed onto the base of the eyelashes at night.

XXtralash is not a thick-clumpy mascara or make-up that only provides temporary volume. It has been specifically formulated to deliver fast results, without any side effects; there is no darkening or pigmentation of the iris. The serum stimulates new growth, repairs weak and thinning lashes, nourishes the eyelash and prevents lash loss.

Key Ingredients • Hydrolyzed soy protein helps repair damaged lashes, nourishing and strengthening them.

• Magnesium ascorbyl phosphate and vitamin C are antioxidant boosters that support and fortify lashes.

• Adenosine to nourish lashes.

• Myristoyl pentapeptide-17 improves the appearance of lash length, stimulating growth through the hair follicle and softening the lash.

• Lysophosphatidic acid is a bioactive growth stimulator that helps improve appearance of lash length, growth, and softness.

All ingredients are considered ‘GRASE’ (Generally Regarded As Safe and Effective) by the US FDA Clinical results In just four weeks, 100% of patients reported having the appearance of thicker, fuller, longer and darker lashes. Patients experienced an average increase in the appearance of eyelash length and density of 54% - 82% in four weeks with daily use. RIPT and Corneal Opacity Tests resulted in zero signs of irritation (irritation may occur if serum goes into the eye).

Easy application Before use it is recommended to remove all make-up from the eyes, and clean and dry near areas before each application. Apply a thin layer to skin at the base of the eyelashes. Repeat once or twice per day for best results. Once reached maximum potential, Xxtralash requires minimal application to maintain the results.

XXtraLash was formulated to provide an effective and safe eyelash conditioner that gives amazing results, using clinically effective quantities of our key ingredients. Our customers from around the world rave about their eyelashes and receive compliments from friends, family and co-workers Ingredients: Distilled water (aqua), hydrolised soy protein, hydroxyethylcellulose, magnesium ascorbyl phosphate, adenosine, myristoyl pentapeptide – 17, lysophosphatidic acid, disodium EDTA, sodium chloride, calcium chloride, caprylyl glycol, phenoxyethanol, polyaminopropyl biguanide.

For more information, please contact AestheticSource, T: 01234 313130; E: info@aestheticsource.com; W: aestheticsource.com

body language I MEDICAL AESTHETICS 49

Male beauty DR SEBASTIAN TORRES gives his perspective on male aesthetics

T

o speak about males who are beautiful has for some time been a taboo. There has long been a primitive concept about how males can be beautiful—and certainly until fairly recently when man was desirable he was stinky, hairy and smelly.

Concepts of male A classical concept of male emerged as men started shaving and putting some perfume, and the male today is now expected to be a little bit cleaner. Our society also has some very modern concepts about the completely perfect face, clean hair and less wrinkles and better aesthetic appearance. These three very different positions have fashion ruling over them—so what was classical can get to be modern or primitive and they all mix altogether.

If we examine how male beauty differs from female beauty, we're mainly talking about volumes. Women have soft prominences or soft angles and elevated raised features, but with male aesthetics, of course we need less volume. We have to favour marked transitions because we want to enhance the bony prominence. And facial hair, is something that could be present or not, but this must be considered when treating a male patient in a way that's completely different to treatment of the females.

Feminising man To feminise a male face involves hairline implantation, epilation, cheek and lip implants, temporal lift, fat grafting, maxillary positioning and probably mandible angle reduction, rhinoplasty and vocal chord plasty and Adam's apple lowering. It's completely different from using fillers.

What used to be masculine is not as masculine anymore. Ten years ago, if you were boxing, you were a male. Now females are boxing. Ten years ago, of course there was no such thing as male modelling. Right now, a lot of guys, they're still males, but they're modelling, taking pictures, looking handsome, taking a lot of care of their hairstyle and everything aesthetic, so things are changing.

Enhancing male skin Male skin is different to females’, in that male skin is thicker and has a higher seborrheic compound, so male wrinkles are mainly created by facial expression.

Harder materials are needed to be able to fill below that skin and the skin of males can protect, or cover hard materials in a more efficient manner. Male skin is more inelastic and less hydrated, because men tend not to be so fond of using creams and lotions. The young face in men and women is an inverted triangle, and when we start getting old, it starts sagging in the mandibular angle and mandibular ligament and we have to invert that proportion. Sometimes this is possible with fillers, sometimes by using threads or other methods. Apart from volumetric depletion, there is also gravitational ageing as everything heads south. Examples are in the lower lid, in the nasolabial and the labiomental fold, which must be addressed to have some sort of rejuvenation. However, since 70% of facial ageing is about volume depletion, the outcome of a facelift on someone who has not done volume repletion, will not be a more youthful appearance. Volume must be replaced and then pulled up, although it’s important to note that to maintain or enhance male beauty, excessive volume must be avoided. The goal is not to create a ball, just a male face. Bony prominences must be enhanced and wrinkles reduced, but the goal is not to eliminate them all, because people just look weird without any wrinkles.

Male behaviour Men like to favour using long-lasting materials, because they don't want to have retouches every few weeks. Male client behaviour is different. They are often tricky at first because they are very precise with their requests and you have to understand that. And you have to be conservative, because they don't like when their friends realise that you have done something with their face.

Naturalness Natural results are far more important in males than females.

50 MEDICAL AESTHETICS I body language

The result must be built up because the skin is not elastic, but not too many times. If you start a very frequent programme with your male patients, you're going to lose them. Twice a year is enoughâ&#x20AC;&#x201D;and for most of them, once a year is the most you will have from them.

Men cheat less than female patients. If your work is good the first time, you have that patient forever. It's trickier at the beginning, but 30% of my practice are male patients and I have them for 10 years more or less right now. So it's something that you could build your practice on.

Treating Cheekbones For cheekbones, the difference between females and males is that in males the projection of the superior pole transits abruptly to no volume in the buccal area with a strong and define transition. Zygomatic and malar area are enhanced giving the aspect of a bony prominence with strong transition desirable to the rest of the soft tissues.

In females the augmentation of the cheekbones needs more volume and foresees a soft transition of volume to connect with the buccal fat pad.

Treating chins Chin and mandibular angle augmentation can be obtained with fillers, mentoplasty/orthognatic surgery, or chin/mandibular angle implants. It gives the face a more defined and determinant frame associated with a more masculine look.

Treating the nose The nose can be improved through medical or surgical rhinoplasty. Medical rhinoplasty with fillers and botulinum toxin is recommended for small defects or minor corrections. The camouflage of small dorsal humps, improval of aesthetic dorsal lines and augmentation of tip projection or rotation are possible with dermal filler. Vascular complications should be prevented and treated promptly if necessary. Surgical rhinoplasty is advised if the aesthetic or breathing disturbances are important, or if a permanent correction is desired.

Treating the lips Lip treatments in males are completely different to females. Lip rejuvenation can be done in five steps. Most patients need some

rejuvenation but not all of them. First step is the treatment of the oral commissures. Second step is the lining of the vermilion.

Third step would be the definition of the columns. Fourth step corresponds to cupidâ&#x20AC;&#x2122;s bow area. The fifth step is volume definition. Generally speaking it is advisable to perform steps 1 to 4 with needles and to use cannulas for step 5. In my hands, it is very difficult to achieve homogeneous volumetric results if you place the filler with needles. The turbulent flux of the material will be seen as a chain of spheres and will have the aspect of a rosary, which is very unnatural. The cannula use allows a linear flux in filler delivery that grants even distribution and natural results.

Research In an article I've just published about the possibility of combining aesthetic medicine with surgery we did some volume placement and volumetric eyebrow lift with fillers in the eyebrows and we simultaneously performed upper lip blepharoplasty. We removed the amount of skin that we need to remove, because most of the time in males we have some sort of hooding because of eyebrow descent. If you replace the eyebrow in the place it should be with volume, then you can get rid of the correct amount of skin and you have more natural result.

Conclusion Male aesthetics although considered a very unusual and taboo subject in the past, is a very hot topic in the present times. The canons of males aesthetic are different from females. Proper knowledge and understanding of these parameters and differences are crucial to perform natural corrections. The physicians should be trained specifically in males techniques before trying to guess what to do. Beauty is universal, but taste is not.

Dr Torres works as external consultant in Plastic Surgery for Humanitas Clinic, Catania, Italy, and in private practice in Rome and Florence. In 2010 he was awarded by EACMFS as one of the most talented young surgeons in Europe and has performed more than 4000 aesthetic procedures in Chile, Brazil, Italy, Spain and Portugal. As an inventor he has patented different devices in the field of Aesthetic Medicine and Surgery in the US and EC. He is an international speaker and company adviser for Intraline, Shippert Medical and Tulip Medical.

Nasolabial and labiomental folds: This treatment to the nasolabial and labiomental folds was done with fat grafting. This was immediately afterwards, and you can see that the wrinkles are much softer after treatment. Photo ageing, will improve with time as well.

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body language I THREADS 53

Bio-resorbable tensor threads DR CATHERINE DE GOURSAC clears up some of the controversy over the use of bioresorbable tensor threads as a medical alternative to a light surgical facelift

I

n the face of growing demand for soft techniques in aesthetic medicine, tensor thread implantation is increasingly being performed to reposition areas sagging in the face, neck and other body areas.

The suspension threads used in these unique biocompatible materials are either resorbable or permanent. Both options aim to correct the moderate ptosis of tissue, under simple local anaesthesia, with very little risk and with no or very little social down time.

For several years, non-resorbable polypropylene threads that remained in the dermal tissue of the patient were used. These implants required small interventional skin procedures. In hindsight, the idea behind this technique was to produce long-term results and offer the possibility of re-tensioning the threads, to obtain a new lifting effect without having to implant new ones (The Easylift concept). However, some medical reports indicated cases of early recurrences and complications after their use, such as protrusions of the threads, numbness and foreign body granulomas.

Post polypropylene we have seen emergence of new tensor threads, made of biomaterials that are fully absorbed once they have played their regenerating and tensioning role. Despite the reversible nature

of their actionâ&#x20AC;&#x201D;which guarantees security for the patientâ&#x20AC;&#x201D;this alternative to a light surgical facelift has stirred controversy within the medical community of aesthetic surgery. The aim of this article is not to detail the resorbable tensor threads in a comprehensive manner but to try to explain the reasons for the current enthusiasm for the new generation of these devices.

Implantable biomaterials The most recent option of threads available to physicians are the CE

marked tensor threads, made entirely of bio-resorbable materials, of which there are two types: threads made of Polydioxanone (PDO) and threads whose main component is a L-polylactique acid (LPA). All these threads share the common characteristic of featuring small notches for the PDO type, or cones for LPA type on their length, all being equally resorbable with a bi-directional orientation to ensure their immediate anchoring to the sub-cutaneous tissue.

Tensor thread implantation can help reposition sagging areas in the face, neck and body

54 THREADS I body language

First a mechanical action is created on the sagging tissue, by moving it upward. The lift effect is immediate and natural, by means of their notching action.

Once attached under the skin, these biomaterials generate the body's natural defence system, or inflammatory action in response to a foreign body. By being gradually and naturally reabsorbed through dissolution in biological fluids, the threads stimulate the production of procollagen molecules and the development of a reactive fibrosis around them, which perpetuates the results beyond their resorption time.

Different threads offer different treatment longevity

PDO PDO is a highly secure material that is used in general surgery for the sutures as well as in cardiovascular procedures. It is naturally biodegraded by the body over a period of six to eight months. The threads made of PDO have increased in popularity in aesthetic clinics and practices in South Korea for the past four years, where the procedure has improved year on year.

LPA Threads made of LPA have a longer effect—being resorbed after approximately 12 months and creating a treatment that’s effective for up to 18 months. Polylactic acid is a polymer derived from lactic acid that is not only highly biocompatible with the human body, but also fully biodegradable—something that has proven its value in a variety of medical applications such as suture threads in aesthetic surgery, cardiac surgery (stents) and ortho-

pedic (screws and pins). Several years of testing has also demonstrated that it’s harmlessness and in aesthetic medicine, this injectable implant has been used for more than two decades to restore lost volume due to ageing. It is the only product to receive a Marketing Authorization (MA = Control level of Drug Product) in France as a treatment to facial wasting, a common side effect of HIV treatment and is covered by French health insurance under such circumstances.

Action mechanisms The new generation of resorbable tensor threads (LPA or PDO) has two main properties:

Evidence Recent studies show that the LPA and the PDO foster the synthesis of collagen in the dermis and increase the proliferation of fibroblasts. Three of these are of particular interest.

The first focused on the implantation of threads made of LPA on two patients. The biopsies were performed at three, six and nine months post-procedure. The observation under an optical microscope and polarised light after a specific colouring of collagens by picrosirius red staining showed the production of endogenous collagen, especially of type I and its persistence in situ, nine months after implantation. These studies presented during the Barcelona Convention in October 2015 demonstrated the inducer effect of tissue that encourages the synthesis of collagen, particularly of Type I. More in-depth studies are currently under review before their publication.

The second was published in 2014 by the Savoia Team. The authors concluded that the tensor effect is potentiated by the fibrosis around the threads, on the basis of histological criteria and ultrasound

66 Threads made of LPA are resorbed after approximately 12 months and create effective treatment for up to 18 months 99

56 THREADS I body language

in mode B. The third study, published by Dr Otto at the end of 2015, focuses on the 100% PDO type of threads.

The histology highlights a large number of fibroblasts around the threads and an increase of new collagen fibres.

These results still need to be validated by more exhaustive studies, but for the first time, they show that the threads made of LPA are collagenous protein inducers.

These wires in PLA have the ability to induce the production of Type I collagen in the dermis during the process of resorption of the threads and cones. This is why the visible benefits of the treatment can be maintained up to 18 months.

Objective and applications This technique is intended to correct the slight to moderate sagging skin of the face and body and to reposition the volume without increasing it. It is mostly intended to be used in very specific cases with both women and men in their forties, but can be used earlier as facial ageing occurs.

This procedure is also designed for patients refusing any type of surgical facelift showing very litREASONS FOR APPLICATION OF TENSOR THREADS  Raise sagging eyebrows on their entire length in order to give them a younger look (different from the botulinum toxin which can only raise the point of the eyebrow)  Lift the cheeks and cheekbones  Mitigate jowls, nasolabial folds or sagging in the neck with platysma bands  Raise the upper lip that starts to sag with the years  Redefine the oval shape of the face.  Restore the curvy line of slightly sagging buttocks  Re-tension the skin of the neckline, the abdomen, the knees and the inside region of the arms and thighs

tle results or having a contraindication preventing this type of surgery. The implant of tensor threads could also be a softer alternative to a surgical facelift for men that are more and more conscious of their looks and the scarring result of the surgery and the risk of hair transfer on the tragus can often be dissuasive.

Contraindications Medical contraindications include pregnancy and breast-feeding, sagging skin from surgical procedure, taking anticoagulants, skin infections on the area that need to be treated, autoimmune diseases and allergy to the biomaterials of the threads, plus areas previously injected by a non-resorbable product to prevent the emergence of granulomas.

There are also contraindications related to the procedure itself. It’s vital to deny non-compatible candidates such as patients who have unrealistic expectations with this technique, in regards to the effectiveness of the surgery. In case of refusal from the patient, they must be informed that the result will be inevitably incomplete.

Pre-intervention consultation The initial consultation is critical to be able to verify the feasibility of the procedure. This first consultation, conducted by a trained practitioner in this technique, allows you to inform the patient on the aesthetic nature of the procedure (not usually covered by health insurance), to make sure that there are no medical contraindications and check that the patient is a valid candidate for the treatment. Once all these conditions are met, the patient should be given a detailed quote, a clear consent form, as well as an information document relating to the procedure. The number of threads and the nature of implantable materials are determined by the practitioner based on the condition of each patient.

Course of Treatment The treatment is performed at an outpatient medical office with the

strictest possible compliance with the rules of hygiene and asepsis.

No preparation is necessary, but it is not recommended to take any aspirin or anti-inflammatory drugs during the days preceding the procedure. For patient comfort, an anaesthetic cream can be applied on the treated area an hour before the session and/or a local anaesthetic can be injected at the entry and exit points of the threads at the beginning of the session. Using a thin needle or a small cannula, the doctor inserts the threads under the skin, one by one, following a specific marking of the area to treat—previously

Threads provide a mechanical action on tissue, pulling it upwards

body language I THREADS 57

strenuous physical activity, to not go inside a sauna or steam room and to avoid any facial massage.

This new therapeutic option offers many advantages: outpatient procedure under simple local anaesthesia without an incision, none or very little social limitation, can be repeated as many times as desired since the materials are fully resorbable and can be supplemented by other rejuvenating procedures such as the injection of fillers or botulinum toxin products.

Reaction Any medical procedure, however small it is, involves a certain number of risks. The usual reactions are generally quite trivial. A few transitional and local reactions are nevertheless possible: bruises, slight edema, erythema (reddening), sensation of skin tightness on the treated areas, small skin folds in front of the ear and a slight asymmetry post-procedure.

marked with a dermographic pencil. The thread is then anchored on the dermis by exerting a slight manual upward pull.

The procedure should take 30 to 60 minutes depending on the type and the number of threads to implant and other indications.

Several areas can be treated at the same time.

After the procedure, the patients are instructed to follow a certain number of recommendations provided by the doctor in order to not compromise the outcome: to rest, to limit any excessive facial expressions and any over-exertion, to avoid any

Results Results occur in two distinct phases. The first is observed during the occurrence of an immediate lifting effect in the tension of the skin, with a gradual loosening the week following the procedure. The second, which leads to the synthesis of collagen around the thread, is more progressive. The threads will be fully resorbed after a few months (usually within six months to one year), but the aesthetic benefits are more durable due to the fibrosis around them (closer to 12 to 18 months). This treatment is therefore temporary and must be renewed to maintain the result, as per patient requests.

The therapeutic success is greatly dependent on the technique and the treatment protocol developed by the doctor and the specificity of each case. Many factors related to the patient can influence the results such as the age, lifestyle and the quality of the skin.

We review the results of the implantation of 100% bio-resorbable tensor threads after two years of observation. Although my personal experience is still fairly new, I often combine the implantation

SURGERY SHOULD BE DENIED ď&#x192;&#x2030; If skin is too thin: threads will be visible or tangible ď&#x192;&#x2030; If the skin is too thick and heavy: the result will be insufficient. ď&#x192;&#x2030; If the skin is too wrinkled: The threads will be ineffective skin and fat is present in excess All of these cases fall into the surgical correction category.

of threads made of LPA (two on each side of the face) with thicker threads made of PDO (at no additional charge), during the same procedure to obtain the best possible results at the lowest price. Our results have been satisfactory in the treatment of moderate sagging of the cheeks, neck, lips and eyebrows but also in drooping buttocks or the inside part of the arm. This is obviously very encouraging and leads us to continue on this path.

The correction of moderate ptosis without excess skin by implementation under the skin of tensor threads made of a fully resorbable material has seen an impressive resurgence in medical aesthetics due to their increased safety. Their recent arrival on the market has generated a growing interest by a good number of fellow colleagues, but also some criticism from some of them. Indeed, today we have two clearly opposing views: on one hand, the followers of the resorbable thread, and on the other, the non-resorbable thread crowd.

With such context, my preference leans toward the resorbable threads because the exclusive use of fully biodegradable materials ensures maximum patient safety The restorability of a biomaterial or the ability to gradually and completely disappear in the tissues is an important quality since no foreign body remains after a certain period of time. This effect limits the risks of the procedure and any eventual local reactions (from the introduction of any foreign body in the skin) are reversible since it

58 THREADS I body language

66 From my point of view as an aesthetic doctor, tensor threads are not meant to replace surgical facelift procedures 99 disappears with the threads. On the other hand, these biomaterials destined to fully degrade cannot provide long-term aesthetic results.

In order to perpetuate the results, the patient will have to repeat the procedure, if they to do so. This relatively short duration of effect is compensated by the advantages in terms of patient safety. The rise of these types of threads is the source of a lot of excitement among many doctors, but created a measure of skepticism from some of them in regard to their biological action.

However, we have already seen that recent studies provide objective evidence in favour of tissue induction, which reactivates the local production of Type I collagen with LPA based threads.

• The suspension threads can be a source of discomfort or dissatisfaction for the patients.

In these cases, the resorbable threads will eventually disappear.

The removal of a permanent thread can only be done by a trained professional.

• We do not perform small surgery procedures at our medical office.

The implantation of permanent threads requires a small operation on the skin such as an incision, a suture or a small detachment of the scalp.

Conclusion The choice between a resorbable thread, or a non-resorbable one will depend on the practitioner’s technique, personal experience, familiarity with the subject and own results. In my clinic we do not implant non-resorbable threads for aesthetic purposes, even if the side effects of permanent products remain very rare considering the number of patients treated. For all the above reasons, it seems reasonable to favour the use of bio-

degradable materials, which, despite their relative short duration, provide satisfaction and safety to the patients. The implantation of resorbable tensor threads is a technique that is still relatively new in the field of aesthetics, and for the most part, still under evaluation and development. Only a limited number of practitioners have recently published their clinical trial results, and have shared their personal experience. Nevertheless, recent studies have demonstrated the local regeneration of collagen after implantation. They are still insufficient and need to be validated by larger studies and sufficient observation.

Generally speaking, implantable medical devices for aesthetic purpose only, whether or not re-

sorbable, still lack sufficiently reliable and objective scientific data.

From my point of view as an aesthetic doctor, tensor threads are not meant to replace the surgical facelift procedures that—even if they are more intensive and more invasive—remain irreplaceable when the damage of time is simply too severe.

Today, the implantation of resorbable tensor threads is the only temporary and reversible soft technique that gives you that natural "lift" effect, provided that the procedure is done by a doctor who has mastered the art and after a strict selection of valid candidates.

Dr Catherine de Goursac is an aesthetic medicine expert. She is a member of the French Association of the Board of Aesthetic Medicine, a member of the board of directors of the FSMEA, general secretary of the French Association Anti-Aging and a member of the SFME. She has authored numerous scientific publications and published numerous works for the general public. W: degoursac. com; esthetiquemedicale.com

References 1. AFME. La Revue du Médecin Esthétique (The Journal of Aesthetic Physician). October 2006.

2. Wu WT. Barbed sutures in facial rejuvenation. Aesthet Surg J 2004;24:582-7.

3. Lee CJ, Park JH, You SH, Hwang JH, Choi SH, Kim CH. Dysesthesia and fasciculation: unusual complications following face-lift with cog threads. Dermatol Surg 2007;33:253-5.

4. Garvey PB, Ricciardelli EJ, Gampper T. Outcomes in thread lift for facial rejuvenation. Ann Plast Surg 2009 May;62(5):482-5.

5. Rachel JD, Lack EB, Larson B. Incidence of complications and early recurrence in 29 patients after facial rejuvenation with barbed suture lifting. Dermatol Surg 2010;36:348-54.

6. Suh DH, Jang HW, Lee SJ, Lee WS, Ryu HJ. Outcomes of polydioxanone knotless thread lifting for facial rejuvenation. Dermatol Surg. 2015;41(6):720-5.

7. Savoia A, Accardo C, Vannini F, Di Pasquale B, Baldi A. Outcomes in thread lift for facial rejuvenation: a study performed with happylift revitalizing. Dermatol Ther (Heidelb) 2014;4 (1):103-14.

8. Otto J. Polydioxanone threads for skin rejuvenation and facial tissue anti-ptosis. Body Language Journal 2015, Issue 76.

9. Sulamanidze M, Sulamanidze G. APTOS suture lifting methods: 10 years of experience. Clin Plast Surg 2009; 36 (2):281-306.

10. Sulamanidze M, Sulamanidze G, Vozdvizhensky I, Sulamanidze C. Avoiding complications with Aptos sutures. Aesthet Surg J 2011;31:863-73.

11. Yoo KH, Kim WS, Hong CK, Kim BJ. Chronic inflammatory reaction after thread lifting: delayed unusual complication of non-resorbable thread. Dermatol Surg.2015;41(4):510-3.

12. Guillo D. Permanent threads vs resorbable threads: the gap between marketing speech and biochemical realities.. J. Méd Esth et Chir Derm. 2014, Vol. XXXXI, 164, 223-232.

13. New medical suspension bidirectional resorbable conical threads. The Journal of Aesthetic Physician 2013, 21-24.

14. De Goursac C. Rejuvenation of the face and the body with resorbable tensor threads. www. afme.org. March 2016.

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