Body Language Issue 64

july/aug

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

STRESS AND AGEING

Lifestyle choices are critical influences on the skin and body

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body language I CONTENTS 3

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contents CONTRIBUTORS Dr Sohaib Rufai Mr Christopher Davis Dr Stefanie Williams Dr Haroun Gajraj Dr Raj Acquilla Dr Zein Obagi Dr Aamer Khan Dr Sandeep Cliff Dr Terry Loong Michael Polakov Jamie O’Sullivan Wendy Lewis

EDITOR Helen Unsworth 020 7514 5981 helen@face-ltd.com COMMISSIONING EDITOR David Hicks 020 7514 5989 david@face-ltd.com EDITORIAL ASSISTANT Arabella Tanyel 020 7514 5989 arabella@face-ltd.com SALES EXECUTIVE Monty Serutla 020 7514 5976 monty@face-ltd.com ASSISTANT SALES EXECUTIVE Simon Haroutunian 020 7514 5982 simon@face-ltd.com PUBLISHER Raffi Eghiayan 020 7514 5101 raffi@face-ltd.com ISSN 1475-665X The Body Language® journal is published six times a year by FACE Ltd. All editorial content, unless otherwise stated or agreed to, is © FACE Ltd 2014 and cannot be used in any form without prior permission. The single issue price of Body Language is £10 in the UK; £15 rest of the world. A six-issue subscription costs £60 in the UK, £85 in the rest of the world. All single issues and subscriptions outside the UK are dispatched by air mail. Discounts are available for multiple copies. 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

13 REPORT COSMETIC COMPLIANCE Industry guidelines have been put in place to ensure patients make informed decisions about cosmetic treatment, but many websites use aggressive marketing. Dr Sohaib Rufai and Mr Christopher Davis investigate whether providers and cosmetic surgeons are complying with the latest regulations

16 ANTI-AGEING LIFESTYLE AND AGEING Lifestyle choices are critical influences on how long we are likely to live and how good our skin will look along the way.

In the second of her two-part series, Dr Stefanie Williams looks at how stress can be a significant ageing factor, not only for our skin, but our entire body.

23 VEINS VEIN TREATMENTS Sufferers concerned about the aesthetic effect of problem veins on their legs are turning to private practice. Over the last 15 years professionals using everything from heat to glue

have risen to the challenge, writes varicose vein specialist Dr Haroun Gajraj

26 INJECTABLES RHINOMODULATION Dr Raj Acquilla describes his eight-point technique for injection rhinoplasty, involving a combination of hyaluronic acid fillers and botulinum toxin

31 SKIN ON THE BRIGHT SIDE Hydroquinone can be effective for certain indications but prolonged use has the potential to cause severe side effects. Dr Zein Obagi discusses skin brightening alternatives and combination treatments

33 LASERS THE FUTURE OF RADIOFREQUENCY The use of radiofrequency is progressing with combined treatments for better, safer results. Shared information between clinicians and manufacturers helps to improve protocols and the technology. Dr Aamer Khan explains what the future holds for radiofrequency

4 CONTENTS I body language

editorial panel

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

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

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

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

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

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

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

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

She is now director of education at LCS Academy Ltd.

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

Dr Cummings works as an expert witness.

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

36 INJECTABLES FACIAL HYPERHIDROSIS There are several treatment options available to patients suffering from facial hyperhidrosis. Dr Sandeep Cliff discusses these options and explains his preferred techniques

40 ANTI-AGEING HORMONE BALANCE Different types of hormones have different effects on our skin. As we age our hormones can become imbalanced and cause skin problems and ageing. Dr Terry Loong shares some common hormonal problems affecting the skin and reveals some simple actions for hormone and skin optimisation

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

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

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

PLANNING A CLINIC The look and atmosphere of your

clinic can make as much difference to your image as the quality of your treatment.

Michael Polakov, who has spent 27 years in medical architecture, explains how to show your practice at its best

47 MARKETING SOCIAL SOS If you are active on social media you should have a crisis management strategy in place.

Jamie O’Sullivan discusses why

53 PRODUCTS ON THE MARKET The latest products and services in aesthetic medicine

58 EXPERIENCE SOCIALISED MEDICINE Wendy Lewis reminisces on how she came to be called the Knife Coach and found her true calling in social media 44

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

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

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

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

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

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

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

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

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

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body language I NEWS 7

observations

GOVERNMENT EYES COSMETIC SURGERY TO HELP NHS DEFICIT Research claims a quarter of cosmetic patients lie to get free treatment As the National Health Service faces a potential funding shortfall, the Secretary of State for Health has declared his opposition to using taxpayers’ money for cosmetic surgery. His comments follow research earlier this year showing that a quarter of patients surveyed by a team of medical negligence solicitors lied about their mental health to secure NHS funding.

Increased demand on health services—partly attributed to population growth, an ageing population and pension costs—could cause the NHS a £2bn funding shortfall in the next financial year.

While £100bn has been allocated to the NHS budget from April 2015, health sector regulator Monitor has warned that even after realistic efficiency savings, there will be a £1.6bn deficit in secondary healthcare.

Secretary of State for Health, Jeremy Hunt, says public money should not be used to pay for vanity-driven cosmetic surgery. “We should not be doing cosmetic work on the NHS. The decisions are taken on the basis of clinical need, but I have made it very clear that I am against purely cosmetic work being done,” Mr Hunt says.

But where do we draw the line between who is eligible for surgery and who isn’t? Criteria for cosmetic treatments on the NHS include: breast implants for severe underdevelopment or lopsidedness; breast reduction to treat back pain or shoulder pain; rhinoplasty for breathing problems; tummy tucks to remove excess fat or skin after essential abdominal surgery; and eyelid reduction to treat affected vision. However, those patients

granted state-funded treatment may face long waiting times due to limited resources.

As NHS-funded cosmetic surgery requires a major physical or psychological need for treatment, many people don’t qualify. The alternative—cosmetic surgery carried out privately—is a comparatively expensive option for those seeking treatment for cosmetic reasons so the system can be open to abuse.

“There will be times when there is a mental health need, which the local doctor has said is very serious.

But I do completely understand people’s reservations about some of the things that happen,” says Mr Hunt.

Research carried out by Medical Accident Group surveyed 1,394 adult patients who had received cosmetic surgery in the past five years. A quarter of those surveyed were ineligible for NHS treatment and had been dishonest to their GP about their mental state; 41% claimed that their appearance made them feel self-conscious and

11% said their looks were causing them to feel depressed.

Around 9% pretended to be in pain to get treatment and 3% claimed their health was being affected. Mr Hunt’s recommendations would not apply to reconstructive surgery, but would ensure only the most severe cases should justify treatment on psychological grounds.

Cosmetic surgery will be one of many areas under public scrutiny over the coming months, as the health service races to avert a funding crisis. But the Department of Health is confident the funding gap will be addressed, assuring: “We’ve taken tough decisions to protect the NHS budget, which is allowing us to strengthen family doctoring, reform out of hospital care, and improve GP access for 7.5 million people across the country.

“The NHS is on track to make £20bn savings this parliament to reinvest into frontline care and we are confident that it will continue to make the savings necessary to meet rising demand,” they say.

8 NEWS I body language

events 31 July-3 August, IMCAS Asia, Hong Kong, China

EARLY-LIFE SKIN CANCER RISKS Excess sun exposure in youth boosts melanoma risk, says study

JULY 6-11 JULY, 12th Quadrennial Congress of the European Society of Plastic, Reconstructive and Aesthetic Surgery (ESPRAS), Edinburgh, UK W: espras2014.org

Medicine, Frei Caneca Conventions Center, São Paulo, Brazil W: euromedicom.com

SEPT

10-11 JULY, Medical Devices Summit West, Newark, USA W: opalevents.org

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

26-31 JULY, Pain Review Course, San Antonio, USA W: painreviewcourse.com

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

29 JULY-3 AUGUST, Australasian Society of Aesthetic Plastic Surgeons 37th Annual Conference, Hobart, Australia W: asapsevents.org

7-10 SEPTEMBER, DASIL 3rd Annual Congress, Sun City, South Africa W: thedasil.org

31 JULY-3 AUGUST, IMCAS Asia, Hong Kong, China W: imcas.com

11 SEPTEMBER, RSM Interventional Cosmetics: New and Controversial Treatments 2014, Edinburgh W: rsm.ac.uk

AUG

6 AUGUST, AAD Summer Meeting, Chicago, USA W: aad.org 22-24 AUGUST, 6th Scandinavian Aesthetic Surgery Meeting 2014, Karlstad, Sweden W: sfep2014.se 28-30 AUGUST, International Congress of Aesthetic Dermatology and Healthy Aging

18-21 SEPTEMBER, 1st Euro-Asian Melanoma Congress 2014, Sarajevo, Bosnia W: melanoma.ba 25-26 SEPTEMBER, British Association of Aesthetic Plastic Surgeons 2014 (BAAPS 2014), QEII Conference Centre, London W: meeting.baaps.org.uk/ 25-27 SEPTEMBER, Aesthetic and antiaging Medicine Asian Congress, Sands Expo & Convention Center, Marina Bay Sands, Singapore W: euromedicom.com Send events to arabella@face-ltd.com

As summer approaches each year, media headlines call out the risks of UV exposure and the sun’s damaging effect on the skin. But skin cancer rates are still rising—improvements in public education is key, particularly among young people.

Recent research has focused on the link between sun exposure during adolescence and skin cancer.

One such study, published in Cancer Epidemiology, Biomarkers & Prevention, suggests that five or more severe sunburn incidents between the ages of 15 and 20 could increase the risk of melanoma by 80% in later years. In the UK alone, over 13,000 cases are diagnosed with malignant melanoma each year.

The US study used 20 years of data from 108,916 female nurses, documenting the number of blistering sunburns experienced as teenagers as well as personal and family history of skin cancers. Every two years, participants completed a follow-up questionnaire, covering skin cancer risk factors such as familial disease updates, tanning bed use, smoking habits, alcohol consumption and body mass index.

Researchers found that those with five or more severe sunburns between 15–20 years old had a 68% increased risk of basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) and an 80% increased risk of melanoma.

Corresponding author, Dr Abrar Qureshi, says: “Our results suggest that sun exposures in both early life and adulthood were predictive of non-melanoma skin cancers, whereas melanoma risk was predominantly associated with sun exposure in early life in a cohort of young women. Parents may need to be advised to pay more attention to protection from early-life sun exposure for their kids in order to reduce the likelihood of developing melanoma as they grow up,”.

While general sun exposure can—

to some extent—be controlled, artificial light emitted from tanning bed lamps presents a different problem.

While an increased risk of skin cancer from indoor tanning has been widely reported, few studies have focused on the effects on younger populations.

Young people exposed to UV radiation from tanning beds may have a greater risk of developing BCCs at a young age, according to research published in Pediatrics journal.

Researchers noted that UV from indoor tanning devices can be up to 10–15 times stronger than radiation from the midday sun. The study involved 657 patients with newly diagnosed BCC and 452 controls, documenting historical use of indoor tanning devices, skin sensitivity to the sun and proportion of time spent outdoors in childhood. More BCC patients than controls reported using tanning beds, and had skin that was more likely to burn than tan.

The researchers echoed the importance of education, noting that their findings “underscore the importance of counselling adolescents and young adults about the risks of indoor tanning and discouraging parents from consenting minors to this practice.”

But what if sun exposure had “addictive” properties, similar to the effects of opiate drugs such as heroin or morphine? Sunbathing increases natural endorphin production which, according to research published in Cell journal, triggers feelings of euphoria or opiate-like highs.

Researchers at Massachusetts General Hospital and Havard Medical School exposed shaven mice to daily UVB exposure for six weeks, equivalent to 30 minutes of midday sun.

Results showed that UV radiation led to the production of the protein proopiomelanocortin—which is then broken down into melanin—but the UV exposure also produced endorphins. Following the six-week study, the mice showed withdrawal symptoms such as tremors, chattering teeth and shaking. A second experiment on mice genetically-engineered to block the production of beta endorphins did not produce the same effects.

Critics of the study comment that social pressures may be behind the “addict-like behaviour” rather than a physical dependency, as well as an aesthetic preference for tanned skin.

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ELEGANT • FULFILLED • MY TIME

Bocouture® 50 Abbreviated Prescribing Information Please refer to the Summary of Product Characteristics (SmPC). Presentation 50 LD50 units of Botulinum toxin type A (150 kD), free from complexing proteins as a powder for solution for injection. Indications Temporary improvement in the appearance of moderate to severe vertical lines between the eyebrows seen at frown (glabellar frown lines) in adults under 65 years of age when the severity of these lines has an important psychological impact for the patient. Dosage and administration Unit doses recommended for Bocouture are not interchangeable with those for other preparations of Botulinum toxin. Reconstitute with 0.9% sodium chloride. Intramuscular injection (50 units/1.25 ml). Standard dosing is 20 units; 0.1 ml (4 units): 2 injections in each corrugator muscle and 1x procerus muscle. May be increased to up to 30 units. Not recommended for use in patients over 65 years or under 18 years. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. Contraindications Hypersensitivity to Botulinum neurotoxin type A or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, Lambert-Eaton syndrome). Presence of infection or inflammation at the proposed injection site.

Special warnings and precautions. Should not be injected into a blood vessel. Not recommended for patients with a history of dysphagia and aspiration. Adrenaline and other medical aids for treating anaphylaxis should be available. Caution in patients receiving anticoagulant therapy or taking other substances in anticoagulant doses. Caution in patients suffering from amyotrophic lateral sclerosis or other diseases which result in peripheral neuromuscular dysfunction. Too frequent or too high dosing of Botulinum toxin type A may increase the risk of antibodies forming.

Should not be used during pregnancy unless clearly necessary. Interactions Concomitant use with aminoglycosides or spectinomycin requires special care. Peripheral muscle relaxants should be used with caution. 4-aminoquinolines may reduce the effect. Undesirable effects Usually observed within the first week after treatment. Localised muscle weakness, blepharoptosis, localised pain, tenderness, itching, swelling and/or haematoma can occur in conjunction with the injection.

Temporary vasovagal reactions associated with pre-injection anxiety, such as syncope, circulatory problems, nausea or tinnitus, may occur. Frequency defined as follows: very common (≥ 1/10); common (≥ 1/100, < 1/10); uncommon (≥ 1/1000, < 1/100); rare (≥ 1/10,000, < 1/1000); very rare (< 1/10,000). Infections and infestations; Uncommon: bronchitis, nasopharyngitis, influenza infection. Psychiatric disorders; Uncommon: depression, insomnia Nervous system disorders; Common: headache. Uncommon: facial paresis (brow ptosis), vasovagal syncope, paraesthesia, dizziness. Eye disorders; Uncommon: eyelid oedema, eyelid ptosis, blurred vision, eye disorder, blepharitis, eye pain. Ear and Labyrinth disorders; Uncommon: tinnitus. Gastrointestinal disorders; Uncommon: nausea, dry mouth. Skin and subcutaneous tissue disorders; Uncommon: pruritus, skin nodule, photosensitivity, dry skin. Musculoskeletal and connective tissue disorders; Common: muscle disorders (elevation of eyebrow), sensation of heaviness; Uncommon: muscle twitching, muscle cramps. General disorders and administration site conditions Uncommon: injection site reactions (bruising, pruritis), tenderness, Influenza like illness, fatigue (tiredness). General; In rare cases, localised allergic reactions; such as swelling, oedema, erythema, pruritus or

rash, have been reported after treating vertical lines between the eyebrows (glabellar frown lines) and other indications. Overdose May result in pronounced neuromuscular paralysis distant from the injection site. Symptoms are not immediately apparent post-injection Bocouture® may only be used by physicians with suitable qualifications and proven experience in the application of Botulinum toxin Legal Category: POM. List Price 50 U/vial £72.00 Product Licence Number: PL 29978/0002 Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer Landstraße 100, 60318 Frankfurt/Main, Germany. Date of revision of text: November 2013.

Full prescribing information and further information is available from Merz Pharma UK Ltd., 260 Centennial Park, Elstree Hill South, Elstree, Hertfordshire WD6 3SR.Tel: +44 (0) 333 200 4143 Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Merz Pharma UK Ltd at the address above or by email to medical.information@merz.com or on +44 (0) 333 200 4143.

1. Bocouture 50U Summary of Product Characteristics. Bocouture SPC 2012 September Available from: URL: http://www.medicines.org.uk/emc/medicine/23251. 2. Prager, W et al. Onset, longevity, and patient satisfaction with incobotulinumtoxinA for the treatment of glabellar frown lines: a single-arm prospective clinical study. Clin. Interventions in Aging 2013; 8: 449-456. 3. Sattler, G et al. Noninferiority of IncobotulinumtoxinA, free from complexing proteins, compared with another botulinum toxin type A in the treatment of glabelllar frown lines. Dermatol Surg 2010; 36: 2146-2154.

4. Prager W, et al. Botulinum toxin type A treatment to the upper face: retrospective analysis of daily practice. Clin. Cosmetic Invest Dermatol 2012; 4: 53-58. 5. Data on File: BOC-DOF-11-001_01 Bocouture® is a registered trademark of Merz Pharma GmbH & Co, KGaA. 1139/BOC/NOV/2013/LD Date of preparation: March 2014

body language I NEWS 11

60 CONSULTING ROOM CHARITY CYCLE RIDE On 13th – 14th September, The Consulting Room Team will be embarking on another Coast 2 Coast Charity Cycling Challenge as they have done for the last two years. Having conquered 140 miles across England and 200 miles across Ireland, they’re now taking on Wales!

Ron Myers, Martyn Roe, Dan Huxley, Danielle Lowe and Joe Kerrigan from The Consulting Room will be joined by Paul Simmonds from Syneron Candela and the team will be assisted by Paul Stapleton and Jo Martin from Mapperley Park Clinic in the support van.

This year’s charity is Parkinson’s UK, chosen by Paul Simmonds. His father was diagnosed with Parkinson’s disease in 2006 and has found the support from the charity to be invaluable.

To donate please visit justgiving. com/The-Consulting-Room.

Focus on accredited hands-on training and research resources Founded in France, mesotherapy is now a popular aesthetic treatment across much of Europe and South America but is relatively new to the UK. The technique was first devised over 50 years ago to improve blood circulation and treat conditions such as fibromyalgia, osteoarthritis and chronic pain.

The procedure can now be used successfully for a number of aesthetic indications, including skin rejuvenation, localised fat reduction and cellulite.

COSMETIC TOURISM Medical tourism has more than doubled over the past two years, according to new research, and Eastern Europe has proven to have the largest number of hubs for cosmetic procedures due to cheap flights and treatment. The Czech Republic has seen a 304% increase in rhinoplasty enquiries in the past year while Turkey and Belgium are hot spots for buttock lifts and abdominoplasty.

Enquiries for breast augmentation in Poland have risen by 57% since early 2013, and Hungary is popular for cosmetic dentistry—procedures can be around a quarter of the cost of private treatment in the UK. Top 10 treatments and most popular locations  Dentures Thailand  Rhinoplasty Czech Republic  IVF Czech Republic  Veneers Thailand  Dental implants Hungary  Buttock lift Turkey  Tummy tuck Belgium  Hair transplant Turkey  Breast implants Poland  Egg donor Greece Source: WhatClinic.com

The Society of Mesotherapy of the United Kingdom (SOMUK) has now been formed to promote and support development of the treatment in the UK. SOMUK provides educational resources and hands-on training to all licensed practitioners through CPD-accredited and boardcertified courses, regardless of their speciality, as well as providing access to the latest mesotherapy tools and research.

Practitioners can also learn protocols for all treatment techniques, including facial rejuvenation, lipolysis-lipodissolve, fat reduction, mesosculpting and mesolift, and alopecia and pain management.

The society aims to educate practitioners and “equip them with the skills to develop this relatively new field of aesthetic medicine within the UK market.”

SOMUK is a member of the International Society of Mesotherapy and works closely with the French Society of Mesotherapy. For more information, visit somuk.co.uk.

Ann Hand has been appointed as sales manager for Ireland and the UK at Adare Aesthetics.

Ann will manage the sales of Adare’s product portfolio, and is well known in the beauty and aesthetics industry, having worked for Salongenius.

Liz Robinson has joined Healthxchange Pharmacy as a product specialist looking after clients in the East of the UK. She is a qualified trainer specialising in aesthetic dermatology with strong commercial insight and expertise in developing clinic sales.

Toni Warran-Smith has also joined Healthxchange Pharmacy as a product specialist looking after clients in the South East of the UK. She has a passion for skincare having qualified as a beauty therapist in 2003, and is committed to educating clients and getting results.

NEW APPOINTMENTS

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12 DERMATOLOGY I body language

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References 1. Rzany B et al, Dermatol Surg 2012;38: 1153â&#x20AC;&#x201C;1161 2. Cartier et al, J Drugs Dermatol. 2012; 11 (1)(Supp): s17-s26 (*Results taken from a mean value across all treatments performed in study) 3. Farhi D et al, J Drugs Dermatol 2013; 12: E88-E93

body language I REPORT 13

Cosmetic compliance Industry guidelines have been put in place to ensure patients make informed decisions about cosmetic treatment, but many websites use aggressive marketing to entice new customers. DR SOHAIB RUFAI and MR CHRISTOPHER DAVIS investigate whether providers and cosmetic surgeons are complying with the latest regulations

T

he cosmetic surgery industry is booming, with a reported 15 million people worldwide undergoing surgery in 2011. However, Hippocrates’ words, “first do no harm”, are especially relevant in cosmetic surgery, where harm can include risks and complications for the patient as well as legal repercussions and a negative reputation for the surgeon.

High-profile examples of these risks include: the death of footballer Colin Hendry’s wife after liposuction inadvertently resulted in bowel perforation and fatal infection; a Surrey businesswoman receiving a £6million legal pay-out after complications from a facelift; and the death of rapper Kanye West’s mother following breast reduction and abdominoplasty.

“Book now and save up to 15%.” “You too can be happy! Limited offer on breast

impla nt surgery for the first 50 customers.” “We even provide a complimentary chauffeur service!”

Aggressive marketing techniques and enticing cosmetic surgery offers like these have unfortunately become widespread on the internet, luring patients towards potentially impromptu decisions.

Regulations In a bid to safeguard patients and regulate the UK’s cosmetic surgery industry, the Department of Health (DH) and Cosmetic Surgical Practice Working Party (CSPWP), based at the Royal College of Surgeons of England, set out the following guidelines for cosmetic surgical practice: • Consultations with a medical professional rather than a sales “consultant” • Banning free consultations

• Restricting time-limited promotional deals • Two-stage written pre-operative consent • A two week cool-off period We performed a study, essentially putting ourselves in a potential patient’s shoes—browsing the internet in search of a cosmetic surgeon to consult. We looked at the top fifty Google-ranked companies and quantified their compliance with the national safety guidelines above.

We studied their websites and called the clinics to assess individual compliance against each guideline. Unfortunately, the overall compliance with all the above guidelines was only 41%.

Sales consultants Five of the providers in the study (10%) offered consultations with an individual other than a plastic surgeon. Of these

14 REPORT I body language

66 The question of whether these guidelines are realistic and appropriate for safeguarding patients remains, especially when many providers continue to use aggressive marketing techniques and enticing offers, regardless of the recommendations 99 providers, three were offered with patient care coordinators—or sales consultants—while two consultations were offered with specialist nurses.

An ethical issue exists if patients are coaxed into the first stage of the decisionmaking process before meeting the operating surgeon to discuss their risks on a case-by-case basis. Specific examples included companies taking a deposit for a procedure during the initial consult as part of a “special discount” for the patient.

Free consultations The majority (54%) of providers in this study offered free consultations. It is unclear how much of a factor this plays in putting patients under pressure to proceed with cosmetic surgery. According to the DH review, free consultations may make a patient feel obliged to proceed with the operation, while a nominal consultation fee encourages impartial advice about the risks and benefits of surgery.

One provider charged a small consultation fee and donated this to charity, in order to meet this guideline. On further questioning during our telephone followup with providers, a proportion justified their complimentary consultations on the basis that it felt unreasonable and too “business-like” to charge for the service.

Promotions Promotional deals were offered by 52% of the providers. Of these, 27% were time-restricted deals. The DH Review encourages banning time-limited deals due to the risk of enticing and pressurising patients into undergoing a cosmetic procedure.

Another pattern of promotions identified were “multibuy” packages, including mother and daughter discounts and bridal packages. Again, these offers could potentially entice patients into undergoing

more surgery than first intended. Finally, certain providers offered free chauffeurs and photoshoots in an attempt to glamorise cosmetic surgery.

Two week cool-off period Only 62% of providers stipulated a compulsory two week cool-off period to give the patient time to think about their decision, discuss their options informally and weigh up the risk-benefit ratio of surgery.

Some providers explained by telephone that this two week cool-off is simply a suggestion and can be waived if the patient signs a disclaimer in the first visit.

Two-staged consent We were surprised to find that none of the top fifty Google-ranked cosmetic surgery providers at the time of this study stipulated a two-staged consent process. The DH and CSPWP recommend two-staged signed consent to ensure the patient is

absolutely sure of their decision before proceeding.

Recommendations This study elucidated the poor compliance of a sample of cosmetic surgery providers with national safety guidelines.

Aesthetic surgery offered by fully trained plastic surgeons—who were often affiliated with the British Association of Aesthetic Plastic Surgeons—was generally more compliant than that of the major cosmetic surgery companies.

The question of whether these guidelines are realistic and appropriate for safeguarding patients remains, especially when many providers continue to use aggressive marketing techniques and enticing offers, regardless of the recommendations.

We recommend a dialogue between cosmetic surgery providers and government regulators to agree on tighter controls and mandatory regulations to limit unprofessional practice and maximise patient safety.

The full research paper was published in the Journal of Plastic, Reconstructive and Aesthetic Surgery in May 2014. Sohaib R. Rufai is a final year medical student at the University of Southampton. His supervisor, Dr Christopher R. Davis, works in the Division of Plastic & Reconstructive Surgery at Stanford University, CA. E: sohaibrufai@ gmail.com; chrisdavis959@hotmail.com

References 1. Bates C. “15million people worldwide had plastic surgery in 2011... but why ARE South Koreans so much more likely to go under the knife?” The Daily Mail. 31st January 2013. http://www.dailymail.co.uk/health/article-2271134/15million-people-plastic-surgery-worldjust-year--SOUTH-KOREA-leading-way.html 2. Taylor J. “Ex-football star’s wife dies after botched plastic surgery.” The Independent.

10th July 2009. http://www.independent.co.uk/life-style/health-and-families/health-news/ exfootball-stars-wife-dies-after-botched-plastic-surgery-1741493.html 3. Quinn B. “Surrey businesswoman wins £6m payout over botched facelift.” The Guardian. 23rd May 2011. http://www.guardian.co.uk/uk/2011/may/23/surrey-businesswomanpayout-botched-facelift 4. Hernandez A. “Donda West Died of Heart Disease after Surgery.” People Magazine. 1st October 2008. http://www.people.com/people/article/0,,20170370,00.html 5. Department of Health. “Review of the Regulation of Cosmetic Interventions.” 2013. https://www.gov.uk/government/publications/review-of-the-regulation-of-cosmetic-interventions 6. Cosmetic Surgical Practice Working Party. “Professional Standards for Cosmetic Practice.” 2013. http://www.rcseng.ac.uk/publications/docs/professional-standards-forcosmetic-practice/ 7. Rufai SR, Davis CR. “Aesthetic surgery and Google - ubiquitous, unregulated and enticing websites for patients considering cosmetic surgery.” Journal of Plastic, Reconstructive and Aesthetic Surgery. 2014 May;67(5):640-643.

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16 ANTI-AGEING I body language

Lifestyle and ageing Lifestyle choices are critical influences on how long we are likely to live and how good our skin will look along the way. In the second of her two-part series, DR STEFANIE WILLIAMS looks at how stress can be a significant ageing factor, not only for our skin, but our entire body.

S

tress is a combination of entirely physiological reactions we have in response to certain stimuli, be they external or internal. For our primal ancestors, a short, sharp burst of stress hormone release was advantageous when faced with danger, as the stress-induced fight or flight reaction enabled an optimal response.

The release of stress hormones causes the body to become more alert—blood sugar levels increase to fuel instant energy, heart and breathing rates accelerate, blood pressure rises and blood clotting increases (beneficial, should you be wounded in fight…).

Under circumstances ‘as intended’ by nature, an intense physical activity (i.e. fighting or fleeing) burned off the sugar energy provided and our metabolism would return back to normal very quickly.

However, in our modern society we are exposed to a fairly constant, albeit mostly low-level of stress, for which there usually is no physical release. This type of chronic lowlevel stress has worse long-term consequences than the occasional strong, but acute burst. It can age our skin and shorten our life.

Types of stress Two different types of stress have been described: ‘eustress’ (good) and ‘distress’ (bad). Eustress is an enjoyable, elating type of (temporary) stress, which keeps us motivated, challenged and happy. It’s

often when we feel out of control however or when stress becomes chronic, that we become disstressed. Distress can have profound negative influences on our skin and longevity.

A very interesting study confirmed the highly subjective experience of stress. The study examined the stress levels of ‘leaders’. Leaders who take up more powerful positions in their professional life invariably take on more responsibility and are exposed to increasing demands. As a result, there is a perception that leaders must have higher stress levels.

The study by Sherman confirmed that leadership level correlates to stress. However, surprisingly, this is an inverse relationship, with leaders having lower levels of the stress hormone cortisol and feeling less anxious. The explanation for this seeming paradox might be the leaders’ greater sense of control.

Stress hormones Cortisol is an extremely important stress hormone in the human body.

Under normal circumstances, cortisol levels are high when we get up in the morning, then go down gradually until the next morning.

Chronic stress, however, may lead to persistently raised levels of cortisol and other stress hormones.

Cortisol is one of our more catabolic hormones. It suppresses our immune response and leads to in-

creased degradation of collagen in our skin. Not without reason, dermatologists use intralesional cortisol injections to break down excess collagen in keloid scaring.

Raised cortisol levels are also known to increase our blood sugar which leads to increased cross-linking of collagen in our skin, known as advanced glycation end products (AGEs) production.

A recent study confirmed that people with higher blood sugar lev-

Distress can have profound negative influences on our skin and longevity

body language I ANTI-AGEING 17

‘youth hormones’ including dehydroepiandrosterone (DHEA) and Human Growth Hormone (GH).

DHEA is considered one of our ‘youth hormones’ as its level declines dramatically as we age.

DHEA is a precursor to other sex hormones including testosterone and has an anti-inflammatory effect. It lowers the level of proinflammatory cytokines, while enhancing certain immune functions.

When applied topically, DHEA has been shown to increase collagen production and improve the structural organization of the dermis.

Levels of the ‘youth hormone’ GH also decline as we age. GH is another anabolic hormone that plays an important role in tissue formation. Decreasing levels of GH are known to lead to an age-related reduction in lean muscle mass as well as a corresponding accumulation of fat. GH decline has also been described as partially responsible for thinner skin in old age.

els are perceived as older.

Whether triggered by diet or stress, high blood sugar levels inevitably lead to increased insulin production. Insulin promotes lowlevel inflammation, hypes cortisol production even more and hinders the positive work of some of our ‘youth hormones’. Good insulin sensitivity on the other hand benefits many aspects of health and has also been linked to longevity that runs in families.

But it’s not only glucose and insulin levels that are the problem.

Cortisol itself has long been known to affect health and even longevity. However, it has now been confirmed scientifically that stress also takes a toll on our skin. A study found that higher levels of cortisol are associated with our face looking older.

Chronic stress can also induce other hormonal imbalances such as reduced levels of certain anabolic

Oxidative stress and telomere length Oxidative stress and poor repair or disposal of the damaged material is acknowledged as a key aspect of ageing, not only in skin, but all major organ systems. Every cell in our body generates free radicals.

Products of routine metabolism that takes place every second of every day, free radicals are usually neutralised by antioxidants.

However, today’s lifestyle with chronic stress significantly increases free radical generation. Our natural antioxidant pool can’t cope with the increased demand - oxidative stress and cell damage are the inevitable consequences.

It’s also been demonstrated that chronic stress depletes glutathione, our ‘master antioxidant’, and disturbs mitochondrial (energy) function, causing further increased oxidative stress.

Chronic stress also accelerates the shortening of our cells’ telomeres. Telomeres are the protective end parts of our chromosomes, there to maintain the integrity and stability of our genetic data. Every time a cell divides, our chromosomes naturally erode and shorten a little.

To keep our vital genetic data safe, telomeres bear the brunt of

18 ANTI-AGEING I body language

66 Having a mostly positive mindset not only makes life more enjoyable, but may also have antiageing benefits 99 each cell division so that the functional part of the chromosomes is replicated without damage. Telomere length is therefore seen as a good marker for biological age as opposed to chronological age.

Shorter telomeres have been linked to a shortened life span.

Skin cells have been described as particularly susceptible to accelerated telomere shortening because of their high proliferation rate and exposure to DNA-damage from influences such as oxidative stress.

We know today that telomere shortening happens at different rates and our lifestyle plays a role too. Chronic stress and raised stress hormone levels have been linked to telomere shortening.

Anti-ageing weapons We need to raise awareness about the influence of stress on skin health and ageing. Naturally we can’t offer an easy solution to combat stress to our patients. However, I would like to share some selected, interesting ‘tricks’ to lower stress hormone release, with scientifically proven benefits.

Stress and the subsequent hormonal and metabolic changes are designed to put us in an ideal situation for a physical response (i.e. fight or flight). However, as in our modern world, there’s hardly ever a physical response needed to stress, we suffer with the long-term health consequences of chronic stress.

So when feeling stressed, do the one thing your body wants—move!

This will greatly help to ‘neutralise’ the high-alert stress state and return our hormones and metabolic changes back to balance. How about doing some jumping jacks

in the clinic room after the next demanding patient or running up and down the stairs after receiving a stressful email? Every little helps…

The other important thing is not to eat sugary snacks or quick release starchy foods, when you are feeling stressed, as this will further elevate glucose and insulin levels, which are already out of sync when we are stressed. Drinking stimulants such as coffee or energy drinks will also contribute to cortisol release and should be avoided, especially when feeling stressed.

Another influencing factor is our general outlook on life. Having a mostly positive mindset not only makes life more enjoyable, but may also have anti-ageing benefits. A recent study involving nearly 1000 participants revealed that optimistic people have higher levels of antioxidants in their blood.

Fascinatingly, it’s been shown that ‘power postures’ (think leaning back in your chair with your elbows behind your head or standing upright with your hands on your hips) can actively help to release stress, pretty much instantaneously. A study conducted by a team of psychologists found that sitting or standing in a power posture for two minutes significantly lowers the level of cortisol, while raising testosterone.

Interestingly, smiling or laughing can also partly override the stress response in our body. Via biofeedback, you are essentially ‘tricking’ your body into thinking you must be happy if you engage those smile muscles.

Don’t forget to breathe slowly and deeply as you ‘power posture’, since this is another technique that instantly helps to lower stress levels.

Again, you are ‘tricking’ your body into thinking you are relaxed, as opposed to registering the signals of fear and anxiety that rapid, shallow breathing triggers.

The biofeedback theory ties in with recent studies, which confirm that treatments with botulinum toxin can significantly improve clinical depression.

Increasing mindfulness is another useful method to reduce stress levels and stress hormone re-

lease. Studies have shown that trying to focus calmly on the moment instead of mindlessly multi-tasking can reduce the inflammation marker C-reactive protein (CRP) in our body.

One method of stress reduction that has been successfully applied by many different cultures throughout the ages is meditation.

Studies have confirmed that regular meditation can lower cortisol levels and even improve telomere length. In an interesting study, it was shown that practicing meditation for only three months was able to induce telomerase, the enzyme that lengthens our telomeres.

People who meditate regularly have also been shown to sleep longer and more deeply. One of the reasons for improved sleep might be that meditation increases the levels of serotonin and melatonin.

Melatonin, a hormone derived from serotonin, is a neurotransmitter produced in the brain’s pineal gland. Melatonin is a powerful antioxidant with receptors expressed in many different types of skin cells.

As patients found the stress aspect of lifestyle anti-ageing particularly difficult to tackle, I now give all my new cosmetic patients a specially produced, guided meditation CD. In collaboration with external experts we have combined the neuro-linguistic programming (NLP) of a skin and longevity oriented voiceover with a high-tech, EEGtested ‘brainwave entrainment’ background audio, which guides the listener into regenerative alpha, theta and delta brainwaves. Our meditation audio has been shown to be able to successfully lower cortisol levels after only 20 minutes (unpublished data).

Sleep and Skin Average stress hormone levels such as cortisol are not only elevated in chronic stress, but also rise when we are not sleeping enough. Incremental sleep debt has become a hallmark of our Western society.

Over the past five decades, our average sleep duration seems to have decreased by about two hours, due to ‘voluntary bedtime curtailment’.

body language I ANTI-AGEING 19

When feeling stressed, it is important not to eat sugary snacks or drink stimulants such as coffee

Good quality, restorative sleep is crucial for cellular repair, regeneration and immune function. Every night, we go through repeated cycles of two distinctly different sleep phases: Rapid Eye Movement (REM, when the most active dreaming happens) and non-REM sleep (NREM, the deeper sleep).

During NREM, blood flow is directed from our brain and body core, more towards the body’s pe-

riphery including the skin. Thus, a restorative hormone flow is established and cellular repair is enhanced.

Sleep deprivation is known to contribute to systemic inflammation, even after a short period of only a couple of weeks. In fact, sleep deprivation is thought to increase age-related processes as well as chronic health problems.

Sufficient sleep is also important for the nightly peak of our anti-ageing hormone GH. If we don’t get enough sleep, our natural GH level is sub-optimal and this gets worse as we get older.

At night we naturally release the ‘sleep hormone’ melatonin.

Melatonin levels start to rise in the evening and peak around midnight before slowly subsiding again. This diurnal sleep-wake cycle is governed by the changes of light and darkness. If we don’t get enough sleep however, our melatonin levels are impaired.

Interestingly, melatonin can even protect our skin from the sun’s damaging effects and counteracts mitochondrial and DNA damage.

Unfortunately, like so many other skin-friendly hormones, our melatonin level declines with age. Sleep debt will only hasten this decline.

Sleep deprivation is also known to impair insulin sensitivity and glucose tolerance and is connected to the development of diabetes.

With regards to the skin, higher blood sugar levels mean higher generation of AGEs, which accelerate the skin’s ageing process.

Sleep is even connected to telomere length. Shorter telomeres have been associated with poorer sleep quality in women and shorter sleep in men. And in a fascinating genomic study, it was shown that sleep debt of only two nights led to a change in the expression of 500 genes. These changes were notably related to DNA damage and repair as well as stress and diverse immune system responses.

Several studies now also confirm that lack of sleep as well as other types of stress can impair skin integrity. An animal study in wound healing (which is a good model for skin rejuvenation) furthermore showed that sleep depri-

vation leads to a reduced number of skin fibroblasts.

Lastly, a paper published in 2013, clearly linked good quality sleep to better skin and the ability to recover from stress. Scientists from the University Hospitals of Cleveland assessed sleep quality in women aged 30 to 50 using a special sleep questionnaire.

They then compared this data to signs of the women’s internal (biological clock) and external (environmental) skin ageing and tested their skin barrier function.

What they found was that poor sleepers had significantly higher scores for internal ageing than good sleepers, who slept 7–9 hours per night. Poor sleepers also displayed an impaired skin barrier function.

Apart from actual sleep deprivation, there is another important factor to consider. This is the circadian rhythm. The circadian rhythm is an endogenous timekeeping system that monitors a daily cycle of roughly 24 hours. A disruption of this internal clock is associated with ageing and disease, while trying to keep to our natural rhythm improves wellbeing and increases lifespan.

So it’s not only about how many net hours we sleep, but also when and how we sleep. Respecting our circadian rhythm means that we should try to adhere to a regular bedtime when possible.

Try to darken the room completely during sleep time, since exposure to light at night can disturb the circadian clock. Good sleep hygiene also includes avoiding artificial light and digital stimulation just before bedtime—so say goodbye to the TV and laptop in bed...

I hope that I have given you some food for thought on the connection between stress, sleep, diet and skin ageing. It’s a difficult topic to address, but I advocate integrating this subject routinely in our consultations with aesthetic patients.

Dr Stefanie Williams is a Dermatologist and Medical Director at European Dermatology London W: futurapproved.com, eudelo.com References on p20

20 ANTI-AGEING I body language

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body language I VEINS 23

Vein treatments The NHS is largely withdrawing from the treatment of problem veins until serious complications arise. Sufferers concerned about the aesthetic effect of symptoms on their legs are therefore turning to private practice. Over the last 15 years professionals using everything from heat to glue have risen to the challenge, writes varicose vein specialist DR HAROUN GAJRAJ

A

bout half the adult population suffers with telangiectasia—unsightly thread veins on the legs—and approximately a third of all adults have visible varicose veins. The first description of surgery for the problem was over 2,000 years ago: a hook extraction by a Roman called Aulus Cornelius Celsus. Doctors in the 1800s identified saphenous veins, which let blood flow in the wrong direction, as the major cause vein disease and surgeons went on to ligate and strip out such veins with varying degrees of effectiveness.

Treatment didn’t change significantly for 100 years.

Innovation In 1995 the phlebologist Juan Cabrera invented ultrasound-guided foam sclerotherapy. His first demonstration wowed the surgical audience—injecting an ultrasoundguided foam solution into veins, causing them to close and disappear.

Soon after, Lorenzo Tessari invented his own method. He produced foam using a three-way tap, two syringes, some sclerosant and air. Both methods hit the scene in the mid-90s and revolutionised what we did for veins.

A series of innovations followed.

In 1999 endothermal ablation arrived: under local anaesthetic inserting fine needles and catheters into refluxing veins to ablate them using heat energy—in this instance from radio frequency.

Then endovenous laser treatment appeared, another way of heating the vein from inside and ablating it. In 2010 we had mechanicochemical ablation (MOCA) a combination of sclerotherapy and mechanical methods;

and in 2011 cyanoacrylate arrived, using one tiny local anaesthetic injection to insert a catheter and superglue a vein shut. Both endothermal ablation using radio frequency and endovenous laser treatments have now have US Food and Drug Administration (FDA) approval, as has MOCA. Cyanoacrylate is awaiting FDA approval but is available in Europe. The National Institute for Health and Care Excellence (NICE), just a few months ago described surgery as the last resort. Endothermal first, foam sclerotherapy second, surgery last.

Ultrasound-guided sclerotherapy The treatment that Juan Cabrera

invented is the only approach that can treat nearly any sized vein in the leg—from thread to articular, varicose and sephenous.

The results of this treatment are comparable to surgical stripping, it’s very safe, avoids general anaesthesia and it’s a walk in/walk out procedure.

When it was introduced there was concern about the possibility of stroke, but we now know that this is rare and most neurological symptoms are a form of migraine with aura.

Anaphylaxis is unlikely but a possibility and a practitioner should be prepared to resuscitate a patient, with adrenalin available as a minimum.

Around half the population suffers with telangiectasia, and a third of all adults have visible varicose veins

24 VEINS I body language

Endovenous thermal ablation This works by heating the vein in a variety of ways—the French are particularly keen on steam— but laser and radio frequency are my methods of choice. Tumescent local anaesthetic has helped transform veins treatment from a surgical procedure to an office procedure. Not only can patients walk in and out, with rapid recovery, they’re better in terms of cosmesis and recurrence.

There is a list of minor complications for thermal ablation, but compared with surgical procedures, it’s extremely safe. The only important one is endothermal heatinduced thrombosis, but in general people walk out very quickly and DVT is not very common.

Telangiectasias lateral left thigh: before and after two microsclerotherapy treatments

DR HAROUN GAJRAJ

Bilateral saphenous vein reflux: before and after endovenous laser (EVL) treatment

Non-thermal treatments We’ve got so good at treating veins that the discomfort of the administration of tumescent local anaesthetic seems to be the main issue – people don’t like being jabbed with needles.

In treatments to glue the vein from the inside we introduce a catheter with a single local anaesthetic jab. Because we’re not using heat energy we can’t burn the skin or cause nerve injuries.

Published studies only involve a few hundred patients, but so far no significant or severe adverse effects have been reported. Perioperative pain is minimal, I get people who walk in and walk out.

In summary, leg vein treatments have gone from invasive treatments performed by the Romans, to treatments under general anaesthesia by surgeons, to the very latest treatments that don’t involve very much local anaesthetic or invasion at all.

Not only are they associated with better recovery, they allow clients to walk in and walk out, they’re better in terms of recurrence. The chance of the veins coming back is lower and the complication rate is significantly reduced.

Dr Haroun Gajraj is a vein specialist and former vascular surgeon, and is director and founder of The VeinCare Centre, W: theveincarecentre.co.uk

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26 INJECTABLES I body language

Rhinomodulation DR RAJ ACQUILLA describes his eight-point technique for injection rhinoplasty, involving a combination of hyaluronic acid fillers and botulinum toxin

N

oses come in all shapes and sizes, so how do we determine which are attractive and which aren’t? Some say beauty is subjective; in the eye of the beholder.

But perhaps there is a structure and strategy behind beauty that we can follow to achieve optimum aesthetic outcomes.

There are snub noses; elegant, narrow noses; fleshy noses; hawk noses; Grecian noses and Roman noses to name a few.

Despite their countless forms, we typically recognise what is pleasant and what’s not within 0.3 seconds.

Symmetry The structure behind a beautiful nose has been studied, recorded and published. In terms of facial symmetry, beauty doesn’t just concern the midline symmetry; it’s

also about the rule of vertical fifths in the face. With specific reference to the nose, the nasal width should equal the intercanthal distance and mirror the same width as each eye. Symmetry is not just about two halves.

When we look at people who are generically or exceptionally beautiful, we see that they display very high degrees of symmetry. Denzel Washington was voted one of the sexiest men in Hollywood and he also has one of the most symmetrical faces in Hollywood.

We all know about the golden ratio— the rule of five, the rule of thirds and the rule of one to 1.618. We can apply this to the face; for example, while the nasal width is one, the width from the alar to the tragus should be one to 1.618. Optimising the aesthetic appearance of our

patients towards this ratio will give a better cosmetic outcome.

We can also study facial geometry.

The naso-philtral angle should be between 90–105 degrees, the naso-facial angle should be 120 degrees, the nasomental at 130 degrees and the naso-facial angle at 36 degrees. This doesn’t mean we should get a protractor out and measure the angles but if we did, we would arguably get a very good aesthetic outcome.

History In ancient India, an Ayurvedic physician called Sushruta wrote the first compendium of medical and surgical procedures, specifically in plastic and cosmetic surgery—one of the first documented chronicles from 800BC. With rhinoplasty, he was using a

body language I INJECTABLES 27

cheek flap transposing to the nose and securing with liquorice, sesame oil or castor oil. This was a very primitive use of nasal augmentation, but documented working towards an aesthetic ideal.

In later years, this compendium moved towards the Roman Empire, then Italy, followed by Greece—where they used different strategies and techniques.

There is documentation on the primitive use of sutures, the use of the bicep muscle as a pedicel, using flaps from not just the cheek, but also the forehead, and securing with wax.

Eventually they were performing closed rhinoplasty using an intra-nasal technique resulting in no visible scarring, submucosal septal resection for septal deformities and deviations. Now, a popular form of surgery is open columella rhinoplasty—an incision is made in the columella itself to give direct visualisation of the cartilage and bone.

Injectables The evolution of injection rhinoplasty made perfect sense, as surgery in this area can be quite complex. It takes a high degree of precision and skill, and the aesthetic outcome is not always guaranteed.

Going back into the 1900s, liquid paraffin wax was used, which was very unstable and biologically harmful. Between the 1960s and 70s, silicone gel was used.

66 Noses come in all shapes and sizes, so how do we determine which are attractive and which aren’t?

Some say beauty is subjective; in the eye of the beholder. But perhaps there is a structure and strategy behind beauty that we can follow to achieve optimum aesthetic outcomes.

99 Forms included small droplets but nevertheless, silicone proved to be a problem.

It was hazardous with granuloma and ulceration, particularly in this vascularly friable part of the anatomy.

In 2002, the FDA approved Restylane for nasal contouring and the hyaluronic acid solution proved to be a safe, reversible option that could be moulded without producing the same kind of risk to the tissue.

Later on, injectables like Aquamid and Radiesse were recognised and the biggest study of its kind for injectable rhinoplasty, conducted by Alexander Rifkin from California on 385 cases, showed efficacy and safety.

Aesthetic changes Specific indications from superior to in-

ferior, such as nasion depression, dorsal hump and tip depression, can be injected strategically to influence individual parts of tissue and give one overall, uniform aesthetic outcome.

All indications can be broken down into congenital versus acquired, but it is important to remember that some may be caused by trauma to the nose. Traumatic injury may produce asymmetry, which we can correct using injectables.

Typically the areas that we’ll treat are the nasium, the dorsal hump, the tip and the septal projection. Different injection sites will give different outcomes. When pinched at the glabella, the skin is quite loose with low pressure but very thick.

You can expand the subcutaneous space and the skin will hold it in position, so it’s an ideal area for injection augmentation.

28 INJECTABLES I body language

Moving to the dorsum, the skin gets thinner. It’s the thinnest skin on the whole of the nose, but there is more pressure in this area. On the tip, we can hardly lift the skin at all, but it is thick and sebaceous.

So there are different qualities of skin and different pressures throughout the nose. The safest area to treat would be in the nasium; the least safe would be the tip. We use very small quantities in the tip to avoid any vascular complications.

Anatomy The area below the skin on the nose and perinasal area is pretty much devoid of fat so there isn’t much room to bury material and safety margins are quite narrow.

The muscles in the nose are all fairly separate, but they sometimes act in cohesion with one another and produce complex movements. During an oral smile with nasal activation, we will see activation of the nasalis, the levator labii superioris, alaeque nasi, dilator naris and the depressor septi nasi muscles. We get “bunny” scrunch lines, alar widening, upper lip elevation and tip depression.

The snarl complex doesn’t involve the upper lip, so we just see “bunny” scrunch, alar elevation and tip depression. When we’re looking to treat certain indications, we can also use botulinum toxin to weaken specific muscles.

Nasal vasculature is derived from the facial artery, which tracks superiormedially from the anterior border of the masseter oral commissure. There is also a superior labial branch which gives a columella artery to the septum and the ascending angular artery, the marginal artery, with a medial branch—the dorsal artery—that supplies the external nose.

The tip of the nose is particularly prone to embolic problems, or vascular compromise, so we don’t want to inject too much in this area. Respecting the anatomy from a vascular point of view will minimise risks further, but it is a high risk area.

The innovation sensory part of the nose and the medial branches of the infra-orbital nerve are relevant in terms of blocks—we would hit those areas to block the nose—but generally, topical anaesthesia is sufficient.

Typically, we inject the midline of the nose, between the two crura in the inferior third of the nose, to give the best expansion. We also have the lowest risk of causing damage to cartilage, again which is very friable and sensitive to pressure. If

we had a haematoma in the tissue, this could lead to cartilaginous degeneration which could cause volume loss.

There are many different factors which cause aesthetic changes in the nose and contribute towards ageing, such as glabella volume loss and cartilaginous laxity which can cause tip elongation and tip depression. Crural dehiscence causes the tip depression, the opening of the pyriform aperture and muscular components.

Eight point treatment We have an eight point rhinomodulation technique, using fillers and toxins which is both dynamic and resting. The treatment can be carried out in one session, starting with hyaluronic acid injection, massage and moulding, followed by treatment with botulinum toxin so we don’t disrupt or migrate the toxin.

Position number one for hyaluronic acid is the alar fossa, up against the pyriform aperture, to lift the nostril forwards and begin the anterior lifting process. I then inject into the nasal spine, and/or the columella, to give a tip projection.

We can treat the nasal tip itself if more refined local work is needed, but be aware this is very high risk.

Generally I don’t directly treat the midline, which has more vascular flexis, and instead treat either side. Next, I inject the nasium to elevate the naso-frontal angle and give a straighter appearance and a more uniform junction—a linear transition from frontal to the nasal area.

I then continue treatment with botulinum toxin, from superior to inferior. I first treat the nasalis into the transverse component, followed by the levator labii alaeque nasi. If the patient has nasal flare, I would treat the dilator naris next and it’s useful to assess that during their movements. Then I would inject the depressor septi nasi, which is a very easy technique.

Filler technique I begin treatment by injecting to elevate the dome of the alar using deep injections with a 13mm, 27 gauge needle. I may or may not touch bone, depending on the facial fat of the patient. It is vital to aspirate the area because the facial artery, which then becomes the angular and marginal artery, is right under where the needle is going to be. The idea here is that the dome of the alar is elevated, starting the anterior projection process of the threedimensional appearance of the nose.

In terms of volume, there is no definitive answer—you’re looking for the aes-

thetic result. Next I reposition, injecting right into the sulcus of the nostril, and then aiming a little more medially, and a little more inferiorly as well.

In doing this, I can start to push the patient’s left side of the nose towards the right side, and when that happens, I know that I’m generating anterior lift. It will change the configuration of the nostril slightly when you do this. But of course, now you have to lift at position number two, the nasal spine, and/or into the columella itself.

Cleaning has to be meticulous in this The area below the skin on the nose and perinasal area is pretty much devoid of fat so there isn’t much room to bury material and safety margins are quite narrow.

body language I INJECTABLES 29

area because of the infection risk, so I use chlorhexidine or alcohol, and ensure this area is perfectly clean. In terms of blocking, I use EMLA cream. You can use a regional block as well, but it may distort the tissue.

I then inject directly into the midline, again using a 13mm, 27 gauge needle with Juvederm Ultra 4 and I look to achieve a degree of tip elevation—perhaps no more than 1–2mm—but in this part of the face, it can be a lot.

I use deep aspiration again in this area because of the columella artery, the ver-

tical branch of the superior labial artery and a slow injection technique behind the base of the septum, to observe and appreciate an anterior lift of the tip.

Moulding The columella will widen slightly and I pinch it with my fingers to make sure that it’s located very tightly in position. I push upwards, and pinch it directly, moulding it into position and squeezing the product to give more vertical lift in the septum.

Once the tip has started to elevate, I begin the process after two injection points.

I could use a needle at the tip, and then go up to the nasion separately. Instead, I use a 1.5–2”, 27 gauge cannula. I run this from the nasal tip up to the glabella, so I can treat in one linear passage. This way, with a blunt tipped device, I won’t cause any shearing or damage to vessels and will reduce haematoma risk.

It is important to be aware that the haematoma risk at the nasium can be increased.

I inject into the supra tip—not directly into the tip itself—using a 27 gauge needle with a 27 gauge cannula. You can use a larger needle, but this can cause more trauma.

The technique must be subcutaneous, not intra-dermal. You very slowly dissect the tissue in between the two crura, so you’re in the midline and up against the nasal bones. It takes a little pressure to get past into the glabella.

The tip of the cannula should be up in the naso-frontal angle, and should be kept there as it directs the kind of aesthetic outcome I will achieve, because if I leave product in that linear plane, I will get a good result.

Once I’m satisfied with the position, I then pinch the glabella so I know that the product will be moulded to conform to my index finger and thumb, and it will be retained in the nasal bridge. If you don’t do this, the product can escape laterally and give you an asymmetry.

I correct with more volume at the top and less going down. Then at the nasal tip, I may inject more to create a leaf curl effect depending if the patient wants it.

Sometimes when I do volumetric work in the nose, I can make it look smaller by making it appear sharper, despite the fact that from a volumetric point of view, we’re actually increasing volume.

Following injection at point numbers one, two, three and four, I achieve a linear correction across the nasal bridge. If I want to finish by achieving a little more

tip elevation, I inject directly into the columella, and you can bend the needle to achieve more anterior injection, if you wish, and then pinch into place.

Next I move onto the toxins and mark four points, from superior to inferior— the nasalis, levator labii superioris alaeque nasi, dilator naris and depressor septi nasi muscle.

Interestingly, patients will often complain of more pain with the toxin injections in this area than they do with the filler, because there’s no aesthetic component in the product. In the depressor sept nasi muscle I use an 8mm, 30 gauge needle, and push it hard to get to the nasal spine insertion. Ideally, use a 15ml needle to get all of the way.

Risks and complications We have to counsel our patients very carefully about having this procedure because there are risks involved. Redness, swelling, bruising are common, but we don’t want haematoma because it can compress the cartilage. Infection and abscesses can occur so meticulous disinfectants like chlorhexidine and alcohol washes before you inject are essential.

The four Ps are the biggest nightmare; if we see pallor, purport, if there’s pain, and if there are pustules, we’re looking at impending necrosis. You can rescue with hyalase warmth, glyceryl trinitrate (GTN) and patient management.

Visual acuity compromise is also a risk. Complications can happen, because of the close proximity of the dorsal artery, the angular or marginal artery, and its direct anastomosis with the ophthalmic artery which feeds into the central retinal artery. Good technique, aspiration if you’re using a needle and the avoidance of large volumes are all vital.

Nodules and granuloma are more of a volume and produce-related issue. If you’re using a hyaluronic acid filler with a non-particular, low molecular weight, there should be no problem.

The osteo-cartilaginous junction between the septum and the upper lateral cartilages is an interesting structure. On inspiration, there is no resistance, but on expiration, there is. If you put more pressure in there, you can definitely obstruct air flow so be aware of that.

Dr Raj Acquilla is a cosmetic physician who runs private clinics in Cheshire, London and Ibiza and has his own facial aesthetic academy where he is a recognised masterclass trainer

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body language I SKIN 31

On the bright side The controversial skin lightener hydroquinone can be effective for certain indications but prolonged use has the potential to cause severe side effects. DR ZEIN OBAGI discusses skin brightening alternatives and combination treatments

W

hile I am a strong proponent of hydroquinone, there are good reasons for physicians to prescribe alternatives for patients with chronic discolouration concerns.

Used in reasonable concentrations and under physician supervision, hydroquinone is safe and effective for pigment problems such as sun damage, melasma and post-inflammatory hyperpigmentation. It can also prepare skin for rarer issues, like nevi of Ota and Huri, which require laser treatment.

However, to save money and avoid paying consultation fees, some patients continue hydroquinone treatment for years without medical supervision. This is dangerous and can result in severe consequences that are difficult to reverse.

DR ZEIN OBAGI

Resistance Even under the best medical supervision, patients can develop resistance to the lightening effects of hydroquinone. In my practice, I have found 4% concentration of hydroquinone, used for four to six months, to be the most effective.

After this time, some melasma pa-



tients stop showing improvement in their skin pigmentation. As the hydroquinone no longer affects the dark spots of melasma, the bleaching effects appear more pronounced in unaffected areas. As the active melanocytes in the affected areas develop resistance to hydroquinone, the patient’s hyperpigmentation in these areas worsens.

To avoid such problems, after no more than five months of hydroquinone application, all patients should stop using this drug for two to three months. This allows melanocytes to stabilise, so they can withstand external and internal factors that might otherwise increase their activity, and restore the skin’s natural melanin. During this phase, patients can use other lightening agents and then resume hydroquinone if necessary afterwards.

Some dermatologists may choose to treat resistant melasma by increasing the concentration of hydroquinone. I strongly advise against this approach. Aggressive application of 4% hydroquinone combined in equal parts with retinoic acid for five months works well, after which patients should



use retinol alone for two to three months and then resume hydroquinone treatment if needed.

Photosensitivity Sun exposure is the main cause of the over production of melanin, but exacerbating factors include hormonal fluctuations, acne, medication and aesthetic treatments.

Any condition causing redness and inflammation can enhance the discolouring effects of UV exposure, including overuse of hydroquinone.

We now know that decreasing the amount of melanin in skin, as hydroquinone does, creates photosensitivity. Without proper sunscreen use (SPF ≥30, with frequent reapplication), photosensitivity leads to inflammation which stimulates melanin production.

The sun can also affect melanocytes directly, increasing melanin production and possibly leading to rebound pigmentation. In addition, phototoxic reactions can trigger a chemically altered bluish melanin compound which is responsible for ochronosis. This is tough to treat because it involves pigmentary changes deep in the dermis associ-



1. Before and after a series of 3-Step Peels. 2. Before and after Level III Aggresive AntiAging Program. 3.

Before and after treatment for sun damage with a series of 3-Step Peels.

32 SKIN I body language

66 You should have multiple approaches for each condition and be able to choose the right one for your patients 99 ated with altered skin texture.

In the last few years, I have observed a higher incidence of ochronosis in patients who have used various concentrations of hydroquinone, often for years on end. In these patients, ochronosis has occurred in the areas of the face that experience the most sun exposure.

Using multiple modalities such as chemical peels, IPL and fractional laser treatments simultaneously with continuous hydroquinone use, also contributes to ochronosis. This serves as a reminder that when treating hyperpigmentation, we should not use exfoliative procedures, chemical peels, laser resurfacing, or other thermal rejuvenating devices as our first step.

Instead, we should focus on proper skin conditioning—using hydroquinone, hydroquinone plus retinoic acid, alpha hydroxy acids, antioxidants, and any disease-specific agents necessary—for four to six weeks before and after any procedure, once skin healing is complete. This helps to restore normality and functionality to the skin and improves treatment results.

Hydroquinone combinations A number of products combine hydroquinone with ingredients such as retinoic acid, glycolic acid and topical steroids. But prolonged use of such products can worsen pigmentation and create additional issues. This is especially true of products that combine hydroquinone, retinoic acid and steroids, and the combination of hydroquinone, tretinoin and fluocinolone. Longterm use can lead to skin atrophy, telangiectasias, skin sensitivity and more stubborn pigmentation.

The topical steroids in these formulations aim to suppress inflammation. This is critical because inflammation excites melanocytes, stimulating melanin production.

However, topical steroids only work

on pigmentation induced by trauma or disease—post-inflammatory hyperpigmentation. In contrast, we must avoid prescribing topical steroids for patients with pigment problems not caused by inflammation, such as melasma.

To avoid disrupting cellular function, these triple-combination products should not be used for longer than five to seven days, in accordance with their instructions.

As an alternative, a combination of hydroquinone and retinoic acid without a steroid can be used. It is safer and quite effective when used properly for three to five months with strict sun protection.

Brightening alternatives Non-hydroquinone brightening agents may also be prescribed instead of hydroquinone as a healthy maintenance system and to avoid atrophy, carcinogenesis and other local or systemic side effects with long-term exposure.

You should have multiple approaches for each condition and be able to choose the right one for your patients. We have created a non-hydroquinone protocol—not to bleach, but to stabilise cells in order to stop the melanocytes from being active all the time.

The ZO Non-Hydroquinone Hyperpigmentation System is a five-product regimen formulated to reverse discolouration, prevent new spots from forming and fight lines, wrinkles and rough texture. Brightenex Skin Brightener and Correcting Crème is the protocol’s anchor, formulated with retinol, vitamin C, melanin inhibitors and antioxidant vitamins E and C to target the three stages of discolouration.

If redness or flaking occurs, the system includes Restoracalm Soothing Recovery Crème that can be applied as needed. Retamax Active Vitamin A Micro Emulsion supports the lightening effects of Brightenex, and fights signs of age with a blend of retinol, plant stem cells and bio-mimetic proteins to stimulate collagen and restore the skin’s barrier function.

Ossential Daily Power Defense is a daytime treatment that features retinol, antioxidants and DNA repairing enzymes to help minimise UV oxidative damage and uneven

pigmentation, while restoring skin function and elasticity.

Sun protection is vital in any regime. Oclipse-C Broad-Spectrum Sunscreen SPF 50 contains fractionated melanin and antioxidants to shield skin from high-energy, blue violet light. I recommend always using a mineral-based broadspectrum sunscreen as in OclipseC for effective UV protection without potential reactions.

The C-Bright 10% Active Vitamin C Serum harnesses the brightening powers of ascorbic acid. It’s a water-free formula that self activates upon contact with skin. Our non-hydroquinone skin brightener, Brightalive Non-Retinol Skin Brightener uses a multi-vectored skin pigment management approach with alpha-arbutin and bioengineered plant phytotechnology to inhibit melanin production.

The face, chest and the back of the hands are the most common places for discolouration, although dark spots can also develop on the arms and legs. Brightening products developed specifically for the body is a new category and takes into consideration the difference between facial and body skin.

Brightamax Non-Facial Brightener is a full body treatment formulated to manage every stage of skin discolouration on contact.

Retinol and vitamin C work to brighten existing pigmentation.

Gluccosamine, glutathione, and soy isoflavones prevent future dark spots and discolouration. Stachys officinalis and acetoside mediate redness caused by histamine release, preventing post-inflammatory pigmentation.

Through careful management of hydroquinone usage—optimally four to six months at the most— followed by non-hydroquinone treatments for maintenance, hyperpigmentation can be lessened and controlled. Every case is different, and some patients require additional modalities, such as chemical peels or laser treatments, although in many instances topical treatment is adequate as a solo approach.

Dr Zein Obagi is a dermatologist in Beverly Hills, California and is Medical Director of ZO Skin Health.

W: zoskinhealth.com

body language I LASERS 33

The future of

radiofrequency The use of radiofrequency is progressing with combined treatments for better, safer results. Shared information between clinicians and manufacturers helps to improve protocols and the technology.

DR AAMER KHAN explains what the future holds for radiofrequency

I

first started working with radiofrequency in 2005, doing minor operative surgery. We found that the actual end results were much better this way. Healing was improved and the actual dissipation of energy and trauma into the skin was reduced. It was a very precise method.

One of the philosophies at our clinic is to be at the cutting edge—it is important to innovate.

We have got to look at combining treatments, so we don’t push any one treatment to the point of risk.

We don’t just use radiofrequency for cosmetic medicine—there is a lot of evidence behind its use in other fields too. However, cosmetic and aesthetic medical sur-

gery are relatively new and we want to gather more information to see where these two particular fields can progress.

Benefits of radiofrequency A lot of the companies that are using radiofrequency are developing whitepapers and case studies. We’re starting to look at the specifics of what we should be targeting, the length of time that we should be targeting the energy and what the results are.

The three types of thermal effect that we get with all energy delivery systems are: 1. Ablation of tissue—used specifically for cutting and removing with high power density.

Rdiofrequency can be used for tissue contraction, tissue de-bulking and skin tightening

2. Coagulation of tissue—a subnecrotic to necrotic border and that creates release of thermal induced proteins and cytokines which will then trigger healing.

3. Sub necrotic healing—for collagen contraction using low power density.

The good thing about radiofrequency is that you get all three of these happening at the same time.

The gentle heating has also been shown to increase the healing of tissues, in fact in physiotherapy it’s used to heal injury.

The technical advantages are high efficiency and reliability of radiofrequency sources. Because it’s an electrical ‘solid state’ type of technology there is consistency in the delivery. We can choose how much power we apply, and with stretch marks, the higher the power the better. But delivery of power isn’t everything—safety and reduction of side effects is why we’re combining treatments.

Multiple uses In our clinic we use radiofrequency for cosmetic radio surgery, which gives us ‘microscopic’ scar healing where we can almost ‘airbrush’ lesions away. We use it for cutting surgery as well because we find that the tissue healing is much better.

We also use it for radiofrequency assisted liposuction where different tissues are targeted with radiofrequency. As well as fat apoptosis, the interstitial fibrous bands can be contracted significantly. We use it for tissue contraction, tissue de-bulking and skin tightening.

Tissue de-bulking relates to post-obesity problems. One of the problems with putting on weight is that there is expansion of the tissues around the fat, and there is actually a hypertrophy of the

DR AAMER KHAN

34 LASERS I body language

Before and six months after RFAL treatment

interstitial fibrous bands, and the inter-adepose cellular tissue, which prevents efficient contraction of the tissues when people lose weight.

So they can have skin that weighs far more than normal skin and is much thicker.

Radiofrequency can be used to de-bulk this, and we are working on protocols with surgeons where tissue is being removed, but we’re also de-bulking tissues to make it thinner and tighter.

The fibrosis and microfibrosis that occurs prevents tissue weakness, so we’re also working with invasive, interstitial, heating and radiofrequency. This causes microscopic interstitial fibrosis in a diffuse fashion, strengthening and contracting the tissues.

We also use radiofrequency for significant scars by using deeply penetrating probes, including 3mm probes for burn scars. We’re doing a lot of work with soldiers after they’ve been burnt and injured and we’re seeing really good results. In the future we will be able to use this in combination, certainly, with PRP and with other modalities.

In treatment of acne and the application of non-necrotic, subablative thermal healing energy, we have seen that it reduces the acne process. Patients have come in with active acne, which has settled down quite significantly and quite quickly as a result of treatment with radiofrequency.

Looking to the future So what does the future hold? The future has to be developed through

teamwork. Through observation, study and clinical research by the people who are using the technologies in combination with technical developments by the companies.

Through talking and sharing information, and having peer reviews, so we can evolve better and safer protocols for our patients.

We’re always learning and moving forwards. That’s part of our role as clinicians—to have safer ways of achieving results and we’re coming back again and again to combining treatments. We’re also now using radiofrequency skin rejuvenation prior to cosmetic surgery.

A very interesting study looking at expectations in cosmetic surgery was done by Ohio University. One of the issues in our field is expectations and outcomes—we have got to match them. If we don’t match them as closely as possible and if we don’t manage the expectation, there can be a huge disappointment gap, and this is when patients complain.

Ohio University asked patients and doctors what the expected age reduction was after a facelift.

People thought it was anything between five and ten years. They then did a study looking scientifically at what actually was achieved, and the average improvement was about three and a half years. Now when you combine surgical and non-surgical or minimally invasive treatments, then we can achieve a five to ten years.

So the future of radiofrequency, I believe, is in preparing for surgery. This means that our surgical colleagues have much better skin (material) to work with when they operate. Post surgically we can maintain that improvement with further treatments.

It’s not just about treating. With the stretch marks there are studies being done looking at epidermal thickness after ablative and subablative radiofrequency treatment.

That thickness will last about 12 to 18 months before it regresses back to age. Ongoing treatment with retinols will help, but remember the skin needs a rest as well. Ongoing treatment with non-ablative surface radiofrequency every three

months can keep that topped up because we’re putting energy in without ablating.

Looking at protocols for longterm maintenance is something that we can do to move forward.

It’s important to support our patients long term, putting together treatment programs for them, rather than just ending at surgery and coming back three to five years later to say this has not worked, or lasted Understanding the required end points and developing technological advancements to monitor and achieve these endpoints is what we’re moving towards.

For example, when we started doing radiofrequency assisted liposuction we were putting energy in for tissue contraction. The temperatures were going up to 80 degrees and we were getting coagulated tissue which was actually preventing early contraction of tissues.

We were seeing end results after two years rather than three to six months and patients were unhappy because of the gap between expectation and outcome.

With the newer protocols we now know we only have to go up to 60 degrees for significant interstitial fibrous contraction to occur, so we’re seeing those results a couple of months after they’ve had their treatment. This is now exceeding their expectations, and the patients are much happier, despite the two years outcome remaining unchanged.

This advancement only occurs when we feed back to each other and share information, not just between ourselves but also to the manufacturers. If the manufacturers can work with us in achieving technologies which can monitor the end results that we’re aiming for, then we can get better results.

So the future is quite exciting.

We have a modality here which can do a number of things—anything from ablation all the way through to gentle warming and healing.

Dr Aamer Khan is a cosmetic doctor, and co-founder of the Harley Street Skin Clinic, W: harleystreetskinclinic.com

36 INJECTABLES I body language

Facial hyperhidrosis There are several treatment options available to patients suffering from facial hyperhidrosis. DR SANDEEP CLIFF discusses these options and explains his preferred techniques sweat spontaneously—it is the unpredictability of the sweating that causes patients the most distress.

There are four main types of hyperhidrosis, but the most common type I see is sweating of the forehead, which is diffusely present.

Of the patients I’ve seen, one example is a nurse who was transferred from one department to another because she was dripping all over her patients.

Or a shy, reticent teenager who, after having had treatment, became a spokesman for the Hyperhidrosis Society. Treating patients clearly has a positive impact on their quality of life.

When I see a patient I will write down whether I perceive their sweating to be mild or severe. This severity scale would be my interpretation—I’ll then ask them where they fit into that category and we often correlate on the same part of the scale. It’s very useful for me as a guide to how they respond.

Insurance companies will recognise treatment for hyperhidrosis of the face, provided you use this hyperhidrosis severity scale. It’s worth remembering this when supplying information and discussing the case with insurance companies in order to secure authorisation.

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efining hyperhidrosis can be tricky. I don’t tend to strictly adhere to the literal definition and define sufferers as anyone who gets significant sweating to the point where it affects their quality of life.

Typically, patients do not complain of excess sweating at night—a useful pointer that there is unlikely to

be a secondary cause. It is, however, important to take a full medical history from patients to exclude a secondary cause such as medication and anxiety disorders.

Around 10% of patients who come to me with excessive sweating have hyperhidrosis of the face. This can have a significant impact on their life. People with hyperhidrosis

Hyperhidrosis of the face can have a significant imapct on quality of life

Available treatments Iontophoresis is an electrical current that passes through the skin and blocks the sweat glands very effectively. However, although it’s an effective treatment, it’s very difficult to get masks that stay on the face and produce the effect you want.

Patients find it very uncomfortable because of the vibratory sensation as the electric current goes through the skin. It’s not as effec-

body language I INJECTABLES 37

Propantheline bromide is an effective way of treating hyperhidrosis—it’s fast-acting, so patients can take it two days before upcoming events in which they’re worried about sweating

tive for the face as it is for the palms and the soles.

I use a lot of propantheline bromide, which is a very effective way of treating hyperhidrosis. It’s given in a dose of 15mg and you can increase the dose up to 60mg.

It’s very fast-acting, so many patients will take the drug two days before they have a big presentation or event in which they’re worried about sweating. They may take it for that event and then only take it when and if they need to, which is a reasonable way to manage the problem.

Many patients in studies published since 2002 have taken the drug and found it to be very effective. However, around a quarter of patients have to stop because of adverse events.

The majority of patients get a good response to all anticholinergics but it is clearly not the solution for some patients due to side effects and the unpredictable nature of the drug There is a cream called glycopyrrolate, which is an anticholinergic. Another potential problem

is that people put the cream on the face and then they start sweating on the neck—compensatory hyperhidrosis. For that reason I don’t tend to use it, but you can get it on the market.

Botulinum toxin Botulinum toxin is my main treatment for patients who’ve failed the other conventional treatments.

The sweat glands sit in the middermis—there’s the top layer of the skin, the epidermis, the dermis, the fat layer and the muscle, deep down. In the forehead, these are the eccrine sweat glands and they sit 1mm into the skin, so they’re very superficially placed.

The muscle contracts the sweat gland and pushes the sweat out through the duct. Therefore, if you think about the principle of how toxins work, it’s meant to inhibit the muscle contraction by inhibiting acetylcholine release.

A study with 12 patients was originally published in 2000, showing that an average dose of 60 units of botulinum toxin used in the forehead had very effective efficacy,

lasting up to 27 months. I’ve never been able to replicate the duration of the effect in clinical practice.

Other studies follow on, showing that botulinum toxin is an effective and safe treatment. There’s a good satisfaction score.

More recent studies have also shown that by using 50 units of botulinum toxin (a significantly smaller dose than the original studies), you get no major side-effects.

That’s very reassuring for our patients and for us.

They used four units of botulinum toxin injected over every 1cm, so 100 units used on the entire forehead. People who practise aesthetic dermatology know that with 100 units in the forehead, the patient won’t be able to move their entire forehead. So why are we using such a high dose for patients with hyperhidrosis?

The data, which was published in numerous journals in 2002, used 100 units—one vial in the forehead—which is no bigger than six or seven postage stamps.

If you inject four units, 25 injections across the forehead, avoiding

38 INJECTABLES I body language

1cm above the eyebrow to avoid brow ptosis, you get a therapeutic benefit. I treated patients four years ago using exactly that protocol.

However, patients were getting significant paralysis of their forehead muscles, which they found unacceptable.

They got a very satisfying response to their sweating, but they were not happy with the fact they couldn’t move their forehead at all. They got the frozen effect. So I moved on to using a technique of injecting the hairline only.

New technique If you inject the hairline, with around seven units per injection, you’ll find that there is a diffusion effect. You get reduced sweating, and a significant therapeutic benefit without causing the frontal paralysis that we were seeing.

I’ve performed this in over 100 patients. Never once have I had a problem with brow ptosis or any other complication related to it.

Another study compared two toxin products—Botox and Azzalure. They showed that if you use a ratio of roughly one to three, you get the same therapeutic benefits.

So if you’re using Azzalure, 10 Spey units is equivalent to one injection point.

The studies show that you get an area of anhidrosis, very effectively showing a reduction in sweating in both the Botox and the Azzalure group of patients.

However, the Azzalure patients had a greater area of diffusion, suggesting it may have a greater risk of side effects but this has not been

borne in clinical studies or in my practice.

Micro-injection technique What about other areas of sweating? It’s a big problem for some of our patients. We see patients who have complained of sweating on the upper lip and sweating on the cheek.

We don’t try to inject four units, 1cm apart into the cheek as it causes problems with the zygomaticus major and minor. I use a so-called micro-injection technique. I use 50 units of Vistabel, diluted conventionally with 1.25ml of normal saline. Bacteriostatic doesn’t make any difference in terms of pain because they are superficial injections. I then dilute it tenfold—so I make up 0.1ml and dilute it to 1ml.

Every 0.1ml is therefore 0.4 of a unit.

I dilute it down, and with one syringe I inject with multiple injections. With this technique, you get no problems with muscle paralysis from a functional perspective, but you get a significant reduction in their sweating. I find this to be very effective in therapeutic practice.

My patients are very satisfied but the longevity in my experience lasts no more than three months.

So I frequently tell these patients that they will need around four treatments per year.

The upper lip can also be a big problem for patients. When we did the starch iodine test on these patients, we found the principle problem with sweating was just below the nasal sill.

So that’s where we want to direct our injection technique. This

66 I don’t try to inject four units, 1cm apart into the cheek as it causes problems with the zygomaticus major and minor.

I use a so-called microinjection technique 99 avoids the orbicularis oris and turns the sweating off very effectively.

However, it only lasts one to two months and it is painful for patients and sometimes needs a local anaesthetic.

I would say, of the patients who present to me with hyperhidrosis, about 15–20% will have hyperhidrosis of the face, which is a major problem for them. They’re not particularly keen on systemic treatment because of the associated side effects that have been related to it.

Patients prefer local treatment and botulinum toxin is very therapeutically effective with minimum downtime. However, I keep my doses relatively low, which has a good response. Treatment results in a very satisfied group of patients with few side effects. Temporary muscle weakness has been reported, but I’ve never seen it in the patients I’ve treated.

Dr Sandeep Cliff is a consultant dermatologist, dermatological surgeon, and the lead consultant for Cliff Dermatology Ltd with an aesthetic practice in Surrey.

W: cliff-dermatologist.co.uk

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40 ANTI-AGEING I body language

Hormone

balance Different types of hormones have different effects on our skin. As we age our hormones can become imbalanced and cause skin problems and ageing. DR TERRY LOONG shares some common hormonal problems affecting the skin and reveals some simple actions for hormone and skin optimisation

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here are lots of hormones in our body which have direct and indirect effects on our skin. A few in particular are important—oestrogen, progesterone, testosterone, cortisol thyroid and insulin.

Oestrogen Oestrogen, the female hormone, increases the rate of cell renewal and increases collagen and elastin production. It slows the rate of hair growth, keeps sebaceous secretions thin and less fatty and reduces hyaluronidase. This is important because hyaluronidase is the enzyme that breaks the hyaluronic acid, which maintains the moisture of the skin and bone density. As we age, we lose the reabsorption of the chin and our cheeks, so the foundations

of our facial structure fall.

The International Academy of Cosmetic Dermatology (IACD) in 2008 showed that after 10 years of menopause women can lose 30% of their dermal collagen. We may be pumping our patients up with fillers, skin boosters and toxins, but as we age we lose around 30% of our collagen. That’s a huge amount.

Oestrogen is very important to the skin, but if we lose oestrogen does it actually work to replace it? The IACD analysed almost 3,000 women going through the menopause. They found that women on oestrogen replacement therapy showed a decrease in wrinkling and dryness.

The International Journal of Pharmacology in 1998 found that after six months of treatment with oestrogen, the elasticity,

firmness and hydration of skin improved and wrinkle depth and pore size actually decreased by 61-100%. In August 2005, Fertility and Sterility Magazine looked at long-term effects of hormone therapy on skin rigidity and wrinkles and found that wrinkle scores were lower in hormone users than in non-users.

Some of my own patients who are on HRT or bio-identical hormone replacement therapy tell me that their skin feels springier and tighter. They’ve continued to use dermal fillers but they feel their skin has improved generally.

Progesterone and testosterone Progesterone is oestrogen’s best friend.

Its role is to support oestrogen, helping to fight immunity and reduce swelling

body language I ANTI-AGEING 41

and inflammation. It assists oestrogen in firming up the skin and maintains nerve function. The British Journal of Dermatology in 2005 used 2% progesterone cream on the skin of perimenopausal and menopausal women. The results were a greater reduction in wrinkle count, depth and skin firmness without any side-effects.

As for testosterone, all women produce it and a little bit can be good for skin. It increases cell renewal, skin thickness and libido, but if there’s too much it increases hair growth, sebum size and sebum activity. IGF, growth hormone, research in 2002 shows that testosterone increases collagen and maintains skin thickness.

Cortisol and stress Cortisol, the stress hormone, is a huge

topic in regenerative anti-ageing. We get it from pollution, from smoking, from the food we eat, from caffeine and all sorts of stressful conditions in our daily lives.

When you have too much stress, or cortisol, it’s referred to as the death hormone. As we grow older we have more and more cortisol in our lives. Daily stresses and big stresses such as divorce, death and financial worries can make people feel and look as though they’ve aged considerably.

Excess cortisol inhibits collagen production because it limits protein synthesis. It also reduces bone formation and immunity. That’s why people who work really hard for the whole year end up falling ill during Christmas time. Stress raises DHEA and testosterone levels and

lowers thyroid hormones, oestrogen, progesterone and growth hormones.

Hormone imbalances There are many types of hormone imbalance and they cause a variety of skin problems. There are a few common ones that I see in my practice. I once had a patient who was drinking 17 cups of coffee a day just to keep going, which greatly increases cortisol production. She came to me at the verge of 50 years old trying to improve herself. She had low progesterone, PMS, heavy periods and insomnia.

Women between 35–50 years often experience oestrogen dominance (excess oestrogen) and low progesterone. This is a common presentation for women going through peri-menopause due to the

42 ANTI-AGEING I body language

toxic environment, unhealthy lifestyle, chronic stress and diminishing ovarian reserves. Oestrogen dominance and low progesterone can present with PMS, feeling bloated, weight gain, painful breasts, heavy bleeding, breast cysts, endometriosis or fibroids.

When women go through menopause, all the hormones will drop due to age.

However, testosterone which maintains firm skin and muscle tone becomes relatively high (as oestrogen drops further) and it can cause acne, facial hair and male pattern balding (hence older women may suffer from whiskers, breakouts and thinning hair).

A low thyroid is also very common and often misdiagnosed. It can cause get weight gain, fatigue, mood problems, dry skin and weak hair, usually visible in the eyebrows. When you examine someone’s face and you notice thin hair on the lateral parts of the eyebrows, this is potentially a low thyroid problem.

So why does it happen? Why are we seeing much more hormone imbalance?

Modern lifestyle—a high sugar and carbohydrate diet, pollution, radiation and low environmental toxicity—causes high stress levels, high cortisol, low progesterone, high testosterone and oestrogen dominance.

All the hormones present when we’re drinking water or drinking from plastic or Styrofoam cups or eating—chicken is pumped full of them—are absorbing into our fat. Our fat holds a lot of these hormones and that’s why children are becoming bigger, earlier. We have too much oestrogen going around in the environment.

So what does this affect? It increases free radicals, increases breakdown of cells and means poor gut function and a toxic gut environment. When I started prescribing hormones for patients, often they thought that it would solve all their problems. It doesn’t work that way. It’s a process which means if your gut is toxic, it’s still going to be toxic after taking hormones. So you have to clean everything up to get the most out of it.

Hormones and the menopause Why do perimenopausal and menopausal patients get all the problems that we see? When we have declining oestrogen and progesterone, there’s a reduction in cell renewal—so patients get rough skin.

Their vessels become more fragile, they get broken veins and they get facial bone loss, so they literally shrink.

Patients also get reduced immunity, which can mean increased sensitivity.

We work with patients to resolve stress, perhaps through meditation or exercise

Some patients get much redder in the skin and much more sensitive to skin products. There is an increase in the breakdown of hyaluronic acid in their skin so they get dryer skin. There’s also the 30% reduction in collagen production 10 years into menopause mentioned above, which can mean wrinkles and loss of volume. So when oestrogen and progesterone drop, that’s what we get.

Oestrogen, progesterone and testosterone are always in balance, but in menopause all of them drop. Oestrogen and progesterone drop faster, or lower, than testosterone—it doesn’t mean there are higher levels of testosterone, just high relative to oestrogen or progesterone levels.

When you have relatively high levels of testosterone, sebum increases in size and activity. That’s why patients come to us for adult acne. As well as increased hair growth on their face, some women get male pattern balding with thinning and finer hair on top. This can also be caused from too little of the thyroid hormone.

Not all people with a low thyroid put on weight so it’s worth testing for this.

Melasma—overstimulation of melanin by oestrogen—can also happen in menopause. People on the pill or going through pregnancy can get melasma too, so it can be a common skin ailment.

Treating hormone imbalance If someone is on or has been on HRT they can experience new hormone balance; peace of mind, a good night’s sleep, a good libido, good energy, better muscle tone and better sugar regulation for weight loss. It also helps cortisol levels because patients are less stressed, which will have an indirect effect on the skin.

So how do you treat hormone imbal-

ance? We always start with the mental and emotional health. We look at how people respond to stress, their nutrition and gut function, cortisol and insulin levels. We then look at their thyroid, oestrogen and progesterone, discussing everything from the bottom level up.

We look at how to resolve stress, with an anti-stress kit. Every person has their own modalities. Some people love meditation or exercise. Some people watch a film or have a glass of wine. So it’s just finding out what works for the patient.

We might look at mental and emotional wellbeing, perhaps talking about therapies, relationships and support networks.

I work with a nutritionist and a detox company to help with gut function and nutrition. I get patients to go to a detox program so they can detox the gut, the liver, the gallbladder, kidneys, lungs and skin. Before prescribing something I look at all these things, including healthy eating, healthy food plans, superfoods and supplements as well. If patients do need extra help then we might go towards herbal therapies or alternative therapies.

If you suspect someone isn’t 100% healthy, then definitely look at the above.

If someone is internally very toxic and they start taking hormone replacements they will become sick because their system won’t be able to process it.

Hormones play an important role in healthy young skin and modern lifestyle causes many hormone imbalances. We must remember that hormone balancing is a process, not a magic pill.

Dr Terry Loong runs The Skin Energy clinic in London. She originally trained as a surgeon before specialising as an integrative cosmetic and skin doctor.

44 DESIGN I body language

a clinic The look and atmosphere of your clinic can make as much difference to your image as the quality of your treatment. MICHAEL POLAKOV, who has spent 27 years in medical architecture, explains how to show your practice at its best

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hose who open clinics always say afterwards, “I should have made this a little smaller, that a little larger, changed that around.” If you spend 90% of your time planning what you’d like to accomplish, you only need to spend 10% on architecture and building, and you eliminate the need for changes before, during or after the build.

Three goals You should have three goals,

achieved together. The first is that you, your staff and patients should feel beautiful when you cross the threshold. I want a patient who walks into a clinic to be destabilised almost, by the comfort, the coolness. You want them to hope to spend a few extra minutes in this gorgeous private salon.

The second goal is to receive remuneration at the top of the scale for the skill level you have. It’s not just about making money, it’s about feeling compensated for the effort

you are putting in. It’s a nice feeling when patients are glad to engage your services. The third goal is that your calendar is booked enough in advance that you maintain a sense of security.

Size You need a total of about 600 square feet if you have a number of consulting rooms in someone else’s facility. For a private office with three examination rooms, bathrooms, a kitchenette, reception

For a private office, 1,000 square feet is ideal—1,500 if you want the opportunity to have a partner or rent out a room

body language I DESIGN 45

and waiting room I’d recommend 1,000 square feet. But a 1,500 square foot facility will give you the opportunity to have a partner or rent out one room.

If you do that, bring in someone with a similar clientele, which you can share. You can help build your practice, just by adding a few hundred square feet for somebody else to share the space.

If we go up to 2,000 square feet we have the ability to add a procedure room. At 3,000 square feet we can have a procedure room, two doctors and an aesthetician department. Above 5,000 feet we are creating a heavy machine.

Above 7,000 feet, unless you are a plastic surgeon with two other surgeons, two operating rooms and ancillary doctors, you have overbuilt and will work to pay the landlord or bank.

Cost Costs per square foot run from £25 a square foot to freshen up existing consulting rooms; to £100 a square foot to renovate a facility or build a facility in raw space; up to £150 a foot for full operating theatres.

Style It is key for you to decide the internal style based not just on what you like, but on the strata of patient that you would like to be the foundation of your practice. Consider internal flow—do not build a bowling alley; a hallway with rooms on either side. A beautiful clinic is the same square footage and cost, someone

just took more time to plan it.

A waiting room is a horrible thing. If I’m sitting and you walk past me I feel left behind because someone was taken in before me.

But if your waiting room is a reception room where people are received, greeted and wait in a private area without others passing to and fro in front of them, it’s a pleasure.

Creating a network is also vital. Dermatology, plastic surgery, aesthetician services, cosmetic dentistry, personal trainer, dietician— these are all necessary if you want to have a growth practice where you do makeovers, because that is the future of aesthetic medicine.

You don’t need to have these people in your facility, you need to build a network of practitioners you

trust, who can give the service that completes. For example, if you do a phenomenal facial rejuvenation on a person with bad teeth, send them to a dentist who’s a teammate of yours. To be unable to complete the look loses the overall wow factor.

Finally, understand your mission. What is it that you want to accomplish with your patients? Set your long-term goals three, five and 10 years ahead. Not only this but build something that you will either be able to turn over or sell very profitably rather than walk away from at the end of your lease term.

If your waiting room is a place where people can wait in a private area without others passing to and fro in front of them, it is a pleasure

Michael Polakov is an international consultant to hi-end medical aesthetics practices around the world, E: michaelp@ medi-build.com, W: medi-build.com

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body language I MARKETING 47

Social SOS If you are active on social media you should have a crisis management strategy in place. Jamie O’Sullivan discusses why

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he convergence of social media and the medical aesthetic industry is arguably stronger than it ever has been. With the increasing level of “selfies” and self portrait photography being shared, we can only see this increasing. In fact, in May 2014, we estimate there to be over 3,000 social media conversations in the UK alone, relating specifically to the term “cosmetic surgery”.

Cosmetic surgeons, practices and establishments alike, need to sit up, take notice and be aware of social media as a real force. Whether you are using social or not, users can still comment on and target feedback on your services—therefore you need to be aware of how to deal with this. It’s simple, you just need to be crisis-ready.

Crisis, what crisis?

First off, a crisis isn’t a patient commenting on social media about the lack of good magazines in your practice waiting room. Social media is a great place for everyone to have a good moan about all sorts of minor issues, such as these, and it’s quite commonplace.

A crisis, however, would be a patient who has experienced severe post-operative complications and is taking to social media to voice their anger and frustration. This is also a direct threat to cosmetic providers and their reputation, if mismanaged and not addressed.

In fact, research conducted earlier this year on behalf of the Social Media Marketing University (SMMU), provides a sobering insight into the devastating

effects of social media negligence.

The study investigated over 1,000 businesses (across all sectors) using Facebook, reporting that: “26.1% of respondents say their brand’s reputation has been tarnished as a result of negative social media posts, 15.2% have lost customers, and 11.4% have lost revenue.”

A cosmetic surgery-specific survey also found that 1.5% of surgeons saw a negative impact

66 The convergence of social media and the medical aesthetic industry is argueably stronger than ever before 99

48 MARKETING I body language

on their business, as a direct result of social media mismanagement.

There is a real danger here if social media is not used correctly.

I advise three simple steps to take to avoid these pitfalls and keep your cosmetic practice in a positive light. In fact, by managing a crisis properly, you may even come out with an improved reputation.

1. Listen Social media—unlike a clinic, surgery or practice—is open 24 hours a day and seven days a week, so it needs to be carefully monitored, should any complaints, issues or queries occur.

From a business perspective and to take Twitter as an example, recent research has suggested that over 53% of users who tweet at a brand expect a response within the hour. To keep in control, we recommend adopting real time tools for social media monitoring, such as HootSuite (free of charge)—a simple tool which allows you to track specific mentions, comments and hashtags across all of your social platforms.

By getting into the habit of checking this daily, you can maintain a healthy online presence and also a healthy piece of mind. Other great free tools for up to date monitoring of conversations include Twitter Alerts and Google Alerts.

At the very least adopt these tools before a crisis occurs.

2. Prepare for the worst One of the best ways to ensure an

effective response to a crisis situation is to pre-formulate tweets, updates and other material around where you perceive your potential key problem areas lie. Essentially, begin formulating a crisis response document and make this your bible for social media crisis moments.

It’s also important to remember that the issues voiced via social media are not dissimilar to those voiced in person, so draw on offline crisis management and use this experience in your favour. By unifying your efforts and prearranging responses (where possible), you will also serve to unify the tone of voice in your social response and therefore convey a consistent message.

Make a point of regularly checking and updating this document and make sure it is approved by your legal team of course!

Obviously you can’t plan for every crisis, but you can take each case as a learning experience and then, once the crisis is dealt with and the resolution has been successful, incorporate any newly found technique into your crisis strategy. For us, this method of preparation and active learning is the most proactive way of ensuring smooth interactions with the social media user.

We have used this methodology across a range of medical channels, from cosmetic surgeons to licenced medicines, and it has proven to be 100% efficient to date.

3. Tackle the issue Do not shy away from a crisis! It’s a well-used social media cliché, but

Take an immediate step back and divorce yourself from the comments personally. Then plan your response.

in times of crisis you must “own the conversation” and keep control of the situation.

The principles of good social media business practice are applicable here; take control and harness the negativity to benefit you.

One gleaming example of proactive crisis management is most notably ditital communications company O2, whose activity in times of crisis should be taken note of—even if the industry is far from that of cosmetic surgery, the basic social principles remain.

So, take on a crisis, turn it around and make the negative into a positive. Here are a couple of methods of tackling crisis events that we use ourselves: Breathe. Take an immediate step back and divorce yourself from the comments personally. Then plan your response.

Remain transparent by being honest, open and caring in your treatment of a situation.

If need be, take the conversation offline by introducing an email address or phone number for the user to contact you with. This will reduce the activity on social from that user and allow you to help them, quickly and efficiently.

Do not take it personally, remain professional and keep calm!

Ensure all key staff with access to social are briefed on how to deal with a crisis event, just in case they need to act quickly.

Jamie O’Sullivan is an account manager at Orbital Media, a social media marketing agency and a specialist in healthcare marketing.

W: orbitalmedianetwork.com

References 1. Data extracted utilising social media keyword analysis tool Radian 6. Data relates to the 1st May to 31st May 2014 and is applicable for the keywords “cosmetic surgery” (findings are based on UK only conversations).

2. http://www.marketingprofs.com/charts/2014/24698/ most-brands-are-not-prepared-to-manage-negativesocial-comments#ixzz35jy76npI 3. http://journals.lww.com/plasreconsurg/pages/articleviewer.aspx?year=2013&issue=05000&article=0005 1&type=abstract 4. http://blog.bufferapp.com/social-media-stats-youneed-to-know

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50 DIRECTORY I body language

DERMATOLOGY

classified classified

TRAINING

FOR SALE

Platelet Rich Plasma (PRP) SOPRANO XL BLUE LASER HAIR REMOVAL Training £36,000 The machine is in excellent

condition and PRP the skin Cosmetic Courses are proud to announce our new tightening head has been training course - a revolutionary approach in tissue hardly used SYNERON CANDELA regeneration. Contact: Adeboye Oloritun

FRACTIONAL CO2 Bloom Healthcare RESURFACING SYSTEM, ONLY £295 + VAT T: 01908 693400 (CO2RE) £30,000 M: 07760 788822 Includes safety glasses, E: info@bloomhealthcare.co.uk additional parts and manual.

PRP is an increasingly popular treatment in the Laser vac can be included for aestheticanindustry, to reduce fine lines and wrinkles additional able £1,500 Contact: Rekha Tailor of the skin. It is a valuable and improve the texture 01252 procedureT:for any820690 aesthetic clinic either as a standalone 01252 820690

treatment or to compliment E: rekha@healthandaesthetics.co.uk

other products.

Cosmetic Courses is one of the most established providers of aesthetic training in the UK, with over 10 years of specialist experience.

ALMA ACCENT RFteaching XL £7,500 In goodthcondition, six years old th 13 January 2014 | 7 Contact: Amanda Stokes T: 01708 225555

February 2014

E: amanda@aestheticsofessex.co.uk

ask@cosmeticcourses.co.uk | www.cosmeticcourses.co.uk LPG Endermologie Cellu M6 Keymodule £6,695 Never used, includes bed, marketing and manuals.

We can deliver.

Contact: Amanda Stokes T: 01708 225555

EQUIPMENT FOR SALE

E: amanda@aestheticsofessex.co.uk

SYNERON CANDELA FRACTIONAL CO2 RESURFACING SYSTEM, PALOMAR VECTUS DIODE (CO2RE) £30,000 LASER £39,000 Includes safety glasses, Brand new machine with additional parts and manual. full manufacturers warranty.

Laser vac can be included for Available immediately, training an additional £1,500 included. Pre-purchase demonstration available.

Contact: Paul Edwards T: 01245 227752 E: paul@edenaesthetics.com

Contact: Rekha Tailor T: 01252 820690 01252 820690 E: rekha@healthandaesthetics.co.uk

SOPRANO XL BLUE LASER HAIR REMOVAL £36,000 CHERISHED NUMBER PLATE The machine is in excellent AND AUDI TTS condition and the skin £50,000 (ono) tightening head has been Brownish grey colour, in very hardly used with less than good condition 21K Miles. Full black leather interior with Bose sound system.

We will consider selling the number plate (B8TOX) separately.

Contact: Susan Judodihardjo T: 07796017018 E: susan@cellite.co.uk Contact: Adeboye Oloritun Bloom Healthcare T: 01908 693400 M: 07760 788822 E: info@bloomhealthcare.co.uk

dermamelan® is a professional whitening treatment designed to eradicate or eradicate or attenuate cutaneous blemishes with melanic origin while it homogenizes skin tone and increases skin luminosity. dermamelan® application inhibits the melanogenesis process paralysing melanin production for a long period of time in which corneum stratum desquamation and the action of macrophage cells drag melanin deposits.

www.mesoestetic.co.uk

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Read, learn and apply

Medical aesthetics is at your fingertips. Body Language passes on the knowledge of leading practitioners, who will help you with your technique. spring 2014 july/aug 2011

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FACIAL AESTHETIC CONFERENCE AND EXHIBITION

PREVIEW INSIDE

PREVIEW INSIDE

COSMECEUTiCALS

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Scientific measurement of patient outcomes

Diagnostic and therapeutic challenges

SKiN HeAltH MELAnOMA EpiDEMiC patient education and prevention strategy

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 SCAR REVISION

Patient diversity and treatment options

LiFESTYLE AnD AgEing the effect of diet on skin ageing processes

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A nEW LighT i SKinCARE pRODUCTS i ROSACEA alternatives to hydroquinone

our expert panel provide their recommendations

volume 05 issue 04 number 20

volume 16 issue 2 number 62

23/12/2013 14:59

HETI

hYDROXYACiDS FOR AnTi-AgEing SKinCARE

ON

a comprehensive skincare regime

Filler nightmares

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FACIAL AESTHETIC CONFERENCE AND EXHIBITION

Non-invasive fat reduction

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volume 16 issue 3 number 63

volume 16 issue 1 number 61

Eating behaviours and the role of CBT and hypnosis for weight loss

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volume 06 issue 01 number 21

FACI

ShAping Up i COgniTiVE BEhAViORAL ThERApY i FAT FREEZing Combination body lift for men

pERiORBiTAL MELAnOSiS

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our paneL of eXperts disCuss fiLLers, toXins and the future of inJeCtaBLes

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The UK Journal of Medical Aesthetics and Anti-Ageing

FACiNG tHe FutuRe

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International Journal of Medical Aesthetics and Anti-Ageing

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CORRECTing OThER pRACTiTiOnERS’ MiSTAKES

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s new procedures, products and services are launched and patients’ demands intensify, your own knowledge needs to keep up with change. Whether you wish to know about the efficacy and contraindications of a new filler or borrow tips from a master injector of toxins, you can rely on Body Language to keep you informed and up to date.

Body Language is a bi-monthly journal aimed at all medical practitioners in medical aesthetics and anti-ageing. It is full of practical information written by leading specialists with the intention of helping you in your pursuit of best practice.

Assisting professionals in medical aesthetics, Body Language has taken stock of developments and investigates the methods of experienced practitioners around the world, commissioning experts to pass on their knowledge in our editorial pages. Our editorial provides you with professional accountancy and legal advice that alone can save you thousands of pounds.

You can also help yourself to continuing professional development (CPD) points. You can determine how many within the CPD scale that our articles are worth to you and self-certify your training.

As a subscriber, you can access back issues of Body Language.

You will be emailed your own code to enable you to read articles online. That in itself is a big time-saver. Rather than have to track down a misplaced issue from six, nine or 14 months ago to reread an article, you can refer to it online in seconds.

Body Language continues to be at the forefront of publications in the medical aesthetics sector. Its leading position owes much to it being a practical journal that puts theory into practice and assists you to do your job as best as you can.

You cannot afford to be without Body Language.

SUBSCRIBE UK subscription £60 for one year  UK subscription £110 for two years  Name: Company Name: Address:

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15/06/2011 13:58:08

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

body language I PRODUCTS 53

on the market The latest products in aesthetic medicine, as reported by Helen Unsworth

1. SkinCeuticals have launched Resveratrol B E, their first night time antioxidant formulation to help support the skin’s natural defence system against free radical damage and help repair the appearance of accumulated skin ageing. Resveratrol BE contains 1% pure, stable resveratrol with hydrotopes for optimum absorption and 0.5% baicalin and 1% alpha tocopherol.

Suitable for all skin types, Resveratrol B E should be applied at night after cleansing and can help target indications including photodamage loss of skin firmness and loss of skin radiance, poor elasticity and fine lines and wrinkles.

SkinCeuticals, T: 0208 7624987; W: skinceuticals.co.uk

1

2 2. miraDry—a treatment for ecessive sweating—is now available in the UK. The miraDry uses controlled electromagnetic energy to penetrate the sweat glands, heat and eliminate them. Results are long lasting and treatment is non-invasive with no downtime or repeat treatments required.

Aesthetic Business Partners LLP, T: 01788 571200; W: miradry.co.uk

3

3. The deCURE range is now available from Eden Aesthetics, including the NoTox Wrinke Eraser, to help minimise the appearance of fine lines and wrinkles. Effects are said to be seen within five minutes and last eight to 12 hours.

Eden Aesthetics, T: 01245 227752; W: edenaesthetics.com

4

4. The VECTRA H1 delivers clinical quality 3D imaging using intuitive image capture and FACE Sculptor application software. It incorporates an SLR camera body and range of assessment tools to educate patients about their options, explain limitations and set expectations.

Surface Imaging Solutions, T: 07774802409; W: surfaceimaging.co.uk

54 PRODUCTS I body language

5

6. Institute Hyalual have added AquaLual MELTWATER to their product portfolioâ&#x20AC;&#x201D;a facial mist containing Meltwater and hyaluronic acid to refresh, plump and tone the face. Benefits are said to include improvement in skin tone, hydration, moisture preservation and increased cell metabolism.

Rederm, T: 020 3651 1227; W: rederm.co.uk

5. Flint + Flint is a new range of skincare products created by Maxine and Adam Flint, who used their twenty years combined industry experience to create a series of simple products that use active ingredients. The range of nine products can be used on all skin types and are made in England.

Flint Plus Flint, T: 01270 625 172; W: flintplusflint.com

6

7 7. Thermavein offers a new process to treat visible facial thread veinsâ&#x20AC;&#x201D;thermocoagulation. With around 65% of the UK population suffering from some level of visible facial vains, the treatment is growing in popularity, say Thermavein. The procedure quickly seals the vein wall preventing blood from re-entering and therefore eliminating the vein. It can be used to treat thread veins, spider veins, vascular blemished and spider naevi.

Thermavein, T: 08456262400; W: thermavein.com

9

8 8. Enerjet from Breit Aesthetics, is a new dermal remodelling system that pneumatically introduces a jet of hualuronic acid to help remodel skin, repair scars and lift facial tissue. Breit Aesthetics say it is designed for hard-to-treat indications and gives immediate results and more youthful looking skin.

Breit Aesthetics, T: 0207 193 2128; W: breitaesthetics.com

9. The Oxy Xtra Med is a device designed to infuse molecules of oxygen and active ingredients inside the vascular glomus. Once inside, the oxygen is said to act on microcirculation, adipose tissues, epidermis and derma.

Vida Health & Beauty Limited, T: 01306 646526; W: vidahealthandbeauty.com

Private Dermatology Centre, London Dermatologist or Physician with special interest in Dermatology



The Cranley Clinic, a well-respected private clinic offering a comprehensive range of dermatological and cosmetic treatments, is expanding.

This is a rare opportunity to work alongside leading consultant dermatologist Dr Nick Lowe in London, W1.

The ideal candidate will be a dermatologist and/or physician with a special interest in cosmetic dermatology, lasers and all related treatment systems plus an interest in skin disease.Valid GMC registration and Medical Indemnity Insurance required.

The successful candidate will receive training where needed.

Please send your cv in confidence to cranley@cranleyclinic.com

TRAINING

WIGMORE

medical TRAINING

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

All courses in London unless specified.

JULY

AUGUST

SEPTEMBER

OCTOBER

1 ZO Medical Basic 2 ZO Medical Interm.

4 Angel PRP* 7 Platelet Rich Plasma (PRP)* 8 ZO Medical Basic (Dublin) 9 ZO Medical Interm. (Dublin) 10 ZO Medical Adv. (Dublin) 10 Advanced Fillers-TT* (am) 10 Advanced Fillers-CH* (pm) 11 CPR & Anaphylaxis Update 12 Microsclerotherapy* 14 glōMinerals 15 glōTherapeutics 21 Medik8 Dermal Roller 23 Skincare & Peels 24 Intro to Toxins* 25 Intro to Fillers*

1 Sculptra(Day 1 of 2) 2 Mini-Thread Lift 4 ZO Medical Basic 5 ZO Medical Interm.

18 Medik8 Dermal Roller 19 Advanced glōTherapeutics 20 Skincare & Peels 21 Intro to Toxins* 22 Intro to Fillers* 30 Microsclerotherapy* 29 Advanced Fillers-F* (pm)

1 ZO Medical Basic 2 ZO Medical Interm.

4 Advanced Toxins* (am) 4 Advanced Fillers-LF* (pm) 5 Mini-Thread Lift 8 Platelet Rich Plasma (PRP)* 10 CPR & Anaphylaxis Update 16 Sculptra 17 Skincare & Peels 18 Intro to Toxins* 19 Intro to Fillers* 21 Microsclerotherapy* 22 Medik8 Dermal Roller 24 glōTherapeutics

1 ZO Medical Basic 2 ZO Medical Interm.

6 Platelet Rich Plasma (PRP)* 9 Advanced Fillers-TT* (pm) 9 Advanced Fillers-F* (pm) 14 Sculptra 18 Microsclerotherapy* 20 Medik8 Dermal Roller (pm) 21 glōTherapeutics 22 Skincare & Peels 23 Intro to Toxins* 24 Intro to Fillers* 30 Sculptra 31 CPR & Anaphylaxis Update

CH = Cheeks/mid-face F = Forehead LF = Lower face TT = Tear troughs

Follow @wigmoretraining on Twitter for the latest updates and course information

Knowledge is success

www.wigmoremedical.com/events training@wigmoremedical.com Twitter: @wigmoretraining 0207 514 5979

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body language I EDUCATION 57

training TOXINS AND FILLERS 16 JULY, Advanced Botulinum Toxin A Course, Newport W: honeyfizz.co.uk 24-25 JULY, Introduction to Toxins and Fillers, Wigmore Medical, London W: wigmoremedical.com 26 JULY, Botox & Dermal Fillers Foundation, The Paddocks Clinic, Buckinghamshire W: cosmeticcourses.co.uk 27 JULY, Introduction to Toxins, Wigmore Medical, London W: wigmoremedical.com 30 JULY, Advanced Dermal Filler or Lips Masterclass Training Day, Newport W: honeyfizz.co.uk 21-22 AUGUST, Introduction to Toxins and Fillers, Wigmore Medical, London W: wigmoremedical.com 30 AUGUST, Botox & Dermal Fillers Foundation, The Paddocks Clinic, Buckinghamshire W: cosmeticcourses.co.uk 6 SEPTEMBER, Botox & Dermal Fillers Advanced, The Paddocks Clinic, Buckinghamshire W: cosmeticcourses.co.uk 18-19 SEPTEMBER, Introduction to Toxins and Fillers, Wigmore Medical, London W: wigmoremedical.com 20 SEPTEMBER, Botox & Dermal Fillers Foundation, The Paddocks Clinic, Buckinghamshire W: cosmeticcourses.co.uk

OTHER INJECTABLES 1 AUGUST, Sculptra, Wigmore Medical, London W: wigmoremedical.com 7 AUGUST, PRP Training, The Paddocks Clinic, Buckinghamshire W: cosmeticcourses.co.uk 15 AUGUST, Angel PRP, Wigmore Medical, London W: wigmoremedical.com 30 AUGUST, Microsclerotherapy, Wigmore Medical, London W: wigmoremedical.com 8 SEPTEMBER, Platelet Rich Plasma (PRP), Wigmore Medical, London W: wigmoremedical.com 16 SEPTEMBER, Sculptra, Wigmore Medical, London W: wigmoremedical.com 21 SEPTEMBER, Microsclerotherapy, Wigmore Medical, London W: wigmoremedical.com

SKINCARE 15 JULY, Epionce Microneedling Training, Eden Aesthetics, Liverpool W: edenaesthetics.com 15 JULY, Systematic Approach to Treating Acne & Related Problems, Clinogen Aesthetic Training Centre, Windsor, Berks W: clinogen.com T: 01628 674 644 21 JULY, Medik8 Dermal Roller, Wigmore Medical, London W: wigmoremedical.com

23 JULY, Skincare & Peels, Wigmore Medical, London W: wigmoremedical.com 29-30 JULY, Dedicated Brand, Science and Product Knowledge, Skinceuticals Training Centre of Excellence, London W: skinceuticals.co.uk T: 0208 762 4860 31 JULY, Advanced Peel Training, Skinceuticals Training Centre of Excellence, London W: skinceuticals.co.uk T: 0208 762 4860 31 JULY, Dermaroller Training, The Paddocks Clinic, Buckinghamshire W: cosmeticcourses.co.uk 1 AUGUST, Chemical Peel Training & Starter Kit, The Paddocks Clinic, Buckinghamshire W: cosmeticcourses.co.uk 4-6 AUGUST, Basic, Intermediate and Advanced ZO training, Wigmore Medical, London W: wigmoremedical.com 6 AUGUST, Microdermabrasion (Face & Body), Academy of Advanced Aesthetics, Cambridgeshire W: academyofadvancedaesthetics.com 6 AUGUST, Epionce Microneedling Training, Eden Aesthetics, Liverpool W: edenaesthetics.com 18 AUGUST, Medik8 Dermal Roller, Wigmore Medical, London W: wigmoremedical.com 19 AUGUST, Advanced gloTherapeutics, Wigmore Medical, London W: wigmoremedical.com 20 AUGUST, Skincare & Peels, Wigmore Medical,

London W: wigmoremedical.com

Birmingham W: sterex.com

1-3 SEPTEMBER, Basic, Intermediate and Advanced ZO training, Wigmore Medical, London W: wigmoremedical.com

28-29 JULY, Advanced Electrolysis (Part I), Sterex Electrolysis International Ltd, Bridgend, Wales W: sterex.com

10 SEPTEMBER, Microdermabrasion (Face & Body), Academy of Advanced Aesthetics, Cambridgeshire W: academyofadvancedaesthetics.com

LASER

17 SEPTEMBER, Skincare & Peels, Wigmore Medical, London W: wigmoremedical.com 22 SEPTEMBER, Medik8 Dermal Roller, Wigmore Medical, London W: wigmoremedical.com 24 SEPTEMBER, gloTherapeutics, Wigmore Medical, London W: wigmoremedical.com 26 SEPTEMBER, Dermaroller Training, The Paddocks Clinic, Buckinghamshire W: cosmeticcourses.co.uk

HAIR REMOVAL 14 JULY, Advanced Hair Removal Techniques for Vellus Hair & Light Hair, Clinogen Aesthetic Training Centre, Windsor, Berks W: clinogen.com T: 01628 674 644 14-15 JULY, Advanced Electrolysis (Part I), Sterex Electrolysis International Ltd, Hastings, Sussex Coast W: sterex.com 18 JULY, Refresher Advanced Cosmetic Procedures, Sterex Electrolysis International Ltd,

13-18 JULY, Fellowship in Aesthetic Medicine (A4M), Institute of Medical Aesthetics, Dubai, UAE W: a4m.com T: +971 50 655 8684

OTHER TRAINING 11 JULY, CPR & Anaphylaxis Update, Wigmore Medical, London W: wigmoremedical.com 28-29 JULY, Radio Frequency (RF), Academy of Advanced Aesthetics, Cambridgeshire W: academyofadvancedaesthetics.com 10 AUGUST, Mini Thread training, Wigmore Medical, London W: wigmoremedical.com 13-14 AUGUST, Radio Frequency (RF), Academy of Advanced Aesthetics, Cambridgeshire W: academyofadvancedaesthetics.com 5 SEPTEMBER, Mini Thread training, Wigmore Medical, London W: wigmoremedical.com 10 SEPTEMBER, CPR & Anaphylaxis Update, Wigmore Medical, London W: wigmoremedical.com Send training dates for consideration to arabella@face-ltd.com

58 EXPERIENCE I body language

Socialised medicine WENDY LEWIS reminisces on how she came to be called the Knife Coach and found her true calling in social media

I

t’s in my blood; writing that is. My late father, David Lewis, a defence attorney by profession, was a correspondent for the Stars & Stripes during WWII when he served in the American Army in Italy. Funnily enough, his parents met in Manchester, having emigrated from Russia at the turn of the century, and ultimately ended up on Ellis Island to enter the USA. (Yes, I do have a British connection). My mother, who holds a Masters Degree in education, is also an excellent storyteller.

I got the moniker “Knife Coach” in 2003 when I launched my book called Beauty Battle (Quadrille) in Australia. I gave an interview over chopped salad at a posh French bistro on New York’s upper east side. The journalist wrote a profile about my unique role as a matchmaker for private clients to connect them with the best plastic surgeons and dermatologists around the world for the magazine Sunday Life, entitled “Knife Coach.”

I thought it was so clever that I trademarked it and started using it.

When I started my cosmetic surgery consultancy in 1997, most of my clients were female, Caucasian, over 40, fairly affluent, living in the New York area, and primarily concerned about their ageing faces. Today, I have no typical client. I work with a cross section of women and men, from teens to silvers, from all over the world. They are barristers, professors, artists, actors, soccer moms, estate agents, and bankers. They are interested in everything from neck lifts to breast lifts, lasers, lipo and volumising fillers. And although some will pay a premium to see me in person, others are quite happy to have a phone or Skype chat at their convenience.

In my first book, The Lowdown on Facelifts and Other Wrinkle Remedies (Quadrille, 2000), I started Chapter One with creams, sailed through peels and lasers, dove into fillers and Botox, but I did not get into proper surgery until Chapter Five, about halfway through the book.

My rationale was that a lot of readers would have a go at the first few chapters, but when it came to reading about scal-

pels, scarring and anaesthetics, many would go pale and toss the book in a drawer, or bin it.

Fourteen years have passed, and I’ve written ten more beauty books since those days in my own name, and almost twice as many for doctors as a ghostwriter. My last book was an e-book, which marked my migration into the digital world.

Wow, how the world has changed!

Consumers have an insatiable appetite for information about all things beauty and anti-ageing. They are knowledgeable, empowered to do their research and make better decisions, and also have far more choices in terms of practitioners, clinics and treatment options. They are also more vocal, log in and out of chat rooms and forums effortlessly, study clinic websites and Facebook pages on their Smartphones, and are making use of ratings and review sites with astounding vigour.

Facelifts meet Facebook I began dabbling on Twitter in 2008 and Facebook in 2009, out of sheer curiosity.

Rarely at a loss for words, I was a like a fish to water. After a lifetime of schmoozing, it was only natural that I would find a voice online.

I started blogging on Beautyinthebag. com in 2008 as a hobby for my daughter Eden and I to do together. I knew instinctively that we could never afford to invest heavily in SEO and PPC, so we put our efforts into grass roots social growth. We never dreamed that it would blossom into an online magazine that now has over 160,000 Facebook fans and 58,000 followers on our primary Twitter (there are four more). We joined the Pinterest party in early 2013 and kind of reluctantly became active on Instagram the same year.

My initial foray into social was to see what all the excitement was about and determine if it really worked for businesses. I quickly saw that it did indeed and realised the power of this new wave of communication. My next move was to harness what I had taught myself, build a team and market our services to brands and companies.

My daughter cringed the first time she overheard me teach a group of 20-somethings how to post and pin. The more active I became on social platforms, the more I started talking about it and sharing what I had discovered. When you have a passion for something, you want to share the love.

So why is social media so addictive to some of us? A fascinating study conducted at Harvard University concluded that the act of disclosing information about oneself activates the same part of the brain that is associated with the sensation of pleasure; the same pleasure that we get from eating food, getting money or even having sex.

In fact, according to the researchers, “Humans devote 30–40% of speech output solely to informing others of their own subjective experiences.” Although sharing a status update may not be as satisfying as having a piece of luscious chocolate, the human brain also considers selfdisclosure to be a rewarding experience.

What’s my next book all about? A guide to social media for aesthetics clinics of course!

Wendy Lewis is President of Wendy Lewis & Co Ltd, Global Aesthetics Consultancy in New York City. wl@wlbeauty.com Reference 1. http://wjh.harvard.edu/~dtamir/TamirPNAS-2012.pdf

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1. BEL-DOF3-001_01. 2. Tran C et al. in vivo bio-integration of three Hyaluronic Acid fillers in human skin: a histological study. Dermatology DOI:10.1159/000354384. 3. Taufig A.Z. et al., J Ästhet Chir 2009 2:29 – 36. 4. Prager W et al. A Prospective, Split-Face, Randomized, Comparative Study of safety and 12-Month Longevity of Three Formulations of Hyaluronic Acid Dermal Filler for Treatment of Nasolabial Folds. Dermatol Surg 2012, 38: 1143 – 1150.

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BEL092/0314/FS Date of preparation: April 2014