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MZ065 Belotero Volume AJ FC BEL191-0215-LD.indd 1 Anatomy of The Vitamin The Patient13/02/2015 14:57 Understanding the Eye Drip Debate Journey Dr Sabrina Shah- We weigh up the pros Dr Hilary Allan Obesity CPD Desai examines the and cons and uncover highlights the best Dr Sotirios Foutsizoglou provides an anatomical significance the latest developments method of perfecting introduction to obesity management of the periorbital area in vitamin infusion the patient experience 2862 Med-fx Ad March 2015_Med-fx Sales Ad 12/02/2015 15:40 Page 1

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From the latest specialist items to everyday consumables – it’s got to be Med-fx! NEW Magnifibres Advanced Medik8 Brush-on Emervel Pigment Retinol 6TR False Lashes Classic Corrector Only £90.00 Only £15.50 Now £10.35 1.0ml 600090 Now £37.08 15ml 630934 Each 630797 30ml 630599 Contents • March 2015 06 News The latest product and industry news 14 On the Scene Out and about in the industry this month Special Feature 16 Conference Report Treating an Aesthetic Patient We report on the International Master Course on Aging Skin Page 21 (IMCAS) conference in Paris 18 News Special A final preview of the highly anticipated CEA 2015 CLINICAL PRACTICE 21 Special Feature: How to treat an aesthetic patient We ask three aesthetic practitioners to assess the same patient Patient Experience and share their individual approaches The Patient Journey Page 54 27 CPD Clinical Article In a two-part weight loss special, Dr Sotirios Foutsizoglou gives an Clinical Contributors introduction to managing obesity Dr Sotirios Foutsizoglou specialises in minor 34 Spotlight On: Plexr Soft Surgery cosmetic surgery and aesthetic medicine. He is founder and medical director of SF Medica, and We look at the latest advancements in non-ablative technology has lectured and presented on various topics both 39 The Vitamin Drip Debate nationally and internationally. Allie Anderson investigates the growing trend for vitamin infusion Dr Tapan Patel is the founder and medical director of VIVA and PHI Clinic. With more than 42 Anatomy of the Eye 14 years of clinical experience, he is passionate about standards in aesthetic medicine and regularly Dr Sabrina Shah-Desai provides an overview of periorbital anatomy participates in active learning. 47 Patient Satisfaction Mr Adrian Richards is a plastic and cosmetic surgeon. He is the clinical director of both Dr Beatriz Molina outlines her role in recent research on measuring Aurora Clinics and Cosmetic Courses, the patient satisfaction largest non-surgical training provider in the British Isles. 48 Hair Transplant Techniques Dr Tamara Griffiths is a consultant Dr Greg Williams on current treatments to restore hair and reconstruct dermatologist and honorary lecture at the previous procedures University of Manchester. She is also clinical research lead and director of the MSc in Skin 52 Advertorial: SkinCeuticals Ageing and Aesthetic Medicine. SkinCeuticals invite you to discover their Vitamin C antioxidant range Dr Sabrina Shah-Desai is an oculoplastic surgeon specialising in eyelid lifts, ptosis, 53 Abstracts and revision eyelid surgery. She is highly A round-up and summary of useful clinical papers experienced in non-surgical periorbital rejuvenation. IN PRACTICE Dr Beatriz Molina is a member of the British College of Aesthetic Medicine (BCAM) and 54 The Patient Journey founder of the Medikas Medispa Clinic. She Dr Hilary Allan on the factors that create the perfect patient experience also teaches techniques for botulinum toxin administration. 56 The Art of Sharing Knowledge Dr Greg Williams is a hair transplant surgeon D Kieren Bong details the best methods of sharing knowledge and member of the British Association of Aesthetic Plastic Surgeons (BAAPS). He has 60 Hiring Staff more than 10 years of experience in hair Victoria Vilas explains how to pick the right candidate for the job restoration procedures. 63 Partnership Agreements NEXT MONTH Shubha Nath outlines the key points to keep in mind when working • IN FOCUS: Smile • Managing Obesity • Treating the Lips • Advances in Laser with a business partner 65 The Mobile Revolution Tracey Prior on why your practice should be mobile-ready 66 In Profile: Emma Davies Aesthetics Conference We talk to aesthetic nurse Emma Davies about her successful and Exhibition journey into the world of aesthetics 68 The Last Word: Training in Dermatology 7-8 March 2015 Dr Paul Charlson argues the importance of dermatological training www.aestheticsconference.com for aesthetic practitioners

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A4 Aneva Derma.indd 1 12/12/2014 14:11 Editor’s letter

One fundamental truth of the aesthetics a ‘factory’ type approach to consultation and treatment (p.66). industry is that without patients we have no For our Special Feature this month (p.21) we asked a surgeon, business, and no working practice. This means dermatologist and cosmetic doctor to share their individual that the work of nurturing a patient, and taking approaches to treating the same patient. Their answers are care of their experience from start to finish is illuminating, and express the wide breadth of our practice. Amanda Cameron essential in ensuring continued practice, and March sees all our ACE 2015 planning come to fruition, after months Editor continued success. Every patient is different, of hard work and incredible contribution from leading names in and the approach to each individual must the aesthetics speciality. The first weekend of March will see top be customised as such in order to fully embrace the notion of the names – the latest of these being renowned aesthetic pioneer Dr ‘patient journey’ – a term often used but not nearly so often fully Arthur Swift – engage in interactive and educational sessions and considered and accommodated for. ground-breaking debate at the Business Design Centre in central This issue is dedicated to the idea of the patient experience. The London. We are extremely proud to present the four key sessions factors that contribute to this, and how they should be exercised that comprise the conference’s Main Agenda; including body image TM in order to ensure patients feel cared for and satisfied. Dr Hilary and fat treatment, injectables to treat the upper and lower face, Allan leads the exploration in In Practice by addressing the in-clinic and dermatology with a focus on the patient. For those attending Aneva Derma elements that together create a positive and long-lasting impression – be prepared to brush up on your anatomy! New technology this on your patients – from reception comforts to members of staff with year allows for audience participation, enabling you to vote on Advanced Nutritional SKIN Beverage dedicated roles for patient care (p.54). Dr Beatriz Molina underlines aesthetic issues whilst observing treatment from all angles with the the importance of documenting and measuring patient satisfaction aid of a three-screen stage. There is still time to register; visit www. in aesthetic research (p. 47), and our In Profile practitioner, nurse aestheticsconference.com now. In the meantime, we love to hear independent prescriber Emma Davies, stresses the importance of a your feedback issue by issue, so make sure to send us your thoughts Anti-Ageing measured and thorough approach to patient care – warning against @aestheticsgroup or email us at [email protected] Editorial advisory board We are honoured that a number of leading figures from the medical aesthetic community have joined Aesthetics Journal’s from Within editorial advisory board to help steer the direction of educational, clinical and business content Dr Mike Comins is fellow and former president of the Dr Raj Acquilla is a cosmetic dermatologist with over 11 years British College of Aesthetic Medicine. He is part of the experience in facial aesthetic medicine. UK ambassador, global cosmetic interventions working group, and is on the faculty for KOL and masterclass trainer in the cosmetic use of botulinum toxin the European College of Aesthetic Medicine. Dr Comins is also and dermal fillers, in 2012 he was named Speaker of the Year at an accredited trainer for advanced Vaser liposuction, having the UK Aesthetic Awards. He is actively involved in scientific audit, performed over 3000 Vaser liposuction treatments. research and development of pioneering products and techniques.

Mr Dalvi Humzah is a consultant plastic, reconstructive and Dr Tapan Patel is the founder and medical director of VIVA aesthetic surgeon and medical director at the Plastic and Derma- and PHI Clinic. He has over 14 years of clinical experience and tological Surgery. He previously practised as a consultant plastic has been performing aesthetic treatments for ten years. Dr surgeon in the NHS for 15 years, and is currently a member of the Patel is passionate about standards in aesthetic medicine and British Association of Plastic, Reconstructive and Aesthetic Surgeons still participates in active learning and gives presentations at (BAPRAS). Mr Humzah lectures nationally and internationally. conferences worldwide.

Sharon Bennett is chair of the British Association of Mr Adrian Richards is a plastic and cosmetic surgeon with Cosmetic Nurses (BACN) and also the UK lead on the BSI 12 years of specialism in plastic surgery at both NHS and private committee for aesthetic non-surgical medical standard. Sharon clinics. He is a member of the British Association of Plastic and has been developing her practice in aesthetics for 25 years and Reconstructive Surgeons (BAPRAS) and the British Association of has recently taken up a board position with the UK Academy of Aesthetic Plastic Surgeons (BAAPS). He has won numerous awards Aesthetic Practitioners (UKAAP). and has written a best-selling textbook.

Dr Christopher Rowland Payne is a consultant Dr Sarah Tonks is an aesthetic doctor and previous dermatologist and internationally recognised expert in cosmetic maxillofacial surgery trainee with dual qualifications in both Aneva Derma™ is a new, dermatology. As well as being a co-founder of the European medicine and dentistry. Based at Beyond Medispa in Harvey Society for Cosmetic and Aesthetic Dermatology (ESCAD), he was Nichols, she practises cosmetic injectables and hormonal- clinically proven, nutraceutical also the founding editor of the Journal of Cosmetic Dermatology based therapies. drink supplement. and has authored numerous scientific papers and studies. The ingredients in Aneva Derma™ Advanced PUBLISHED BY FOLLOW US Nutritional SKIN beverage are digested and EDITORIAL ADVERTISING @aestheticsgroup distributed via the blood vessels into the deeper Chris Edmonds • Managing Director Hollie Dunwell • Business Development Manager T: 0203 096 1228 | M: 07867 974 121 T: 0203 096 1228 | M: 07557 359 257 Aesthetics Journal layer of the dermis, where they multiply and [email protected] [email protected] stimulate ﬁ broblast cells to produce more Suzy Allinson • Associate Publisher Sadia Rahman • Customer Support Executive Aesthetics collagen and hyaluronic acid in the dermis. T: 0207 148 1292 | M: 07500 007 013 T: 0203 096 1228 | [email protected] [email protected] MARKETING ARTICLE PDFs AND REPRO Amanda Cameron • Editor Marta Cabiddu • Marketing Manager Material may not be reproduced in any form without the T: 0207 148 1292 M: 07810 758 401 T: 0207 148 1292 | [email protected] publisher’s written permission. For PDF file support please • Boosts collagen production, HA and skin hydration. [email protected] EVENTS contact Sadia Rahman; [email protected] Betsan Jones • Assistant Editor Helen Batten • Events Manager • Improves overall skin health and supports ageing skin. T: 0207 148 1292 | M: 07741 312 463 T: 0203 096 1228 | [email protected] © Copyright 2015 Aesthetics. All rights reserved. Aesthetics • Once daily, pleasant tasting, easy to digest. www.aneva.co.uk [email protected] Kirsty West • Assistant Events Manager Journal is published by Synaptiq Ltd, which is registered Chloé Gronow • Journalist T: 0203 096 1228 | [email protected] as a limited company in England; No 3766240 T: 0207 148 1292 M: 07788 712 615 DESIGN [email protected] Peter Johnson • Senior Designer Meeting the needs of your business, Hazel Murray • Journalist T: 0203 096 1228 | [email protected] T: 0207 148 1292 Chiara Mariani • Designer DISCLAIMER: The editor and the publishers do not necessarily agree with the views delivering high satisfaction to your patients [email protected] T: 0203 096 1228 | [email protected] expressed by contributors and advertisers nor do they accept responsibility for any errors in the Call us on 01234 313130 [email protected] www.aestheticsource.com transmission of the subject matter in this publication. In all matters the editor’s decision is final.

A4 Aneva Derma.indd 1 12/12/2014 14:11 @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

ACE Talk Aesthetics Dr Arthur Swift to present at #PatientEducation BAAPS Press Office/@BAAPSMedia BAAPS Prez Michael Cadier: “[Patients] are doing Merz Live Demonstration Zone their research, taking their time and coming to us with realistic expectations.” #Finally as part of ACE 2015 #USA Dr. Harold Lancer/@DrLancerRx It has been confirmed that renowned practitioner and trainer Dr Arthur Swift What happens in Vegas never stays in Vegas! will be joining the line-up at the Merz Live Demonstration Zone, as part of the Happy to be at @nordstromlv today sharing the Aesthetics Conference and Exhibition (ACE) weekend in March. Dr Swift will be Method & how to #getyounger launching Belotero+ Volume and joining a panel of specialists to discuss safety #FaceOff Dr Vidhya Maheswaran/@DrVidhyaM in the industry. The renowned practitioner will also be joining the Main Agenda at @aestheticsgroup I am seriously looking forward the highly anticipated conference, where the main programme will include leading to ACE 2015! ‘Face off’ & ‘Getting into the zones’ is practitioners Dr Raj Acquilla, Dr Tapan Patel and Mr Dalvi Humzah presenting on on my agenda. stage together for the first time. Joining Saturday afternoon’s ‘Face Off’ module, #Ambition Dr Swift will be aiding the trio to present the best and most innovative techniques Dr Tapan Patel/@drtapanp in facial rejuvenation today. Dr Raj Acquilla said, “I am delighted to welcome my When Alexander saw the breadth of his domain, he wept for there were no more worlds to dear friend and colleague Dr Arthur Swift to the ACE faculty. We are honoured to conquer. What are your goals? #ambition have him join us for our first live injection symposium where he will showcase his #motivation unique approach to creating the Beautiful Upper Face using a S.A.F.E. anatomical #ACE2015 technique.” He added, “This will be a true masterclass in facial aesthetics and a The Banwell Clinic/@banwellclinic great learning experience not to be missed for injectors of all levels.” The Banwell Clinic is proud to share that Paul ACE 2015 will take place on March 7 and 8 in Central London. Banwell FRCS (Plastic) will be a Key Speaker at ACE For full information and to register visit www.aestheticsconference.com 2105 (7/8th March). @aestheticsgroup. #Journal Look & Feel Younger/@DrTerryLoong Industry @LornaBowes great article on the role of moisturisers in GMC considers action against @aestheticsgroup magazine. #Training individuals involved with Facial Anatomy/@facialanatomy @pdsurgery Busy year ahead for bespoke Facial Anatomy Teaching! Exciting plans ahead! private practice cash referrals #awardwinning Following the exposure of six-figure incentive packages to doctors for patient To share your thoughts follow us on Twitter referrals to private hospitals, the UK General Medical Council (GMC) have @aestheticsgroup, or email us at condemned the practise as wrong. The news comes in lieu of the revelation [email protected] published by the British Medical Journal (BMJ) that, allegedly, private hospital chains have been ‘buying’ referrals to their facilities; by offering practitioners Psoriasis up to £100,000 in rewards and incentive packages. Though the Competitions and Marketing Authority (CMA) had ruled that rewards and cash incentives for Cosentyx approved patient referrals must end in April last year, since being formally exposed in 2011, it was found that the practise had not ceased while the inquiry was on-going. for psoriasis treatment The BMJ reported that one surgeon had recently approached them claiming he had been offered a six-figure package for patient referrals after the CMA in US and Europe had ruled that such practise was detrimental to patient welfare. The BMJ further reported that independent practices, including ones in Harley Street, were Consentyx has become the first interleukin-17 offered free rents in return for referrals to the private hospitals. In a statement prohibitor to be approved for use in the treatment from the GMC, chief executive Niall Dickson said, “The GMC takes very seriously of psoriasis, both by the FDA and the European the issue of conflicts of interests. That is why we have clear and unambiguous Commission. Cosentyx is also the first biologic agent to guidance in Good Medical Practice that doctors must be honest in financial be cleared for front-line use in the EU. Trials indicated and commercial dealings. Our guidance states that doctors ‘must not allow any that Cosentyx had 100% or 90% clearance on the interests you have to affect the way you prescribe for, treat, refer or commission psoriasis area and severity index, in 70% or more of services for patients.’” The GMC are now completing an internal review of the treated patients within 16 months of starting treatment. CMA that highlights the potential for conflicts of interest to arise when doctors Head of Novartis Pharmaceuticals David Epstein said refer patients for medical treatment. “When that is complete, we will be writing the approval marks “a turning point for psoriasis patients, to all independent healthcare providers and their Responsible Officers seeking who can now benefit from the first and only approved assurances from them that they have responded to the report and that they are treatment targeting the IL-17 pathway, proven to play a not operating any schemes that could place their doctors in a position where key role in the development of plaque psoriasis.” they could be acting outside our guidance,” said Dickson.

Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015 aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics

Surgical Technology Popularity of cosmetic Study finds app improves surgery declines sun protection usage

The British Association of Aesthetic Plastic Surgeons (BAAPS), Users of a mobile app have reported using more sun protection has announced that the demand for cosmetic surgeries has after following the advice on their phone. dropped by 9% since 2013. According to BAAPS, the top ten The Solar Cell app provides real-time sun protection advice, based on surgical procedures performed on both men and women in 2014 UV Index forecasts and personal information from the user. The app totalled 45,406, compared to 50,122 in 2013, and their order of also sends alerts to users informing them as to when they need to popularity has shifted for the first time in five years. Although breast apply or reapply sunscreen. augmentation procedures remain the most popular cosmetic A randomised clinical study on Solar Cell’s influence was conducted, surgery choice in the UK, demand for the procedures dropped by enrolling 604 participants. Complete data from the first-phase study 23% in 2014. Breast reduction surgery, however, increased by 3% results was available on 454 individuals (222 in the treatment group in women and 1% overall. Rhinoplasty procedures fell dramatically and 232 in a control group), and found that 41% of participants in from 2013 with 24% less people opting for the surgery in 2014, the treatment group reported spending more time in the shade, whilst abdominoplasty procedures declined by 20% overall. compared to 33.7% in the control group. Liposuction procedures, however, moved from the 6th to 5th most More participants in the control group, however, (34.5%) reported popular cosmetic surgery procedure in the UK, with 7% more using sunscreen than those in the treatment group (28.6%). people opting to have the surgery in 2014. Face and neck lifts in A second randomised trial showed increased improvement in the women were the only other procedures to increase in popularity, use of sun protection. At the seven-week follow-up, researchers with a rise of 1%. BAAPS has suggested that these findings show found that 23.8% of participants who utilised the app deployed the that aesthetic patients are considering surgery with more caution use of wide-brimmed hats more frequently, compared to those in the and rationality than in previous years. control study who did not utilise the app (17.4%). Results indicated that According to former BAAPS president and consultant plastic 46.4% of women and 43.3% of men made more use of combined sun surgeon Mr Rajiv Grover, the results have reflected a ‘more protection (sunscreen, protective clothing and shade) after using the educated’ Britain. He said, “The difference between 2013 and mobile app. The authors said, “The Solar Cell mobile app seemed 2014 may seem surprising, but the dramatic double-digit rise last to promote sun protection practices, especially when it was used. year [2013] was very clearly a post-austerity ‘boom’, and figures are Specifically, it increased use of shade. Shade can substantially reduce simply now returning to a more rational level.” exposure to solar UV radiation, but it needs to be available for it to be Consultant plastic surgeon and BAAPS president Michael Cadier used.” Solar Cell was developed by Klein Buendel under a contract said, “The message to the aesthetic sector is clear: patients want with the National Cancer Institute in the US. subtle and understated and, most refreshingly, they are doing their research, taking their time and coming to us with realistic Surgical expectations.” Grover added, “It might seem counterintuitive that as plastic surgeons we could possibly welcome such a change, but ‘Aesthetic Surgery Services’ we are pleased that the public are now so much more thoughtful, cautious and educated in their approach to cosmetic surgery.” is published as European

Botulinum toxin Standard

Study shows changing pH The European Committee for Standardisation (CEN) and British Standards Institution (BSI) have announced that the ‘Aesthetic in botulinum toxin B can Surgery Services’ has now been published. After four years of development, the document (EN 16372) was approved for publication reduce injection pain in June 2014, however procedural issues halted the process until the New Year. Quoting from the National Foreword of the published A study, published in Dermatologic Surgery, has found that standard, Mike Regan, chair of the BSI Committee, said, members injection pain can be reduced without compromising results by agree that the document provides a valuable framework to work changing the pH level in the acidic solution of botulinum toxin type by for those employed in the aesthetics sector. He also said that B (BTX-B). Two patients who had developed acquired resistance the committee believe it offers useful guidelines for those seeking to botulinum toxin type A were injected with two different dilutions aesthetic treatment. Topics covered in ‘Aesthetic Surgery Services’ of BTX-B, following confirmation of their resistance. BTX-B usually include general requirements and recommendations for procedure has a pH of 5.6, but researchers diluted a dose with sodium rooms and operating theatres, hygiene standards, continuous bicarbonate in the syringe, immediately prior to injection, to professional development (CPD) and continuous medical education normalise the pH to 7.5. Pain assessments were carried out on the (CME). The document does not address dentistry, reconstructive patients to compare the two dilutions. Researchers found that the surgery or non-surgical aesthetic procedures. A two-month European BTX-B formula changed to pH 7.5 significantly reducing pain in the public consultation for non-surgical aesthetic procedures began in late injection site, with retained efficacy over a ten-week period. February 2015, and will be led and administered by the BSI.

Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015 @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

Conference Skincare New speakers announced Harley Street doctor for ACE 2015 launches new skincare

New speakers have been announced for the Aesthetics Conference and product using stem cell Exhibition (ACE) 2015, taking place on March 7 and 8. With an already extensive number of speakers set to take to the floor at ACE 2015 to speak abstracts on a variety of topics, new speakers have been added to all four agendas to offer attendees an even higher quality learning experience. Renowned Aesthetic practitioner aesthetic practitioner Dr Rita Rakus will take part in the highly anticipated Dr Vincent Wong ‘Getting into the Zones’ session with aesthetic experts Mr Dalvi Humzah, Dr has launched a Raj Acquilla and Dr Tapan Patel. Often referred to as the ‘London Lip Queen’, new revitalising Dr Rakus will offer delegates her expertise on lip enhancement during the cream, using stem injectables module on Sunday morning. It has been confirmed that the main cell abstracts with agenda will include input from Dr Samira Yousefi, aesthetic doctor and author a combination of of upcoming book Diet Peace, and plastic surgeon Mr Adrian Richards, antioxidants and who has specialist experience with fat treatments. Dr Yousefi and Mr Adrian vitamins, as the first Richards will be joining Mr Taimur Shoaib and Dr Thuvaraka Vetpillai on the product in his Vivify specialist panel for Saturday morning’s ‘The role of FAT in medical aesthetics’ skincare range. The Stem Cell Revitalising Cream is an module. This will be a dynamic session exploring case studies and discussing organic, non-fragrant cream that is free from parabens treatments within aesthetics for achieving weight loss. The Business Track and sulphate. It aims to promote healthy skin by using will see Mark Lainchbury, managing director and founder of e-clinic, discuss ingredients that synergistically work together to speed up the use of technology to attract new patients, offering expert guidance cell turnover, protect the skin from free radical damage and on how to increase patient retention rates. Eddie Hooker, managing boost the development of collagen production. Dr Wong director of insurance provider Hamilton Fraser, will also be contributing his said, “I’m so excited to be introducing my first skin care expertise to the Business Track programme, advising delegates on the most product, Vivify Stem Cell Revitalising Cream. This product effective ways to protect business from litigation. Dr Sherif Wakil, aesthetic is a unique formula that combines a number of potent, doctor and hair transplant surgeon, will join the Expert Clinics agenda to plant-based ingredients that work synergistically. I’ve had demonstrate non-surgical blepharoplasty. This session, sponsored by Fusion many patients looking for a face cream that really makes GT, will introduce Plexr, a new soft surgery technique for blepharoplasty. a difference and I hope this will be the answer they’ve Institute Hyalual has confirmed that Dr Maryam Borumand, a scientist from been looking for.” The launch of this new skincare product Rederm, will present their sponsored Masterclass on skin rejuvenation with coincides with Dr Wong’s release of cosmetic safety combination treatments using hyaluronic acid and succinic acid. campaign film Life is Beauty-Full. and will be available from For more information on speakers and the ACE agenda visit April. During the film premiere he was also awarded the www.aestheticsconference.com. Sinclair IS Pharma Practitioner of the Year Award.

Weight loss Distribution New statistics reveal one in Unique Skin to five would consider ‘quick fix’ distribute Clinical weight loss treatments Resolution products

A new study by Mintel has found that one in five people in the UK Aesthetics distributor Unique Skin has announced would consider undergoing cosmetic weight loss procedures. The study, that it is now the exclusive UK distributor for Clinical undertaken in light of the UK’s growing obesity rate, showed that 22% of Resolution products. Clinical Resolution offers, amongst people would consider having excess skin removed, while 19% would others, the Microneedle Therapy System (MTS) Roller. This consider liposuction in the future. Three in ten (27%) who had previously non-surgical, non-ablative device can be used to treat a undergone treatment, or would consider doing so, said they would undergo variety of skin conditions, including wrinkles, scarring and cosmetic surgery as what is dubbed a ‘quick fix’ to an area of their body hyperpigmentation. According to the manufacturers, clinical they disliked. Mintel’s consumer lifestyle analyst, Jack Duckett, said, “The studies have shown MTS to be more effective than ablative high level of pressure from the Government and health organisations on treatments such as laser resurfacing, microdermabrasion and consumers to lose weight is likely to continue to intensify over the coming chemical peels. Julian McGlynn, director of Unique Skin, said, years as an increasingly obese population continues to put strain on NHS “We are very proud to have reached an exclusive agreement resources. “This could present the UK cosmetic surgery market with a greater for the distribution of the entire range of products, which are number of opportunities to assist adults with rapid weight loss, or provide all now available and ready for dispatch to both existing and excess skin removal for those that have lost weight themselves.” new customers.”

Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015 aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics

Survey Vital Statistics Study suggests almost a third of acne sufferers receive unsatisfactory treatment Keratosis pilaris aﬀ ects A new survey by the British Skin Foundation has found that almost around 40% of adults a third of acne sufferers who had sought treatment for the condition (www.patient.co.uk) were left unsatisfied by medical professionals. With more than 2,000 responses, the survey provided an insight into the lives of acne sufferers, highlighting the emotional impact of acne on mental health. In 2014, facelifts, browlifts, It further revealed that 56.78% had experienced verbal abuse from friends, family and acquaintances due to the condition, while a fifth and blepharoplasty were most of respondents claimed that the disease had caused a relationship performed on adults over the to end. While it was revealed that almost a third of patients had not age of 55 received satisfactory treatment from a medical professional, consultant (American Academy of Facial Plastic dermatologist and British Skin Foundation spokesperson Dr Anjali and Reconstructive Surgery) Mahto said, “A good dermatologist can offer a large number of potential treatments that can be tailored to the individual. Unfortunately, the skin The popularity is such a visible organ, that it’s only natural that self-esteem is so closely tied to it.” She added, “I think these results highlight that acne should be of liposuction taken far more seriously.” increased by 7% in 2014 Cosmeceuticals (British Association of Aesthetic 7% Plastic Surgeons) Lifestyle Aesthetics to distribute Teoxane A study found that less than 1% of Cosmeceutical Range 1% non-invasive treatments conducted across the Aesthetic distributor Lifestyle Aesthetics has added Teoxane Cosmeceuticals to their product portfolio. Coinciding with their 10th US result in adverse events anniversary, the distribution company has taken on the distribution of (Northwestern University, US) Swiss manufacturer’s Teoxane Cosmeceutical Range, which claims to strengthen, protect and plump the skin. Comprising Resilient Hyaluronic Acid (RHA) technology, Teoxane asserts that their cosmeceutical range of people with offers additional benefits to traditional hyaluronic-based skincare products. The RHA Serum, which has the highest concentration of the range’s core melasma are men ingredients, showed promising results after an independent lab study with (American Academy of Dermatology) 31 participants. It was found that the serum made the complexion 94% 0% brighter, and the skin 91% more resistant.

FDA The demand for lip FDA highlights differences reduction increased by 135% in the last between cosmetics and drugs quarter of 2014 (WhatClinic.com) US-based companies have received letters from the Food and Drugs Administration (FDA) detailing the differences between cosmetics and drugs. According to the FDA, clarification on their differences is needed as firms sometimes illegally market cosmetics with a drug claim or a drug Most people who experience as though it were a cosmetic. In the letters, the FDA emphasises that the psoriasis in their lifetime will have Federal Food, Drug and Cosmetic Act (FD&C Act) does not recognise it by the age of 40 ‘cosmeceutical’ as a category. The Act explains that although a product (American Academy of Dermatology) can be a combination of a drug and a cosmetic, the term ‘cosmeceutical’ has no meaning under the law.

Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015 @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

Register Events diary RCS recommends introduction of 7th - 8th March 2015 approved register of surgeons The Aesthetics Conference and Exhibition 2015, London The Royal College of Surgeons (RCS) has announced that patients having cosmetic www.aestheticsconference.com surgery should be able to check their surgeon is on an approved register. Under the recommendations set out by the Cosmetic Surgery Interspecialty Committee 26th - 28th March 2015 (CSIC), created by RCS in 2013 in response to the Keogh Review, surgeons working in the private sector will have to prove they meet new standards of training to be 13th Anti-Aging Medicine World certified and included on a register. The suggestion was made in the Cosmetic Surgery Congress, Monte Carlo Interspeciality Committee Consultation Document, which aims to improve the quality of www.euromedicom.com/amwc-2015/ care to patients undergoing cosmetic procedures. index.html Chair of the CSIC and vice president of the RCS Mr Stephen Cannon said, “We are determined to ensure there are the same rigorous standards for patients undergoing 27th - 25th June cosmetic surgery in the UK as other types of surgery.” The RCS hope to make the register publically available to employers and patients so they can make informed British Association of Plastic, decisions when considering cosmetic surgery, and have access to clear, unbiased and Reconstructive and Aesthetic Surgeons credible information about their surgeon. To obtain certification, surgeons will have Summer Scientific Meeting 2015, to be on the GMC’s specialist register in the area of training that covers the operation Bruges www.bapras.org.uk they wish to perform. They will be required to have the appropriate professional skills to undertake cosmetic surgery and must be able to provide evidence of the quality 7th - 9th July 2015 of their surgical outcomes. In addition, surgeons will also have to have undertaken a minimum number of procedures within the relevant region of the body, in a facility British Association of Dermatologists recognised by the health regulator, to be listed on the register. According to the Annual Meeting 2015, Manchester RCS, certification will only permit surgeons working in the private sector to undertake www.bad.org.uk cosmetic surgery on the areas of the body that relate to the speciality they trained in. Cannon said, “This consultation provides the next step in establishing clear and high standards for training and practice so that all surgeons in the UK are certified to the Business same level, irrespective of where they trained.” Patients, surgeons and providers of cosmetic surgery are encouraged to respond to Allergan the consultation by Friday 6 March.

profits exceed Skin Technology expectations Lumenis launches ResurFX system

Botox-maker Allergan has revealed that International energy-based their fourth-quarter profits have beaten medical company Lumenis has expectations. Reaching $537.2 million, announced the launch of its Allergan reported that this was a two million new non-ablative fractional skin dollar increase on the same period last year, resurfacing device, ResurFX. which sat at $312.9 million. The pharmaceutical The device is a stand-alone company also noted that product sales rose desktop system, which made 13.8%, reaching nearly $1.9 million, while its debut at this year’s IMCAS specialty pharmaceuticals net sales further rose meeting in Paris. It uses Lumenis’ 12.4% compared to the last quarter of 2013. The CoolScan technology to provide recorded profit for the year reached $1.5 billion continuous contact cooling, and based on $7.2 billion in revenue. Allergan chief offers practitioners the opportunity executive David Pyott, who recently revealed to customise their treatments, with that he will be leaving the company once the more than 600 different options Actavis acquisition is complete in a few months, for shape and size of treatment said, “Allergan yet again recorded in the fourth area, as well as density and energy quarter the strongest increase in absolute delivery. “We have seen such a dramatic rise in fractional non-ablative skin resurfacing dollar sales in any quarter in our history, driven because the procedure provides excellent results, without the long downtime associated by exceptional performance across all of our with other cosmetic procedures,” said Dr Matteo Tretti Clementoni of Istituto Dermatologico businesses and geographic regions. This is a Europeo. “ResurFX is the leading solution in this space because it provides the best tribute to the focus of our employees during the balance of efficacy and patient convenience – some of my patients are even coming in for unsolicited acquisition attempt.” ResurFX treatment as a ‘lunch-time’ skin rejuvenation procedure.”

Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015 aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics

Industry BACN announces revision to its membership requirements 60 Lorna Bowes, The British Association of Cosmetic Nurses (BACN) has announced a revision director of AestheticSource to its membership requirements. The amendment will allow General Medical Council (GMC) and General Dental Council (GDC) registered doctors and What brought you to aesthetics? dentists to become affiliated BACN members. Once affiliated, they can access I have had a real passion for skin various BACN services, including the Annual Conference, training programmes since my first NHS dermatology and information resources. They may further join the Regional Network, allowing staff nurse role in 1987, which led exchange of best practice and industry discussion – though voting will remain me to take my personal study limited to nurses only. The BACN will also see their membership structure of the skin, skin health, and pharmaceutical/cosmetic ingredients further. reorganised, creating a stronger emphasis on education, training, revalidation I have now been in the aesthetics field for well and CPD, based on the developing standards from Health Education England, over 20 years. I’ve had a wonderful journey, from with membership available internationally. BACN chair Sharon Bennett said, teaching dermal fillers (collagen to start with, then “The introduction of an Affiliated Member category will enable a number of later HAs) to running and successfully selling The highly qualified aesthetic practitioners to become part of the BACN family and Bowes Clinics with a team of nurses around the will cement the already existing processes of joint working and learning.” UK, as well as teaching ‘all things aesthetic’ with Wigmore Medical from 2008. I have experienced Experts various industry roles, including editing the Journal of Aesthetic Nursing in its first couple of AestheticSource invite you to years. My passion for skin grows more each year. Who are AestheticSource? ‘Meet the Experts’ at ACE 2015 AestheticSource was set up in 2011. Our mission is to deliver clinically proven dermatologist- AestheticSource, aesthetic distribution company and headline sponsors of led skin fitness solutions to the aesthetic and the Aesthetics Conference and Exhibition (ACE), will be providing access for beauty markets. We have grown and are now a delegates to ‘Meet the Experts’ at ACE 2015. On Saturday 7 March at 2:35pm, team of aesthetic nurses, therapists and highly plastic surgeon Miss Rozina Ali, dermatologist Dr Sandeep Cliff and cosmetic experienced industry professionals with a wealth doctor Dr Raina Zarb-Adami, will come together at the AestheticSource of experience in brand and clinic development, stand (49) to allow ACE delegates the chance to learn from their wealth of training and customer service. We were thrilled experience. As experts in skincare, the trio will offer invaluable advice on skin to be finalists and even more so to receive health and clinically-effective skincare regimens in order to help delegates Commended in the Aesthetics Awards just before retain patient loyalty and enhance their clinical practice. Dr Maria Gonzalez and Christmas; we are a small company that puts our customers first and foremost, so to be publicly AestheticSource director Lorna Bowes will also be on hand to talk to delegates acknowledged for this is a great honour. at the stand, following their Expert Clinic on Sunday 8 March. They will use their expertise and experience with chemical peel technology to advise delegates What does the future hold? on the best ways to combine peels with other aesthetic treatments, in order to In the world of cosmeceuticals (or rather, boost patient satisfaction. Each AestheticSource Expert Clinic aims to offer a cosmetics), having published clinical data in range of top advice from these respected aesthetic professionals, whilst giving international peer-reviewed medical journals is their guidance on the best ways to utilise skincare and chemical peels. rare. The cost and time implications of performing To register FREE visit www.aestheticsconference.com the randomised double blind placebo or vehicle controlled studies that we are used to in the Fillers medical field does not translate well to the cosmetic market. At AestheticSource we work with leading experts including dermatologists, Adare Aesthetics to distribute dermatopharmacologists, plastic surgeons and aesthetic practitioners in the UK and around the Luminera Crystalys world to source and understand brands with a heritage of evidence-based practice. Finding Aesthetic distributor Adare Aesthetics has added a new dermal filler brands to match the medical heritage to its product portfolio. Available now, Luminera Crystalys is a calcium of NeoStrata Co has proved a challenge, but hydroxyapatite injectable facial implant that can be used for filling deep we have some very exciting developments in lines and wrinkles, as well as for general facial restoration. Director of Adare the pipeline that complement our current portfolio. Aesthetics Dr Naomi Mackle said, “Patients should expect an improvement This column is written and supported by to the area treated with Luminera for six to 12 months. So far we have had excellent results with very high patient satisfaction.” Adare Aesthetics also claims that the risk of granulomas is reduced as Luminera Crystalys is uniformly and homogeneously arranged.

Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015 @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

News in Brief Training SkinCeuticals to introduce New Skin Restoration training Mineral Eye UV Defense SPF 30 SkinCeuticals has announced that it is to course to launch at ACE launch a new product, Mineral Eye UV Defense SPF 30, in April 2015. The Academy of Advanced Aesthetics will launch ‘Advanced Skin Restoration’ at the Designed to protect the delicate skin Aesthetics Conference and Exhibition (ACE) 2015. The training course aims to teach around the eyes from the sun, Mineral trainees how to prepare the skin for invasive therapies and explain the effects of skin Eye UV Defense offers SPF 30 UVA and regeneration technology. It will also aim to detail the importance of balancing the skin’s UVB protection. SkinCeuticals claims the biological functions for improved treatment outcome. Founder of the Academy Barbara product will also enhance skin tone and Freytag said, “The course concentrates on offering specialist advice to familiarise aesthetic optimise make-up application. practitioners with the treatments and their effect on the skin, rather than mere machine operation.” She notes that detailed education on preparing the skin prior to treatment is Evosyal receive FDA approval for beneficial to practitioners as it can aid faster post-treatment healing, decrease the possibility phase 3 study protocol of complications, and provide improved aesthetic results. Visit stands 84 and 86 at ACE Alphaeon Corporation has announced 2015 to find out more. that the FDA has approved its phase 3 study protocol for the Topical use of the botulinum toxin Type A neuromodulator, Evosyal, in the Sepai launches treatment of glabellar lines. Alphaeon Corporation acquired exclusive US Vitamin C rights to Evosyal through its takeover of Evolus last year. Over the past 12 boosting serums months, the company has submitted an investigational new drug application Barcelona-based skincare manufacturer Sepai has launched four serums that each for Evolus, and completed enrollment contain 5% Vitamin C, to aid in protecting skin cells and preventing premature ageing. for the phase 2 clinical trial. Phase 3 Comprising two eye and two face serums, Sepai claim the products have been specifically enrollment will commence soon. formulated to target under eye circles, puffiness, dehydration, dark spots, wrinkles, open pores and dull skin. Dr Lisa Zdinak, a New York-based aesthetic practitioner who stocks Aesthetic Response launches the products, said, “Sepai delivers bioactives that impact directly on the skin cell control telephone message-taking centres so that they behave more like younger, fresher skin cells.” Each product comes with service a Vitamin C booster, which can be added to the serum and applied directly to the skin. The Clinic support company Aesthetic skincare line is available to clinics in the UK now. Response (AR) has launched a message-taking service for aesthetic Business practices. According to AR’s founder Jo Fisher, calls will be answered ‘Aesthetic Business Network’ aims promptly and professionally for up to 66 hours a week. The company aims to provide creative and effective to ensure aesthetic practices never miss a patient call or valuable enquiry, business solutions enabling them to provide excellent customer service and capitalise on A group of aesthetic business experts have established an ‘Aesthetic Business Network’ new business opportunities. with the aim of providing unique advice to industry professionals. Created by Richard Crawford-Small, founder of iConsult software, the group will hold regional business workshops Environ launches Super offering insight, training and knowledge on topical business issues within aesthetics. Crawford Moisturiser+ Small said, “The aim of the Aesthetic Business Network is to ‘disrupt’ the UK aesthetic Environ has launched a new marketplace in a positive and innovative way by helping aesthetic business owners to find moisturising product which it claims creative and effective solutions to their business issues.” Members of the Expert Network will assist in regulating the skin’s include founder of Aesthetic Business Transformations Pam Underdown, who has developed natural moisture levels. Containing the concept alongside Crawford-Small, Mark Bugg, founder of the Web Marketing Clinic, moisturising agents Pentavitin and branding expert, Russ Turner. Also offering their wealth of experience are owners of and Revidrate, both of which have Aesthetic Response Gilly Dickons and Jo Fisher, founder of Vantage Professional Risks Martin been clinically proven to enhance Swann, and founder of the Wright Initiative and PaPPS, Norman Wright. Underdown said, epidermis moisturisation, Super “The group will provide the richest source of knowledge, valuable free resources, networking Moisturiser+ promises to leave skin and interview opportunities to ensure that they not only add value, but ultimately help every richly nourished. UK aesthetic business owner grow their business with a network of trusted and reliable providers.” The first business workshop will be held in the Midlands on June 16.

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‘Life is Beauty-Full’ SkinCeuticals Integrated Launch, London Strategies Summit, London

Aesthetic doctors, dermatologists and plastic surgeons attended an evening discussion on the future of integrated skincare and aesthetics on 2 February. Held at the Royal Society of Medicine in Chandos House, London, the SkinCeuticals event featured talks from facial cosmetic surgeon Dr Steven Dayan, and assistant vice president of Global Education at SkinCeuticals Nicole Simpson. Dr Dayan delivered a presentation entitled, ‘The Future of Aesthetics: Are You Ready?’ where he discussed the popularity of cosmetic surgery in Asia, and noted how the UK and Aesthetic practitioner Dr Vincent Wong launched the US are falling behind in terms of treatments per capita. Simpson gave attendees his documentary, ‘Life is Beauty-Full’, on January an insight into marketing strategies and methods of incorporating skincare into a 28. Guests were welcomed with a champagne medical setting. Her interactive session also touched on ways clinics can improve and canapé reception at the Bulgari Hotel, their retails sales and retention rates. Guests included Dr Rita Rakus, Dr Raina Zarb Knightsbridge, before being seated in the hotel’s Adami, Dr Tapan Patel, Mr Christopher Inglefield and Dr Raj Acquilla. private cinema room for the viewing. Directed by Dr Acquilla said, “My friend Steven Dayan was eloquent and entertaining as ever, Dr Wong in conjunction with awareness campaign combining sublime content with charisma and perfect timing. The incorporation Safety in Beauty, the documentary targets of cosmeceuticals into your aesthetic practice seems common sense, but the consumers, with the aim of encouraging them to be SkinCeutical range seems a natural compliment for what I do.” more safety-conscious when choosing an aesthetic treatment. The film also featured a soundtrack written by Dr Wong himself. Of the evening, Dr Wong said, “The journey itself has been challenging – it is the first time I have produced a documentary, and written a song, but I hope viewers will find it innovative and at the same time entertaining.”

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We report on the highlights from the congress each year. She added, “It’s been interesting to see the transition in the injectable space from mainly botulinum toxin Paris’ international aesthetics conference procedures to vulva-vaginal rejuvenation. It’s been a fascinating conference and really awesome to meet so many new people.” Other highlights of the annual conference included the ‘Facial rejuvenation surgery vs. medicine’ sessions, which took place on IMCAS 2015, the Friday afternoon. The four debates, which centred on different treatment methods for each area of the face, had delegates squeezing into the lecture room and queuing for entry outside. Paris Topics discussed included: the efficacy, safety and financial implications of periorbital rejuvenation, when and how to lift the Aesthetic professionals from around the world descended on eyebrows, eyelid lipofilling, mid-face volume addition, refinements Paris for the 17th International Master Course on Aging Skin of the nose using HA fillers or surgery and surgical enhancement (IMCAS) between January 29 and February 1, 2015. of the jaw-neck complex. More than 5,500 nurses, doctors, surgeons, exhibitors and Dermatologist Dr Heidi Waldorf presented during the ‘nose – manufacturers from 84 countries met at the Palais Des Congrés in mouth – chin complex’ debate, and highlighted the appropriate Paris for four days of knowledge-sharing, educating and learning methods of evaluating and rejuvenating the perioral complex. In about the latest developments in our multifaceted industry. her talk she suggested that practitioners should strive to achieve The varied and engaging agenda comprised 155 scientific sessions, a ‘more cohesive look’ when treating the face, arguing that just presented by 420 Key Opinion Leaders from around the world. treating ‘segmental areas’ would not create the most attractive Themes covered included body contouring, skin rejuvenation, hair face for the patient. After the session, Dr Waldorf said of the removal and practical anatomy workshops using cadavers. conference, “IMCAS Paris is on my calendar every year and One clear trend appearing on numerous agendas, however, will continue to be so. It brings great speakers from around the was vulvo-vaginal rejuvenation. Thursday saw three sessions world, although, sometimes, I learn even more from the hallway that covered the fundamentals of treatment, surgical techniques conversations than the lectures.” and treatment using lights, radiofrequency and laser. Experts This year IMCAS housed 165 exhibition stands, which delivered a discussed the anatomy of the vulvo-vaginal area, G-spot plethora of displays from basic clinical equipment such as surgical enhancements, genital beautification and CO2 laser treatment for scissors, to the latest innovations in laser equipment. Medical vaginal atrophy in postmenopausal women. aesthetic business consultant Richard Crawford-Small noted Chair of session one Dr Nicolas Berreni noted that enquiries for that there was an increase in Far Eastern companies exhibiting vulvo-vaginal rejuvenation treatments are growing year on year their new technology and products, which reflected international – a fact supported by the American Society for Aesthetic Plastic statistics discussed in the conference’s Industry Tribune. He Surgeons (ASPS), which recorded more than 5,000 procedures in shared his predictions on the effect of this development, 2013; a 44% increase on 2012.1 noting, “The repercussions of this could result in the existing Other well-received presentations included neck and décolleté manufacturers who build the kit in Europe and the US coming rejuvenation and lip restoration. Dr Thomas Rappl detailed the under an increasing amount of pressure in coming years.” The anatomy of the neck and décolleté, whilst the lip restoration three-hour long Industry Tribune, on Friday afternoon, saw market session, presented by facial plastic surgeon Dr Frank Rosengaus, experts take to the stage in the main conference room to share taught delegates ‘the happy face treatment’, in which he outlined statistics and predictions for the ever-growing aesthetics specialty. how best ways to treat commissures and marionette lines. It was well attended by delegates, who learnt that the global Cosmetic doctor Dr Raj Acquilla also contributed to the segment, facial aesthetics market was valued at 2.7 billion USD in 2014. presenting his 6-point injection protocol for lip and perioral Medical industry analyst Michael Moretti also told the audience rejuvenation. Audience member and aesthetic practitioner Dr that this figure is predicted to rise to more than 4 billion USD Catherine Stone said, “Raj Acquilla always stands out. I love his by 2019. Attendees also learnt that the Asian aesthetic market techniques and he always manages to make everything incredibly overtook its European counterpart in terms of revenue in 2014, simple.” Dr Stone has been attending IMCAS for three years and and is expected to expand even more over the next four years. travels from New Zealand, where she is based, in order to attend The US, however, is predicted to retain its global market share of

Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015 103110NeoretinTradeAd:Layout110/02/201511:37Page1

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44% within the same time frame. According to the statistics presented, the value of the cosmeceutical industry is set to take over from the breast implant industry this year, and body contouring and energy devices are predicted to become even more sought after, with their popularity predicted to increase by 9.9% annually over the next five years. Eﬀective After Moretti’s presentation, industry leaders from Allergan, Pigmentation Galderma, Merz, Syneron and Lumenis took to the stage to put forward their marketing strategies, and this was followed Resolution by an industry vs. doctors round table debate. This proved an insightful opportunity to learn from experts on both sides of That’s kind on skin the working field, and provided invaluable information on the direction that the aesthetics specialty is headed in 2015. The value of the cosmeceutical industry is set to take over from the breast implant industry this year

Speaking after the Tribune, IMCAS course director Benjamin 74% reduction Asher said, “Feedback on the congress so far seems to be in the area and what we were expecting – the degree of satisfaction is high. severity of We have reached our target and are now the number one melasma as medical aesthetic meeting in Europe.” Adding, “But, of course, measured by we have to improve and get better each year.” Following the clinicians1 Tribune, delegates and exhibitors enjoyed a cocktail networking reception in the Palais Des Congrés, before gearing up for La Nuit des IMCAS Awards 2015 on the Saturday evening, in support of Breast Cancer Research. Feedback was positive; with dermatologist Dr Anne Le Pillouer Prost commenting that it EXCELLENT CLINICAL KIND ON SKIN AND was a “great evening as usual”. EFFICACY GREAT TO USE The much-anticipated event drew to a close on Sunday 1 Clinically proven resolution of Skin-kind, cosmetic tolerability, February, after a morning of ‘Meet the Expert’ series, along pigmentation in photo-damaged an excellent safety proﬁle and a with Research and Development sessions. Topics covered skin and melasma1,2 straightforward regime included 3D technology, the role of botulinum toxin for treating encourages daily use UNIQUE SKIN depression, liquid tissue in a syringe, and myth vs. reality of BRIGHTENING collagen stick formulation by injectable fillers. Overall the FORMULATION congress was well received by attendees; Richard Crawford- FOR FURTHER DETAILS A unique, multi-action formulation or SCIENTIFIC AND Small said, “I’ll definitely be back. If you want to know where of retinoids and skin brightening the market’s going and how it’s developing then you need to ingredients tackling every stage CLINICAL INFORMATION attend these industry events.” Dr Raj Acquilla added, “IMCAS of the melanin production cycle PLEASE CONTACT US has surpassed my expectations of a global major congress. It’s been a pleasure to be here sharing knowledge, skills and www.aestheticare.co.uk techniques with colleagues and friends from around the world.” email [email protected] or call FREE on: 0800 0195 322

REFERENCES © Ferndale Pharmaceuticals Ltd® 2015 1. The American Society for Aesthetic Plastic Surgeons, 2013 Cosmetic Surgery 1Truchuelo M et al, Journal of Cosmetic Dermatology, 2014. National Data Bank Statistics, (US: ASAPS, 2013) @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

With only one week left until the Aesthetics case studies on fat reduction treatments, discussing the journey from consultation and treatment to post-procedure advice. Sunday Conference and Exhibition 2015, we detail afternoon will see leading dermatologists Dr Christopher Rowland Payne and Dr Stefanie Williams host ‘The Aesthetic Dermatology why this is an event not to be missed Clinic’, featuring guidance on differential diagnosis with key insight from dermatologist Dr Daron Seukeran and aesthetic nurses Anna Baker and Lorna Bowes. With this year’s comprehensive Business Last look: ACE 2015 Track, sponsored by Church Pharmacy, delegates can maximise the opportunity to develop their clinic by attending as a whole Next week, the Aesthetics practice, in order to learn about the non-clinical aspects of running Conference and Exhibition a successful aesthetics business. Expert Clinic and Masterclass (ACE) 2015 will provide live demonstrations will show how successful practitioners use the more than 2,000 industry best products to achieve top results, providing invaluable advice on professionals with access to a techniques and avoiding and managing complications. Topics covered multitude of interactive learning in the Expert Clinics will include advanced injectables, bio-generative and networking opportunities skin rejuvenation and non-ablative soft surgery, while the dynamic at the Business Design Centre Masterclasses, led by word-class professionals, will offer invaluable in Islington, central London. learning and practical advice on specific products. Saturday evening’s With one week left to register, join numerous aesthetic professionals Question Time event will be a unique session, hosted by former on March 7 and 8 as they learn how to enhance their business and BBC presenter Peter Sissons, addressing questions asked by you, expand their clinical knowledge. At the UK’s first industry conference our readers, to stimulate debate between industry leaders. Panel of the year, attendees can secure vital connections and be the first members will include professional body chairs Dr Paul Charlson and to discover the latest product and service innovations, with access Sharon Bennett, international business specialist Wendy Lewis, Health to more than 100 leading exhibitors. Based on feedback from last Education England (HEE) performance and delivery manager Carol year’s delegates, our brand new Conference format, created on an Jollie and respected surgeons Mr Dalvi Humzah and Mr Paul Banwell. interactive agenda, is unlike anything seen before in the UK’s aesthetic Within the exhibition, the Merz Aesthetics Live Demonstration Zone will industry. This agenda will provide delegates with engaging, premium feature a presentation from world-renowned aesthetic surgeon content presentations and demonstrations, and up to 50 CPD points Dr Arthur Swift as he introduces Belotero+ Volume. Amongst taking are available across all programmes throughout the weekend. part in a range of demonstrations, he will also join a panel of specialists who will share their expertise on safe practice within the industry. Agendas Complementing registration for the free exhibition pass, Valuable experience which includes access to the Business Track, Expert Clinics Of more than 1,600 attendees last year, 92% said they and Masterclasses, delegates can book main agenda sessions that will return to ACE in 2015. Among the praise received are relevant to their area of practise or interest – with no obligation regarding last year’s event, one delegate reflected that, “Talking to to book all four modules. For just £95 a session, including VAT, the exhibitors helped me because they provided practical material those opting for this flexible pass will receive discounts with each and supplies, and also information I can actually use in my practice.” learning module chosen. Each individual module will demonstrate Headline sponsors, AestheticSource, will be present at the exhibition entire patient journeys, from consultation through to follow-up care, to provide information for their customers, as well as new delegates. outlining exact patient treatment to achieve optimum outcomes. See Lorna Bowes, director of AestheticSource, said, “AestheticSource leading aesthetic practitioners Dr Arthur Swift, Mr Dalvi Humzah, Dr are looking forward to another successful ACE Conference and Tapan Patel and Dr Raj Acquilla present on stage together for the Exhibition. We love the educational content that the various parts of first time in this year’s ‘Face Off’ and ‘Getting into the Zones’ facial the programme provide, with a diverse group of speakers stimulating injectables sessions. Utilising state of the art technology, these thought and discussion.” The esteemed ACE Steering Committee, sessions will use multiple screens for optimal viewing and learning, led by Mr Dalvi Humzah, will guarantee that the education and incorporating live treatment demonstrations, anatomy dissection speakers featured are of the highest quality, giving attendees the exploration and audience participation. Mr Taimur Shoaib will chair most beneficial and valuable experience possible and making this an a panel of specialists, including Dr T Vetpillai and Dr Samira Yousefi, essential event on the aesthetics calendar. during Saturday morning’s session, ‘The Role of FAT’, on weight Don’t miss your chance to attend ACE 2015. management and body sculpting. The panel will present and examine Register today at www.astheticsconference.com

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i o lipomed n How to treat Skin Tightening an aesthetic patient A Powerful Three Dimensional Alternative to Liposuction We asked three practitioners to share their individual approaches to treating No other system offers this advanced combination of a hypothetical aesthetic patient. After assessing the images, our surgeon, technologies designed to target fat removal, cellulite dermatologist and cosmetic doctor share their thoughts and skin tightening without the need to exercise

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A complete approach Face and Body skin Cavitation (Overall Circumference Reduction) to the problem tightening Cavitation is a natural phenomenon based on low frequency ultrasound. The Ultrasound produces a strong wave of Prescriptive Highly profitable pressure to fat cell membranes. A fat cell membrane cannot withstand this pressure and therefore disintegrates into a liquid state. The result is natural, permanent fat loss. Multi-functional No exercise required Dr Tapan Patel, cosmetic doctor Despite her hair being Inch loss National PR support Duo Cryolipolysis down, it would appear (Superficial Targeted Fat Removal) This patient is attractive, with good she has some degree of campaign Using the unique combination of electro and cryo therapy Cellulite facial balance and does not have any bi-temporal recession. Over 20-40% of the fat cells in the treated area die in a natural Treatment List Clinician use only way and dissolve over the course of several months. major treatment indications. Ideally I time this will deepen and Two areas can now be treated simultaneously. would prefer to assess this particular lead to drooping of the tail IPL Complete start up and support package patient with a headband so that we of the eyebrow. This can • Botulinum toxin available from under £660 per month could clearly examine the upper third be rectified by the use of • Radio Frequency (Skin Tightening) of her head. The first intervention I would suggest concerns a volumising filler, injected • Radiofrequency Focus Fractional RF is the 3rd generation of RF technology. • C02 laser It utilises three or more pole/electrodes to deliver the RF the condition of her skin. She displays some degree of mottled deeply into the temporal energy under the skin. This energy is controlled and limited hyperpigmentation, and there is also some suggestion of fossa. Overall she seems • HA filler to the treatment area. Key advantages of this technology erythema. These conditions, which are exacerbated by sun to have good volume, are high treatment efficacy, no pain as less energy is exposure, make her suitable for photo rejuvenation with, for especially in the mid face required, shorter treatment services and variable depths of penetration. example, an IPL system. She might also be a candidate for and in the chin. Because fractional resurfacing with the use of a C02 Laser. This would she has good projection of her cheeks, nose and chin, it does 3D Dermology RF not only improve the tone, but also the texture of her skin. make her lips appear a little undersized, especially in the lower Before After Before After (Cellulite Reduction) Additionally, we could use more aggressive parameters around lip. With this in mind, she may indeed benefit from very subtle The new 3D-lipomed incorporates 3D her eyes to reduce the static periorbital rhytides. injections of the lips with the use of a hyaluronic acid filler. There Treatment Equipment Supplier The Pinnell Award for Dermology RF with the stand alone benefits of the Year of the Year Product Innovation of automated vacuum skin rolling and radio Without animation it is not possible to see to what level she is a suggestion of mild infraorbital hollowing, especially on the 3D Lipomed 3D Lipo Limited 3D Lipomed frequency. has dynamic lines of expression. She certainly seems to have left side medially. This can be softened with a direct tear trough a prominent platysmal band on the right side, which could injection. It would be important to examine the lower eyelid skin What the experts say... be treated with botulinum toxin. The lower aspect of her face to ensure it is not too flaccid prior to this intervention. I suspect ‘As a Clinician I need to know that the treatments we offer are safe, effective, scientifically based and fit in with our ethos of holistic care for our clients. 3D-Lipo suggests she may have some degree of masseter hypertrophy, this patient would benefit from skin tightening, especially on has delivered this to us’ Dr Mohamed Dewji – GP & Medical Director LasaDerm Ltd and this gives her a slightly square look. I would consider treating the neck, perhaps even on the full face. This could be achieved (Milton Keynes) this region with some botulinum toxin to contour the jawline. with a system such as a radiofrequency device, ideally delivered Finally, the chin shows signs of cobblestone appearance. If this is using a needle system. Finally, I would recommend a skin care the case when she activates mentalis, this can be softened with regime comprising of a wash, exfoliating agent, anti-oxidant, botulinum toxin. retinoid and sun protection. For further information or www.3d-lipo.co.uk a demonstration call: 01788 550 440 @3Dlipo 3D-lipo Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015 TREATMENT OF THE YEAR IREJUVENATE & RESOLVEI

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Mr Adrian Richards, surgeon excess in this area. Next, I would consider In order to analyse this patient’s her volume issues. Treatment List ageing process, I would ask her, She has slightly more as part of the initial consultation, natural volume in the • Upper to bring in photographs of herself left side of her face, blepharoplasty taken in each decade of her life. This which appears more • Short scar MACS is important in order to understand youthful, but overall facelift • THE LEADING how a patient’s face has aged, in order to attempt to reverse she has lost volume Fat graft this process. It is also important at this stage to understand the from both cheeks, the • Chemical Peel patient’s motivation for treatment: how much downtime can nasolabial folds, oral • Botulinum toxin they afford and what change they would like to see? For some, commissure, marionette LIGHT IN LED the motivation behind their decision may be the desire to look lines and lips. During ‘refreshed’, for others it may be the desire to look like they surgery I would use 20- did 10 years ago. I tell all of my patients, that in my hands, 10 30mls of the patient’s own fat, removed from her inner knee years younger is the maximum that can be achieved whilst still region. I find that this site produces the most reliable and long- PHOTOTHERAPY maintaining a natural appearance. lasting fat for transfer. I would harvest the fat using the closed In order to achieve natural looking and long-lasting PureGraft system and restore the youthful contours of the face rejuvenation, the four aspects of facial ageing need to be using a multi-layered spot graft technique. addressed: gravity, volume loss, skin quality and active lines. Skin quality is often the most overlooked aspect of the four Harnessing the power of pure light to naturally To correct one or two of these without addressing the others factors of facial ageing. It is, however, crucial to achieving a stimulate skin rejuvenation and resolve can produce a disjointed and unnatural appearance. balanced and natural appearance. I would consider using problem skin conditions Firstly, as with any patient, I look at the changes in gravity. In a peel at the time of surgery, paying particular attention this patient, this includes a heavier upper eyelid fold on the to the mixed pigmentation areas with brown sun-spots right, softening of the jaw line in the jowl areas and platysmal on her cheeks. Following surgery, I would emphasise the TARGETED AND CONTROLLED banding and loss of the neck angle, which again, is more importance of prophylactic skin protection from UV radiation severe on the right side. and recommend an on-going skin treatment programme. Evidence-based red, blue and near-infrared For me as a practitioner, the only way to reverse gravity Skin lesions are representations of ageing and inevitably wavelengths used at a skin-enhancing intensity and dose changes effectively is surgery. For this patient I would enlarge with time. I would therefore recommend removal of the small intradermal naevi on the side of her chin and both ADVANCED recommend an upper blepharoplasty and short scar MACS facelift. I would not advise her to have a lower blepharoplasty, cheeks. Finally, I would address the fourth aspect of facial High-quality, precisely controlled LEDs give the as she does not have puffy lower eyelids or significant skin ageing: active lines and areas over active muscles activity. Our option to deliver all three wavelengths concurrently patient does have some residual active lines on her forehead, glabella, crow’s feet and lateral nose region. I would treat FLEXIBLE these with botulinum toxin treatments before, during or after Standalone treatment or used to enhance surgery. Toxin treatment would also be helpful in treating her other treatments; excellent results and great central playtsmal bands, which are again more pronounced return on investment on the right side. In my opinion, toxin relaxation combined with surgical tightening of the neck would produce the most natural SAFE AND COMFORTABLE rejuvenation of this region. A non-invasive treatment for all skin types - no pain or downtime In order to achieve natural looking and long-lasting rejuvenation, the four The Dermalux® is a ordable, quick and easy to use, has no downtime and has a high patient aspects of facial ageing satisfaction rate. Deciding to purchase the need to be addressed: Dermalux® is a no brainer! DR REKHA TAILOR Health + Aesthetics, Farnham gravity, volume loss, skin quality and active lines

FOR FURTHER DETAILS, SCIENTIFIC & CLINICAL INFORMATION PLEASE CONTACT AESTHETICARE® 0800 0195 322 aestheticare.co.uk [email protected] @aestheticareuk facebook.com/aestheticareuk Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015

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Dr Tamara Griffiths, effect, such as dermatologist hyaluronic acid (HA), will keep her skin hydrated, Achieving successful facial and a stable antioxidant rejuvenation is dependent on several will add further photo- Treatment List factors. These include, an understanding protection. • Cryotherapy of the complex events that occur at Further analysis • IPL multiple anatomical levels associated demonstrates a slight • Chemical Peel with facial ageing; a thorough consultation with the patient, asymmetry in her facial • Tretinoin including an accurate assessment combined with good aesthetic fat pad distribution. The • Hyaluronic acid judgement; and technical skill involving a variety of evidence- light reflects off her • Botulinum toxin based rejuvenation modalities. These together provide a safe, left cheek differently effective and balanced approach to aesthetic treatment. compared with the My first step when meeting with the patient in question would right, suggesting be to discuss what bothers her the most. This is required to flattening or increased better understand the patient’s needs and to establish realistic volume loss on the left. This could be corrected with a deep expectations. Body dysmorphic disorder and other psychological injection of a volume-replacing HA filler; my preference here would issues need to be addressed and supported. The term be the “pillar” technique, placing a deep periosteal injection on the “courageous restraint” has been coined to reflect the practitioner’s left. This is a highly advanced technique due to the vascularisation need to use sound, rational judgement, whilst understanding that of this region, with potential risk of blindness due to retrograde in some cases not treating the patient is the best option. When spread of the filler. Another option would be to use a microcannula analysing this relatively young female patient, the feature that strikes me the most is her sun- or photo-damaged skin. She has The key message to numerous pigmented actinic lentigenes on her cheeks, which could be treated with cryotherapy, light-based treatments such communicate to the as IPL, or a range of chemical peeling agents. The key message to communicate to the patient would be the need to use broad- patient would be the need spectrum (UVA and UVB) sunscreen on a regular basis – I usually recommend that this is applied three seasons out of four in the to use broad-spectrum UK – and to give correct advice on the amount and frequency of use (eg. SPF 15 in foundation makeup is inadequate). If she (UVA and UVB) sunscreen likes the ‘sun-kissed’ look, then false tan is her best option, and as part of the consultation I would emphasise good ‘sun smart’ on a regular basis behaviour. I would recommend the use of a topical retinoid such as 0.025% tretinoin, and combine this with advice and guidance technique to the left malar region. HA filler would also be beneficial on use (frequency of application etc), in order to reduce the risks to a subtle degree in the melomental area; here I would use a of irritation. Tretinoin provides short-term effects with increased microcannula and again the key is a subtle approach to minimise epidermal thickening over the first three months, but I would any kind of unnatural, ‘puffy’ look. When assessing the patient, advise the patient that the repair of collagen and elastin will take it is critical to touch and squeeze/compress affected areas to at least three months. Tretinoin will also help to lighten the actinic accurately determine volume depletion. lentigenes. Recommendation of a cosmeceutical with a hydrophilic Asking the patient to move and animate their face is also important, particularly prior to the use of neuromodulators or botulinum toxins. It appears this patient’s right brow is slightly lower and more horizontal compared with the left. She would need slightly more toxin in the right brow depressor complex and less in the elevator complex to give a symmetrical and attractive brow lift. I would also most likely recommend m. orbicularis oculi injections bilaterally which would not only reduce crow’s feet wrinkles but widen the aperture of the eye. She would benefit from injections in the chin (m. mentalis) to reduce the mental crease and minimise pebbling with speaking/animation. She could also benefit from injection into m. depressor anguli oris and platysma in the anterior neck for the subtle cords, and more lateral injections into platysma for a slight tightening of the jaw line (referred to as the ‘Nefertiti lift’). Depending on the patient, it is likely these procedures would be performed over a few visits. My approach is to achieve a gradual, natural transformation deploying a holistic view of facial ageing and rejuvenation.

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UK WINNER 2014/15 Cosmeceutical of the year Quote #BTLPB02 for our latest equipment promotion one point aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics Managing Obesity: An Introduction In the first of a two-part weight special, Dr Sotirios Foutsizoglou explores the physiology and role of fat against the backdrop of current trends in obesity rates

Introduction The laws of thermodynamics require that overall energy balance resistant.2 However, despite research, the manner in which both should be constantly maintained in living organisms during the leptin and ghrelin systems contribute to the development or periods of stable weight. Weight gain results from an imbalance maintenance of obesity is, as yet, not clear. Obesity is not just a between energy intake and expenditure. Correlation of energy cosmetic problem. It is a complex and chronic disease associated intake and expenditure with energy stores is a complex process, with a multitude of complications and life-threatening conditions controlled in the hypothalamus and involving numerous amine (see Table 1). Health risks such as cardiovascular disease, cancer, and peptide neurotransmitters and neuromodulators. The diabetes, osteoarthritis, and chronic kidney disease increase hypothalamus senses adipose tissue mass (energy stores) by when a person’s Body Mass Index (BMI) exceeds 23. In 2010, reception of leptin, a circulating signal generated in adipose cells. obesity and being overweight were estimated to have caused 3.4 Obesity can result from an altered set point of energy stores, from million deaths worldwide, most of which were from cardiovascular unregulated caloric intake, decreased energy use or resistance to causes. Research indicates that if left unchecked, the rise in the action of leptin.1 obesity could lead to future declines in life expectancy.3 It is Leptin and ghrelin are two hormones that have been recognised difficult to give an exact definition of obesity. From my experience, to have a major influence on energy balance. Leptin is a I would define obesity as the accumulation of excess body fat to mediator of long-term regulation of energy balance, suppressing the extent that it can be associated with reduced life expectancy food intake and thereby inducing weight loss. Ghrelin, on the and a negative impact on the individual’s health. The most other hand, is a fast-acting hormone, playing a role in meal common measure of obesity is the BMI. initiation. As a growing number of people suffer from obesity, understanding the mechanisms by which various hormones and A person is considered overweight if their BMI is between 25 neurotransmitters have influence on energy balance has been and 29.9, or obese if their BMI is 30 or above. Obesity can be a subject of intensive research. In obese subjects the circulating subclassified into hyperplastic (referring to increased fat cell level of the anorexigenic hormone, leptin, is increased, whereas number) or hypertrophic (referring to increased fat cell size). surprisingly, the level of the orexigenic hormone, ghrelin, is Childhood-onset obesity is hyperplastic, whereas adult-onset decreased. It is now established that obese patients are leptin- obesity is characterised by hypertrophic changes. There are

Table 1. Diseases and conditions associated with obesity Relative risk (RR) Associated with metabolic Associated with excess weight consequences

Greatly increased RR > 3 Type 2 diabetes Sleep apnoea Gall bladder disease Breathlessness Hypertension Asthma Dyslipidaemia Social isolation and depression Insulin resistance Daytime sleepiness and fatigue Non-alcoholic fatty liver Atherosclerosis

Moderately increased RR 2-3 Coronary heart disease Osteoarthritis Stroke Respiratory disease Gout/hyperuricaemia Hernia Psychological problems

Slightly increased RR 1-2 Cancer* Varicose veins Reproductive abnormalities/impaired fertility Musculoskeletal problems Polycystic ovaries Bad back Skin complications Stress incontinence Cataract Oedema/cellulitis

*Breast, endometrial, colon, oesophageal and others.

Quote #BTLPB02 for our latest equipment promotion Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015 COMPOSED • CONFIDENT • MY CHOICE

INDICATION

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Now approved for crow’s feet lines

Bocouture® 50 Abbreviated Prescribing Information Please refer to the Summary of Product dry eye. General disorders and administration site conditions; Common: injection site haemotoma.

Characteristics (SmPC) before prescribing. 1162/BOC/AUG/2014/PU Presentation 50 LD50 units of Post-Marketing Experience; Flu-like symptoms and hypersensitivity reactions like swelling, oedema Botulinum toxin type A (150 kD), free from complexing proteins as a powder for solution for injection. (also apart from injection site), erythema, pruritus, rash (local and generalised) and breathlessness Indications Temporary improvement in the appearance of moderate to severe vertical lines between have been reported. Overdose May result in pronounced neuromuscular paralysis distant from the the eyebrows seen at frown (glabellar frown lines) and lateral periorbital lines seen at maximum smile injection site. Symptoms are not immediately apparent post-injection. Bocouture® may only be used (crow’s feet lines) in adults under 65 years of age when the severity of these lines has an important by physicians with suitable qualifi cations and proven experience in the application of Botulinum psychological impact for the patient. Dosage and administration Unit doses recommended for toxin. Legal Category: POM. List Price 50 U/vial £72.00 Product Licence Number: PL 29978/0002 Bocouture are not interchangeable with those for other preparations of Botulinum toxin. Reconstitute Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer Landstraße 100, with 0.9% sodium chloride. Glabellar Frown Lines: Intramuscular injection (50 units/1.25 ml). 60318 Frankfurt/Main, Germany. Date of revision of text: August 2014. Further information Standard dosing is 20 units; 0.1 ml (4 units): 2 injections in each corrugator muscle and 1x procerus available from: Merz Pharma UK Ltd., 260 Centennial Park, Elstree Hill South, Elstree, Hertfordshire muscle. May be increased to up to 30 units. Injections near the levator palpebrae superioris and WD6 3SR.Tel: +44 (0) 333 200 4143 into the cranial portion of the orbicularis oculi should be avoided. Crow’s Feet lines: Intramuscular injection (50units/1.25mL). Standard dosing is 12 units per side (overall total dose: 24 units); 0.1mL Adverse events should be reported. Reporting forms and information can be found at (4 units) injected bilaterally into each of the 3 injection sites. Injections too close to the Zygomaticus www.mhra.gov.uk/yellowcard Adverse events should also be reported to Merz Pharma UK Ltd at major muscle should be avoided to prevent lip ptosis. Not recommended for use in patients over the address above or by email to [email protected] or on +44 (0) 333 200 4143. 65 years or under 18 years. Contraindications Hypersensitivity to Botulinum neurotoxin type A or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, Lambert-Eaton 1. Bocouture 50U Summary of Product Characteristics. Bocouture SPC 2014 August available from: syndrome). Presence of infection or infl ammation at the proposed injection site. Special warnings URL: http://www.medicines. org.uk/emc/medicine/23251. and precautions. Should not be injected into a blood vessel. Not recommended for patients with 2. Prager, W et al. Onset, longevity, and patient satisfaction with incobotulinumtoxinA for the a history of dysphagia and aspiration. Adrenaline and other medical aids for treating anaphylaxis treatment of glabellar frown lines: a single-arm prospective clinical study. Clin. Interventions in should be available. Caution in patients receiving anticoagulant therapy or taking other substances in Aging 2013; 8: 449-456. anticoagulant doses. Caution in patients suffering from amyotrophic lateral sclerosis or other diseases 3. Sattler, G et al. Noninferiority of IncobotulinumtoxinA, free from complexing proteins, compared which result in peripheral neuromuscular dysfunction. Too frequent or too high dosing of Botulinum with another botulinum toxin type A in the treatment of glabelllar frown lines. Dermatol Surg 2010; toxin type A may increase the risk of antibodies forming. Should not be used during pregnancy unless 36: 2146-2154. clearly necessary. Should not be used during breastfeeding. Interactions Concomitant use with 4. Prager W, et al. Botulinum toxin type A treatment to the upper face: retrospective analysis of daily aminoglycosides or spectinomycin requires special care. Peripheral muscle relaxants should be used practice. Clin. Cosmetic Invest Dermatol 2012; 4: 53-58. with caution. 4-aminoquinolines may reduce the effect. Undesirable effects Usually observed within 5. Data on File: BOC-DOF-11-001_01 the fi rst week after treatment. Localised muscle weakness, blepharoptosis, localised pain, tenderness, itching, swelling and/or haematoma can occur in conjunction with the injection. Temporary vasovagal Bocouture® is a registered trademark of Merz Pharma GmbH & Co, KGaA. reactions associated with pre-injection anxiety, such as syncope, circulatory problems, nausea or 1180/BOC/OCT/2014/LD Date of preparation: October 2014 tinnitus, may occur. Frequency defi ned as follows: very common (≥ 1/10); common (≥ 1/100, < 1/10); uncommon (≥ 1/1000, < 1/100); rare (≥ 1/10,000, < 1/1000); very rare (< 1/10,000). Glabellar Frown 1 2,3,4 5 Lines: Infections and infestations; Uncommon: bronchitis, nasopharyngitis, infl uenza infection. PURIFIED • SATISFYING • CONVENIENT Psychiatric disorders; Uncommon: depression, insomnia. Nervous system disorders; Common: headache. Uncommon: facial paresis (brow ptosis), vasovagal syncope, paraesthesia, dizziness. Eye disorders; Uncommon: eyelid oedema, eyelid ptosis, blurred vision, blepharitis, eye pain. Ear and Labyrinth disorders; Uncommon: tinnitus. Gastrointestinal disorders; Uncommon: nausea, dry mouth. Skin and subcutaneous tissue disorders; Uncommon: pruritus, skin nodule, photosensitivity, dry skin. Musculoskeletal and connective tissue disorders; Common: muscle disorders (elevation of eyebrow), sensation of heaviness. Uncommon: muscle twitching, muscle cramps. General disorders Botulinum toxin type A and administration site conditions; Uncommon: injection site reactions (bruising, pruritis), tenderness, Infl uenza like illness, fatigue (tiredness). Crow’s Feet Lines: Eye disorders; Common: eyelid oedema, free from complexing proteins

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gender differences in fat distribution. The male or android distribution is characterised by increased subcutaneous fat in the upper body as well as central visceral fat deposits. The female or gynecoid distribution refers to fat accumulation in Recent studies have peripheral stores, in particular the femoral and gluteal areas. Central obesity is more metabolically active, changes with diet, revealed that adipose tissue and correlates with the risk of disease. Peripheral fat, on the other hand, is less metabolically active and is not significantly is a dynamic tissue with affected by diet restriction.4 Abdominal obesity carries a strong COMPOSED • CONFIDENT • MY CHOICE risk factor in terms of the development of cardiovascular disease, multiple functions atherosclerosis, hypertension, and possibly some female cancers (breast, endometrial, ovarian).5 The visceral fat cells are of particular importance because of their relationship to the portal INDICATION circulation. The breakdown products of lipolysis from visceral adipocytes drain directly into the portal circulation and can carbohydrates in food, sometimes protein. The main reservoir of overcrowd the liver with a high concentration of free fatty acids, fat in the body is the adipose tissue beneath the skin, called the leading to hypertriglyceridaemia.6 Visceral obesity is also strongly panniculus adiposus. There are also deposits of fat between the associated with insulin resistance and impaired glucose tolerance, muscles, among the intestines and in their mesentery, around which are precursors of diabetes type 2.7 the heart, between abdominal organs, and in our cells (e.g liver cells).9 Adipocytes appear packed between the vasculature. This Physiology and Function of Adipose Tissue is because they are compressed by colloid osmotic pressure, The primary function of adipose tissue is to insulate and cushion generated by soluble proteins in the interstitial space, with PURIFIED1 • SATISFYING2,3,4 • CONVENIENT5 the body, to store free fatty acids (FFAs) after food intake and to the most important adipocytes being albumin, globulin, and release FFAs during the fasting state to ensure sufficient energy fibrinogen. The shape of a fat-laden mature adipocyte is that status. During the postprandial phase, FFAs are taken up from of a cygnet ring, as the central lipid accumulation pushes the the blood in adipose tissue after hydrolysis of triglycerides (TG) nucleus to the periphery. Every adipocyte is surrounded by from triglyceride-rich lipoproteins (very low-density lipoprotein- capillaries, which are highly sensitive to epinephrine, causing cholesterol (VLDL-c), chylomicrons and their remnants) by vasoconstriction. Liposuction performed with the use of Kline’s Now approved for lipoprotein lipase (LPL). Mobilisation of this reserve occurs by tumescent anaesthesia takes advantage of the above in order to hydrolysis of adipocyte TG by hormone sensitive lipase (HSL). produce a relatively bloodless procedure.10 crow’s feet lines Insulin is the main regulator of adipocyte fat content, since it is Recent studies have revealed that adipose tissue is a dynamic both a potent inhibitor of HSL and an important activator of LPL, tissue with multiple functions. Adult stem cells are abundant within thereby enhancing FFA uptake and triglyceride synthesis in the adipocytes, and in the case of excess calorie intake, these adipocytes. Fat is an exocrine, endocrine, and apocrine organ stem cells are recruited to form new lipocytes.11, 12, 13 Zuk reported and plays a role in immunity. Fat cells produce hormones such isolation of a population of stem cells from human adipose tissue, as leptin, which is normally released after a meal and dampens where the cells were obtained from a liposuction aspirate, and

Bocouture® 50 Abbreviated Prescribing Information Please refer to the Summary of Product dry eye. General disorders and administration site conditions; Common: injection site haemotoma. appetite. They also produce the hormone adiponectin, which is were then determined to be mesenchymal and mesodermal in Characteristics (SmPC) before prescribing. 1162/BOC/AUG/2014/PU 50 LD units of Post-Marketing Experience; Flu-like symptoms and hypersensitivity reactions like swelling, oedema 8 Presentation 50 thought to influence the response of cells to insulin. Although origin. In vitro these cells could differentiate into adipogenic in the Botulinum toxin type A (150 kD), free from complexing proteins as a powder for solution for injection. (also apart from injection site), erythema, pruritus, rash (local and generalised) and breathlessness Indications Temporary improvement in the appearance of moderate to severe vertical lines between have been reported. Overdose May result in pronounced neuromuscular paralysis distant from the scientists are still deciphering the roles of individual hormones, it presence of proper induction factors.14 This study indicates that the eyebrows seen at frown (glabellar frown lines) and lateral periorbital lines seen at maximum smile injection site. Symptoms are not immediately apparent post-injection. Bocouture® may only be used (crow’s feet lines) in adults under 65 years of age when the severity of these lines has an important by physicians with suitable qualifi cations and proven experience in the application of Botulinum is becoming clear that excess body fat, especially abdominal fat, the removal of fat by liposuction does not necessarily equate to a psychological impact for the patient. Dosage and administration Unit doses recommended for toxin. Legal Category: POM. List Price 50 U/vial £72.00 Product Licence Number: PL 29978/0002 disrupts the normal balance and functioning of these hormones.8 Bocouture are not interchangeable with those for other preparations of Botulinum toxin. Reconstitute Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer Landstraße 100, permanent reduction in the absolute lipocyte number, a common with 0.9% sodium chloride. Glabellar Frown Lines: Intramuscular injection (50 units/1.25 ml). 60318 Frankfurt/Main, Germany. Date of revision of text: August 2014. Further information Adipose tissue consists of adipocytes, fibrous trabeculae, and misconception in aesthetics. Standard dosing is 20 units; 0.1 ml (4 units): 2 injections in each corrugator muscle and 1x procerus available from: Merz Pharma UK Ltd., 260 Centennial Park, Elstree Hill South, Elstree, Hertfordshire muscle. May be increased to up to 30 units. Injections near the levator palpebrae superioris and WD6 3SR.Tel: +44 (0) 333 200 4143 blood vessels. Mammals have two different types of adipose into the cranial portion of the orbicularis oculi should be avoided. Crow’s Feet lines: Intramuscular injection (50units/1.25mL). Standard dosing is 12 units per side (overall total dose: 24 units); 0.1mL Adverse events should be reported. Reporting forms and information can be found at tissue; white adipose tissue and brown adipose tissue. White Gross Anatomy of Adipose Tissue (4 units) injected bilaterally into each of the 3 injection sites. Injections too close to the Zygomaticus www.mhra.gov.uk/yellowcard Adverse events should also be reported to Merz Pharma UK Ltd at adipose, the most common type, provides insulation, serves as Subcutaneous fat is the layer of subcutaneous tissue that is major muscle should be avoided to prevent lip ptosis. Not recommended for use in patients over the address above or by email to [email protected] or on +44 (0) 333 200 4143. 65 years or under 18 years. Contraindications Hypersensitivity to Botulinum neurotoxin type A or to a reservoir of energy, and provides insulation and protection most widely distributed. It is composed of adipocytes, which are any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, Lambert-Eaton 1. Bocouture 50U Summary of Product Characteristics. Bocouture SPC 2014 August available from: syndrome). Presence of infection or infl ammation at the proposed injection site. Special warnings URL: http://www.medicines. org.uk/emc/medicine/23251. against physical injury. Brown adipose, found mainly in newborn grouped together in lobules separated by connective tissue. and precautions. Should not be injected into a blood vessel. Not recommended for patients with 2. Prager, W et al. Onset, longevity, and patient satisfaction with incobotulinumtoxinA for the and hibernating animals, generates heat and actually consumes Subcutaneous fat is found just beneath the skin, as opposed to a history of dysphagia and aspiration. Adrenaline and other medical aids for treating anaphylaxis treatment of glabellar frown lines: a single-arm prospective clinical study. Clin. Interventions in should be available. Caution in patients receiving anticoagulant therapy or taking other substances in Aging 2013; 8: 449-456. energy. In humans, the percentage of brown adipose found in visceral fat, which is found in the peritoneal cavity. Visceral fat anticoagulant doses. Caution in patients suffering from amyotrophic lateral sclerosis or other diseases 3. Sattler, G et al. Noninferiority of IncobotulinumtoxinA, free from complexing proteins, compared which result in peripheral neuromuscular dysfunction. Too frequent or too high dosing of Botulinum with another botulinum toxin type A in the treatment of glabelllar frown lines. Dermatol Surg 2010; the body decreases with age. Its colour and heat-generating has been linked to metabolic disturbances and increased risk toxin type A may increase the risk of antibodies forming. Should not be used during pregnancy unless 36: 2146-2154. clearly necessary. Should not be used during breastfeeding. Interactions Concomitant use with 4. Prager W, et al. Botulinum toxin type A treatment to the upper face: retrospective analysis of daily properties are imparted by the abundance of iron containing for cardiovascular disease and type 2 diabetes. In women, it is aminoglycosides or spectinomycin requires special care. Peripheral muscle relaxants should be used practice. Clin. Cosmetic Invest Dermatol 2012; 4: 53-58. mitochondria found in brown fat cells which utilise fuels also associated with breast cancer and the need for gallbladder with caution. 4-aminoquinolines may reduce the effect. Undesirable effects Usually observed within 5. Data on File: BOC-DOF-11-001_01 the fi rst week after treatment. Localised muscle weakness, blepharoptosis, localised pain, tenderness, to produce energy in the form of ATP.9 The chief chemical surgery.15 One reason excess visceral fat is so harmful could be itching, swelling and/or haematoma can occur in conjunction with the injection. Temporary vasovagal Bocouture® is a registered trademark of Merz Pharma GmbH & Co, KGaA. reactions associated with pre-injection anxiety, such as syncope, circulatory problems, nausea or 1180/BOC/OCT/2014/LD Date of preparation: October 2014 constituents of adipocytes are triglycerides, which are esters its location near the portal vein, which carries blood from the tinnitus, may occur. Frequency defi ned as follows: very common (≥ 1/10); common (≥ 1/100, < 1/10); made up of a glycerol and one or more fatty acids, such as intestinal area to the liver. Substances released by visceral fat, uncommon (≥ 1/1000, < 1/100); rare (≥ 1/10,000, < 1/1000); very rare (< 1/10,000). Glabellar Frown 1 2,3,4 5 Lines: Infections and infestations; Uncommon: bronchitis, nasopharyngitis, infl uenza infection. PURIFIED • SATISFYING • CONVENIENT stearic, oleic, or palmitic acids. Enzymes contained in adipose including free fatty acids, enter the portal vein and travel to the Psychiatric disorders; Uncommon: depression, insomnia. Nervous system disorders; Common: headache. Uncommon: facial paresis (brow ptosis), vasovagal syncope, paraesthesia, dizziness. cells specialise in the hydrolysis of triglycerides in order to liver, where they can influence the production of blood lipids.16 Eye disorders; Uncommon: eyelid oedema, eyelid ptosis, blurred vision, blepharitis, eye pain. Ear and Labyrinth disorders; Uncommon: tinnitus. Gastrointestinal disorders; Uncommon: nausea, dry generate fatty acids and glycerol for physiological processes. Visceral fat is directly linked with higher total cholesterol and LDL mouth. Skin and subcutaneous tissue disorders; Uncommon: pruritus, skin nodule, photosensitivity, The fat stored in these cells partly comes directly from the cholesterol, lower HDL cholesterol, and insulin resistance.16 Most dry skin. Musculoskeletal and connective tissue disorders; Common: muscle disorders (elevation of eyebrow), sensation of heaviness. Uncommon: muscle twitching, muscle cramps. General disorders Botulinum toxin type A fats eaten, or is manufactured within the body from fats and of the remaining nonvisceral fat is found in the hypodermis and and administration site conditions; Uncommon: injection site reactions (bruising, pruritis), tenderness, Infl uenza like illness, fatigue (tiredness). Crow’s Feet Lines: Eye disorders; Common: eyelid oedema, free from complexing proteins Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015

MZ052 ISOBEL A4 AJ 1180BOCOCT2014LD.indd 1 23/10/2014 15:48 @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com can be divided into three layers: apical, mantle and deep. and esterify fatty acids to form other lipid compounds such as Apical Layer phospholipids. After carbohydrate consumption, the amount in This most superficial layer of subcutaneous fat is just beneath the excess of that used for energy, or stored as glycogen, is converted reticular dermis and surrounds sweat glands and hair follicles. It by the liver into triglycerides, which are then stored in adipocytes.17 also surrounds vascular and lymphatic vessels. This layer is rich in Exogenous dietary fats are hydrolysed in the gut and then packed carotenoids and tends to be yellow in appearance. into chylomicrons by the intestinal cells, which are finally released Mantle Layer into the lymphatics and the blood stream. Endogenous fatty acids This layer is composed of columnar-shaped lipocytes and is are synthesised by the liver from carbohydrates and, to a smaller separated from the deep layer of fat by a fascia-like layer of extent, from proteins. These fatty acids are then metabolised into fibrous tissue. The mantle is absent in eyelids, nail beds, bridge triglycerides, packed as the very low-density lipoproteins and of the nose, and penis.10 This layer significantly contributes to the released into the circulation. Lipolysis is under the influence of skin’s ability to resist trauma. It causes external pressure to be the hormone-sensitive lipase. It can be activated by epinephrine, distributed across a larger field; much like a box-spring mattress norepinephrine, corticotrophin, glucocorticoids, growth hormone, absorbs sitting pressure. thyroid hormone, and a decrease in plasma insulin. Catecholamines Deep Layer also stimulate lipolysis acting on β- adrenergic receptors. Regarding This layer extends from the under-surface of the mantle layer lipogenesis, the action of lipoprotein lipase is the rate-limiting step to the muscle fascia below. Its shape and thickness depend on that mediates the uptake of free fatty acids into the adipocyte. An the sex, genes and diet of the individual. In this layer fat cells are integral part of the formation of triglycerides is the formation of α- arranged in pearls, and the pearls are gathered into globules. glycerolphosphate from glucose in the fat cells. Glucose transport These globules are then packaged like eggs in an egg crate is facilitated by insulin receptors on adipocytes.17 Fat is one of the between septa, and arranged between tangential and oblique three main macronutrients along with protein and carbohydrate. fibrous planes. Oblique planes are thinner and interconnect the As we know, ‘fat’ does not necessarily make us fat and should tangential fibrous layers. They also play a role in the formation be included in our diet. As Eva Escofet, a nutritional therapist with of cellulite.10 The apical and mantle layers formerly represented more than 10 years of clinical experience, says, “Restrictive diets the ‘no go zone’ in liposuction, due to their proximity with nerves are generally shown to offer short term resolutions only, which and vessels, disruption of which could lead to seroma, pigment are not sustainable.” Foods that are naturally low-fat (like fruits and disorders and full thickness skin necrosis. Nowadays, however, vegetables) are beneficial, but processed foods with ‘low-fat’ on the with the use of much thinner cannulae, we are able to treat label can sometimes be loaded with unhealthy ingredients, such superficially to the deep subcutaneous layer during a liposuction as high fructose corn syrup and partially hydrogenated soya bean procedure. oil which contains trans fat, rendering them more damaging to our health.18 Fats serve important structural and metabolic functions. Nutrition and Metabolism A large amount of the daily metabolic energy requirement comes Everything we eat contains carbohydrates, fats and proteins in from fat metabolism. There are two metabolic functions of adipose varying amounts. Dr Sam Robson, medical director of Temple tissue. First, it provides storage of triglycerides as long-term energy Medical, says “Sugars are ready made fuels. Carbohydrates can reserve and, second, it has a very dynamic pattern of metabolism, be turned into sugars relatively fast, but fats are stored in the which responds, on a minute-to-minute basis, to the energy fatty tissue for future needs, because turning fat into fuel requires requirements by modulating the supply of lipid energy released to more energy. If the body cannot use the amount of fuel (sugars the rest of the body in the form of non-esterified fatty acids.19 and carbohydrates) immediately, these sugars and carbohydrates, On the other hand, I strongly believe that trans fat and refined as well as proteins, will be stored in the form of fats.” Stored fat oils should be kept to a minimum due to their strong link with is mobilised during calorie restriction through the activation of cardiovascular disease.20 Animal-based fats were once the only trans triglyceride lipase. The hormonal signal to activate triglyceride fats consumed, but by far the largest amount of trans fat consumed lipase is glucagon and, to some extent, epinephrine. When the today is created by the processed food industry21 as a side effect of insulin-glucagon ratio is in favour of insulin, fat cannot be mobilised. partially hydrogenating unsaturated plant fats (generally vegetable oils). Insulin is secreted in response to circulating glucose levels. Thus, a These partially hydrogenated fats have displaced natural solid fats and meal that raises glucose will cause insulin secretion, the magnitude liquid oils in many areas, the most notable ones being in the fast food, of which depends on the carbohydrate load. Fat is stored as snack food, fried food, and baked goods industries. Consumption of triglycerides, it is deposited in the adipocyte by lipoprotein lipase trans fats has shown to increase the risk of coronary heart disease in (lipogenesis), and is released by hormone sensitive lipase (lipolysis). part by raising levels of the lipoprotein LDL (so-called ‘bad cholesterol’), Over a two to three week period, all of the stored triglycerides are lowering levels of the lipoprotein HDL (‘good cholesterol’), increasing either catabolised for energy production or broken down into free triglycerides in the bloodstream and promoting systemic inflammation. fatty acids. The liver is also involved in fat metabolism. The liver can Refined vegetable oils such as soybean, corn and canola oils, contain utilise fatty acids for energy production, synthesise triglycerides large amounts of Omega-6 fatty acids, which are biologically active from carbohydrates and, to a lesser extent, from proteins, and can cause oxidative stress and make the LDL lipoproteins in the body become oxidised, potentially contributing to heart Fats serve important disease.22 The AMP-activated protein kinase (AMPK) is an important integrator of signals managing energy balance. It has been shown structural and metabolic that dysregulation of AMPK activity underlies the pathogenesis of metabolic syndrome. A strong correlation between low activation state functions of AMPK and metabolic disorders associated with insulin resistance,

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This is not intended for use in the U.S. market. ©2014. All rights reserved. UltraShape, Syneron, the Syneron logo and elōs are trademarks of Syneron Medical Ltd. and may be registered in certain jurisdictions. elōs (electro-optical synergy) is a proprietary technology of Syneron Medical. Candela is a registered trademark of the Candela Corporation. PB84611EN @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com obesity and sedentary activities has been established.23 A high fat diet causes dysregulation more, and 6.3% are severely obese (BMI of AMPK, associated with impaired AMPK phosphorylation and protein expression in skeletal >40).25 Despite increased spending on muscle, heart, liver, aortic endothelium and hypothalamus. AMPK inhibition can also be caused by medical and surgical interventions, rates inflammatory signals (i.e. pro-inflammatory cytokines). AMPK is implicated in energy production by of obesity continue to increase inexorably. the cell through phosphorylation on threonine residue 172 (Thr-172), thus inhibition of AMPK will The prevalence of obesity in England has also have a negative effect on cellular metabolism.24 more than doubled in the last 25 years.26 In 2010, it was estimated that about 46% Trends in overweight and obesity rates of men in England and 32% of women are “Obesity is an issue affecting people of all ages and incomes, everywhere,” says Dr Christopher overweight (a body mass index of 25-30 Murray, director of Institute for Health Metrics and Evaluation (IHME) and a co-founder of the kg/m2), and an additional 17% of men and Global Burden of Disease (GBD) study. “In the last three decades, not one country has achieved 21% of women are obese (a body mass success in reducing obesity rates, and we expect obesity to rise steadily as incomes rise in low- index of more than 30 kg/m2).27 In 2012 and middle-income countries in particular, unless urgent steps are taken to address this public a health survey of England showed that health crisis.” In terms of statistics, China and India together represent 15% of the world’s obese 1.7% of men and 3.1% of women had a BMI population.25 The highest proportion of obese people in the world (13%) live in the United States. of 40 or more (morbidly obese).28 Obesity Nationally representative estimates from 2009 to 2010 indicate that 35.5% of the adult population rates continue to increase in all countries in the US is obese (defined as BMI >30). About 15.5% of the US adult population has a BMI of 35 or within the British Isles and Ireland, and Scotland continues to have the highest Figure 1: BMI Chart prevalence of obesity.29 In 2010, 65% of Weight (pounds) Scottish adults aged 16 and over were 30 19017015013011090 350330310290270250230210 overweight or obese (BMI≥25). 40 6’6”

Conclusion Underweight Normal range Overweight Obese Obesity is a complex condition, one 40 BMI <18.5 BMI 18.5-25 BMI 25-30 BMI > 30 6’3” with serious social and psychological dimensions, that affects virtually all age and socioeconomic groups and

40 5’11” threatens to overwhelm both developed and developing countries. Its health consequences range from increased risk of premature death to serious

Height (metres) Height 40 5’7” chronic conditions that reduce overall

Height (feet and inches) (feet Height quality of life. The classical perception of adipose tissue as a storage depot of FFAs has now been replaced by the 40 5’3” notion that adipose tissue is an active endocrine organ playing a central role in lipid and glucose metabolism, and produces a large number of 40 4’11” hormones and cytokines involved in the 40 50 60 70 80 90 100 110 120 130 140 150 160 development of metabolic syndrome, Weight (kilograms) diabetes mellitus, and vascular disease. Better understanding of the Figure 2: Trend in adult prevalence of obesity in the UK (BMI≥30kg/m2) – percentage of the adult population assessed as obese in the UK and Ireland, 1995 – 2011. (Public Health England 2014) physiology and role of the adipocyte may provide the pathophysiological 30 framework within which the relationship between obesity and its associated 25 detrimental metabolic consequences can be found. Weight reduction and 20 increasing physical activity are effective

England interventions for improving adipose 15 tissue function. It has been shown that Scotland after three months of restricted caloric Northern Ireland 10 intake and increased exercise TNF-a, Wales Obesity prevelance (%) prevelance Obesity leptin, and IL-6 levels decrease. On the 5 Ireland other hand, anti-inflammatory cytokines (adiponectin and IL-10) are significantly 0 increased in obese subjects with 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 metabolic risk factors. Insulin sensitivity

Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015 aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics

improves and adiponectin plasma levels increase, suggesting that adipocyte Dr Sotirios Foutsizoglou specialises in minor function improves, as low adiponectin levels are generally associated with cosmetic surgery and aesthetic medicine. He is the adipocyte dysfunction.31 Further knowledge of the underpinnings of adipose founder and medical director of SFMedica, based on Harley Street in London. In addition to his tissue dysfunction may provide new targets for drug development for the MBBS he also holds a BSc(Hons) in mathematics management of obesity, along with better approaches to halt the epidemic from the University of Athens and a MSc in Biostatistics and proportions of obesity before it is too late. Epidemiology from the Harvard School of Public Health.

REFERENCES 1. Berne R M, Levy M N, Physiology, 4th Ed., (St Louis: Mosby 1998) 17. Frayn KN, ‘Adipose tissue metabolism’, Clin Dermatol, 17 (1989), p.49-61 2. Klok MD, Jakobsdottir S, Drent ML. ‘The role of leptin and ghrelin in the regulation of food intake 18. Thomas LH, Jones PR, Winter JA, Smith H, ‘Hydrogenated oils and fats: the presence of and body weight in humans: a review’, Obesity Reviews, Jan;8(1) (2007) 21-34 chemically-modified fatty acids in human adipose tissue’, American Journal of Clinical Nutrition 3. Marie Ng et al., ‘Global, regional, and national prevalence of overweight and obesity in children and 34 (1981) 877-86 adults during 1980-2013: a systematic analysis for the Global Burden of Disease Study 2013’, The 19. Guyton AC, Lipid and protein metabolism. Human Physiology and Mechanisms of Disease Lancet, Vol 384, Issue 9945 (2014), pp. 766 – 781 (Philadelphia: WB Saunders, 1992) p.520-25 4. Larsson B, ‘Regional obesity as a health hazard in men. Prospective studies’, Acta Med Scand Suppl, 20. Mozaffarian ,D Katan MB, Ascherio A, Stampfer MJ, Willett WC. ‘Trans fatty acids and 723 (1988) p.121-134. cardiovascular disease’, New England Journal of Medicine, Apr 13;354(15) (2006) 1601-13 5. Schapira DV, Kumar NB, Lyman GH, and Cox CE, ‘Abdominal Obesity and Breast Cancer Risk’, 21. Casimir C. et al. Food lipids: chemistry, nutrition, and biotechnology. (New York: M. Dekker 2002), Annals of Internal Medicine, (1990) pp. 1–2 6. Klein S, ‘The case of visceral fat: argument for the defense’, J Clin Invest, 113(11) (2004), pp. 22. Westerterp-Plantenga MS, Nieuwenhuizen A, Tome D, Soenen S, Westerterp KR, ‘Dietary protein, 1530–1532 weight loss, and weight maintenance’, Annu Rev Nutr, 29 (2009), p.21-41 7. Kissebah AH and Evans DJ, ‘Mechanisms associating body fat distribution to glucose intolerance 23. Kelly M, Keller C, Avilucea PR, Keller P, Luo Z, Xiang X, Giralt M, Hidalgo J, Saha AK, Pedersen BK, and diabetes mellitus’, Acta Med Scand, 723 (1988) p.79-89 ‘Interleukin-6 regulation of AMP-activated protein kinase. Potential role in the systemic response 8. Ukkola O, Santaniemi M., ‘Adiponectin: a link between excess adiposity and associated to exercise and prevention of the metabolic syndrome’, Diabetes Dec;55 Suppl 2 (2006) 48-54 comorbidities?’, J. Mol. Med. 80 (11) (2002), pp. 696–702. 24. Lee WJ, Lee IK, Kim HS, Kim YM, Koh EH, Won JC, Han SM, Kim MS, Jo I, Oh GT, Park IS, Youn 9. Encyclopaedia Britannica, Adipose Tissue (US: Encyclopaedia Britannica, 2014) [Accessed February 9] of AMP-activated protein kinase’, Arterioscler Thromb Vasc Biol 25 (2005) 2488–2494. 10. Shiffman M and Di Giuseppe A.,Liposuction: Principles and Practice. (Germany, Springer, 2006) 25. Cynthia L et al, ‘Prevalence of Childhood and Adult Obesity in the United States’, JAMA 311:8 11. Cheng AYM, Deitel M, Roncar DAK, ‘The biochemistry and molecular biology of human adipocyte’, (2014), 2011-2012 Int J Obes (2004). 26. Public Health England, UK and Ireland prevalence and trends (England: Public Health England, 12. Van RLR et al. ‘Complete differentiation of adipocyte precursors’.Cell tissue Research 195 (2012) 2015) 317-39 27. Health Survey for England – 2010: Trend Tables. The NHS Information Centre, 2011. 13. Lott KE, Awad HA, Gimble JM, Guilak F, ‘Clonal Analysis of multipotent Differentiation of Human 28. Public Health England, Severe Obesity (England: Public Health England, 2014) 14. Zuk PA, Zhu M, Mizuno H, Huang JBS, Katz AJ. ‘Multilineage Cells from Human Adipose Tissue: 29. Public Health England, International Comparisons (England: Public Health England, 2015) 15. Kissebah, AH, et al. ‘Relation of body fat distribution to metabolic complications of obesity’, J. Clin. 30. Bromley, Catherine et al, The Scottish Health Survey: Volume 1: Main Report Bromley, (Scotland: Endocrinol. Meta, 54 (1982), pp. 254-260. scotland.gov.uk, 2011) < http://www.scotland.gov.uk/Publications/2011/09/27084018/0> 16. Harvard Medical School, ‘Abdominal fat and what to do about it’, Harvard Health Publications, 31. Hajer GR, van Haeften TW, Visseren FL, ‘Adipose tissue dysfunction in obesity, diabetes, and February 2007 update (2007) vascular diseases’, Eur Heart J 29(24) (2008), pp. 2959-2971

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gases in the treatment area. Plexr can also be used for mole removals, stretch mark treatment, excess skin removal, keloid scar Spotlight removal, hyperpigmentation treatment, acne scarring and as an active acne treatment. As Plexr does not directly touch the skin, the manufacturers claim using the device for aesthetic concerns On: Plexr significantly reduces the risk of complications occurring. Studies into the efficacy of Plexr for the treatment of excess skin on the upper eyelid, perioral rhytides and acne have been conducted, with positive results.1,2,3 Dr Sherif Wakil, president Soft Surgery of the International Association of Soft Surgery and lead Plexr

Soft Surgery trainer in the UK, uses the device as an alternative Aesthetics explores the latest to blepharoplasty. He explains, “Plexr works on a completely different mechanism of action compared to laser or cryogenics. By development in non-ablative generating plasma, Plexr maintains the vitality of the tissue much technology equivalent to those better than other methods of skin tightening or rejuvenation, as demonstrated in a histological comparison between Plexr and achieved through surgery radio-surgical methods.”1 “Extra skin on the eyelid is a very common patient complaint in my Patient demand for faster clinic,” says Dr Wakil. “With surgery, there is a standard procedure treatment with minimum which can allow one eye to be more corrected than the other. Plexr downtime is increasing allows the practitioner to sculpt each patient’s upper eyelid and year on year. Aesthetic individualise treatment to each line or piece of skin. As it is a very practitioners are being small tool, it’s very easy to manoeuvre and target the most hidden continually challenged to areas to achieve the best results.” offer non-surgical procedures He adds, “This procedure has less complications than surgery that provide results. In for blepharoplasty – no anesthesia, reduced down-time and the response to this demand, expense is much lower. You find a lot of patients are boasting that Professor Giorgio Fippi, they’ve had an effective procedure without a knife touching their president of the Italian Society face.” Plexr can also be used for dermabrasion. The study, ‘Treatment for Aesthetic Medicine, has of Perioral Rhytides with Voltaic Arc Dermoabrasion’, comprised 15 developed an innovative tool patients (11 female and four male) who were aged between 30 and that uses plasma to treat an 65 years. The majority (90%) had class II and III wrinkle scores within array of aesthetic concerns. the perioral area. After undergoing treatment with Plexr, the study’s The Plexr (which stands for authors concluded that, “Fine rhytides, particularly in the perioral Plasma Exeresis) comprises areas may be completely eradicated with voltaic arc resurfacing; three handheld wireless deeper creases are also improved, probably secondary to a general devices (white, green and red) tightening effect.” A second study, ‘Plexr in Acne Treatment’, treated that each offer varying degrees 30 patients with acne (10 male, 20 female) aged between 14-45 of treatment. The device , which has received CE approval, years. Of the 30 patients, 23 had already tried to treat their acne with works through the non-ablative process of sublimation. Plasma is both local and systemic treatment, with little effect. The remaining formed through the ionisation of atmospheric gas, which works to seven patients had not undergone any treatment prior to Plexr. The stimulate the contraction, shortening and tightening of skin fibres, authors found no relapse in any of the patients, and no side effects thus resulting in the reduction of the skin surface. The amount such as dyschromia, scars, hyperpigmentation or hypopigmentation, of plasma generated depends on which Plexr device is used, air which can occur as a result of laser and peel treatments. They exchange in the ionisation area, and the emission of atmospheric concluded, “Plexr is an alternative way of treating acne without

Treatment case studies

Before Eyelid treatment with Plexr Before Periorbital treatment with Plexr Before mole removal with Plexr After Mole removal with Plexr

After Eyelid treatment with Plexr Immediatly after Perioribtal treatment with Plexr

Images courtesy of Dr Sherif Wakil

Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015 aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics the need of systemic medication.” Depending on the indication, seen any complications following treatment with Plexr, and notes practitioners can adopt two techniques for effective treatment that the procedure is suitable for most patients with all Fitzpatrick results, known as ‘spraying’ and ‘spotting’. The first is more commonly skin types. After cleansing the skin and applying the numbing cream, used for pigment treatments, whilst the second is used to aid skin practitioners should wait around 20 minutes before administering tightening. “Each technique has its own treatment protocol,” explains treatment. Dr Wakil explains that you can then position the patient Dr Wakil. “Practitioners are given patterns to follow for ‘spraying’ appropriately and begin using the Plexr. He says, “Patients can open and are taught how to target treatment areas whilst ‘spotting’.” Dr and close their eyes during the procedure, allowing practitioners Wakil explains that the Plexr should be held 1-2mm away from the to target each area effectively.” Once the procedure is complete, skin during treatment, and says, if the device touches the skin, it will Dr Wakil says he then applies a concealer to the treated area, immediately switch off, preventing the risk of injury. Once treated, which patients can take home. Healing time for patients with higher the skin will develop a crust-like protective layer, which will fall off Fitzpatrick skin types can take four/five weeks, compared to the approximately five-seven days post procedure. The new skin, often usual two/three weeks for patients with lighter skin. He suggests referred to as similar to ‘baby skin’ by Dr Wakil’s patients, will be very that practitioners should advise patients to protect their skin from thin and soft, and pink in colour. Patients can conceal it with makeup the sun and apply ice to the swollen treated area, which, according until it develops to match their natural skin colour. to the doctor, usually goes down after approximately two days. Plexr treatments usually take approximately 20-30 minutes, Dr Wakil also gives patients eye drops to take home, for the rare depending on the area being treated and the severity of each case. occasion that patients develop any redness or infection. Whilst Dr For practitioners using the Plexr as an alternative to blepharoplasty, Wakil reports no complications, he does note that problems could Dr Wakil advises practitioners offer patients two to three treatments, arise if a practitioner does not receive appropriate training for the before the final aesthetic results equate to those achieved through use of Plexr. Adding to the already varied indications Plexr can treat, surgery. “When you are starting out, it’s better to do it bit by bit,” he research is currently underway for its effectiveness as an alternative says, adding, “Don’t be aggressive and make sure you take your treatment to labiaplasty. time.” Dr Wakil says that there are no contraindications for the use REFERENCES of Plexr, and explains it can treat aesthetic concerns not achievable 1. Scarano A et al, ‘Skin lesions induced from the radiosurgical unit and voltaic arc dermoabrasion: A rabbit model’, European Journal of Inflammation,9 (2011), p.89-94. through laser treatment. “You can not use lasers to treat Herpes 2. Scarano A et al, ‘Treatment of perioral rhytides with voltaic arc dermoabrasion’, European Simplex, however Plexr allows you to treat the viral disease, as well Journal of Inflammation,10 (2012), p.25-29. 3. Stamatina G et al, ‘Plexr in acne treatment’, Pinnacle Medicine & Medical Sciences, 2 (2015), as the blisters that could accompany it.” He says he has not yet p.482-486.

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Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015 Advertorial Advertorial ACE 2015 @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com ACE 2015 aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics Last chance to register for ACE 2015 Don’t miss the first and largest UK medical aesthetics event of the year. Register FREE now atwww.aestheticsconference.com

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Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015 SEE US AT STAND 7 AND JOIN OUR MASTERCLASS

THE FUTURE OF WELLNESS HAS ARRIVED LONDON / 7-8 MAR 2015 aestheticsconference.com

“Fatigue, lack of energy and weight gain are amongst the commonest symptoms I see. Reviv with its high concentration vitamin and mineral intravenous therapy, might just be the answer.

Safe and effective, its set to become the go-to treatment for everyone in the UK who likes to work hard and play hard.”

Dr Hillary Jones

BECOME PART OF THE FUTURE TODAY Call 01788 550440 or email [email protected] LONDON • LAS VEGAS • MIAMI • NEW YORK SEE US AT STAND 7 AND JOIN OUR MASTERCLASS aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics

THE FUTURE OF WELLNESS HAS ARRIVED notes that there are some contraindications to treatment, such as LONDON / “potassium issues, certain cardiac problems or those taking specific 7-8 MAR 2015 medications”, adding that around 1% of patients presenting are aestheticsconference.com unsuitable for IVMT. Post-treatment, patients feel more relaxed and energised with enhanced skin and wellbeing, although these benefits are anecdotal. At Reviv clinics, patients can have IV infusions and booster shots containing a mix of nutrients. Former GP, TV doctor and Reviv’s chief medical adviser, Dr Hilary Jones, explains that the IV and intramuscular treatments are designed to combat fatigue, dehydration, sickness, common cold, dry skin and much more. “On average, most people report a benefit within two hours,” Dr Jones says. “Your body will be fully hydrated; individuals report increased energy levels for four to seven days and, from a preventative health perspective, no longer suffer from the common cold and flu. A high percentage see a significant difference in their skin and nail condition.”

The evidence Many studies have been conducted into the efficacy of IVMT, most of which examine its use in particular cohorts of patients with specific The Vitamin conditions. In a 2002 review of evidence, Dr Gaby reported that his modified version of Myers’ cocktail “had been found to be effective against acute asthma attacks, migraines, fatigue, fibromyalgia, acute Drip Debate muscle spasm, upper respiratory tract infections, chronic sinusitis, seasonal allergic rhinitis, cardiovascular disease, and other disorders”.1 He concluded that Myers’ cocktail (or variations thereof) was safe and Allie Anderson examines the effective, but that “most of the evidence is anecdotal”. arguments for and against this growing aesthetic trend Fieldgrass and Dr Jones both cite studies of the use of IV magnesium in treating acute asthma.2,3,4 In a 2000 review of literature describing the effects of IV magnesium sulphate for acute asthma, scientists Background concluded that although routine use of the therapy in asthma patients Intravenous micronutrient therapy (IVMT) has enjoyed a surge in presenting to emergency departments was not supported, the popularity in recent years, perhaps thanks to a string of celebrity treatment appears to be safe and beneficial for others with severe endorsements. The practice was pioneered decades ago by US acute asthma.4 Similar studies claim to demonstrate that IVMT is physician Dr John Myers, who routinely gave intravenous infusions beneficial for people with fibromyalgia,5,6 but a later, randomised containing a mixture of vitamins and nutrients to patients with a placebo-controlled trial found no statistically significant differences range of ailments. After his death in 1984, Dr Alan Gaby continued between patients treated with IVMT and those given a placebo.7 treating some of Myers’ patients with an adapted version of what has become known as ‘Myers’ cocktail’ – which is said to have Dianne Bedford, practitioner at the Lasky Aesthetics and Laser Center contained magnesium chloride, calcium gluconate, thiamine, vitamins in California, administers IVMT to a range of patients. “Individuals B6 and B12, calcium panthothenate, vitamins C and B complex and not only want to look good, but feel good as well,” she explains. “IV diluted hydrochloric acid.1 Dr Gaby expanded the use of IVMT and it vitamin infusions are a way to deliver beneficial nutrients into the cell gained in prominence throughout the United States and, soon after, to help remedy a variety of concerns and improve overall wellbeing.” “Fatigue, lack of energy and weight gain are amongst the internationally. The treatment is now widely available in a variety of Bedford describes the majority of her patients as those seeking to commonest symptoms I see. Reviv with its high concentration settings, most commonly in cosmetic clinics and medispas, but it can boost their immune system and optimise their general health. She vitamin and mineral intravenous therapy, might just be the answer. also be administered in offices and in the comfort of the individual’s says there are benefits to supplementary nutrients because many home. people don’t absorb them sufficiently when they are ingested. “Many factors are needed for optimal absorption and delivery of nutrients, Safe and effective, its set to become the go-to treatment for Reported effects such as optimal gut health, healthy liver function and healthy cell everyone in the UK who likes to work hard and play hard.” According to Esther Fieldgrass, aesthetic practitioner and founder membranes,” Bedford comments. “Most patients have some type of of London’s EF Medispa, IVMT is potentially suitable for anyone with gut complaint, such as poor digestion, acid reflux, food intolerance or dehydration, fatigue and nutrient deficiency. “Our patient profiles cover allergies, thereby decreasing their ability to breakdown and absorb Dr Hillary Jones a wide variety of people: those who lead very active lives, frequent any supplement.” In addition, Bedford suggests that certain nutrients travellers suffering jet lag, people in high-stress jobs and some who are only beneficial to our bodies at higher concentrations. “Vitamin C consider themselves prone to minor ailments,” she says. IV infusions has been known to have an antiviral effect at serum concentrations of BECOME PART OF THE FUTURE TODAY are individually formulated, based on an extensive patient history 10-15mg/dl [micrograms per decilitre]. These levels are not attainable and questionnaire, which are reviewed by a doctor or nurse. “The with oral intake of vitamin C. Most people take 500mg to 1gm of Call 01788 550440 or email [email protected] practitioner may request specific tests – such as urine, saliva and vitamin C daily, [but] a dose of 2.5gm of vitamin C would raise the LONDON • LAS VEGAS • MIAMI • NEW YORK blood – if the patient presents with any health concerns.” Fieldgrass serum concentration to about 1.2 to 1.5mg/dl.”

Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015 @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

A 1990 study indeed found that vitamin C at high concentrations (10 that’s without sufficient evidence to prove its efficacy. “I don’t like to 15mg/dl) had antiviral properties.8 However, the study specifically the fact that we can trivialise things that shouldn’t be trivialised. A examined suppression of the human immunodeficiency virus (HIV) in vitamin drip to improve the quality of your skin seems, to me, a step vitro rather than as a therapy on real-life patients. A more recent study too far. I feel there’s an element of the emperor’s new clothes about reviewed and compared placebo-controlled trials involving more this.” For Duckett, the answer to achieving the health benefits that than 11,000 participants, and found that regular supplementation of IVMT purports to deliver is simple: “Get enough sleep, get enough FREE NEW vitamin C failed to reduce the incidence of colds, but was successful in exercise and eat a healthy diet.” Dr Quinn highlights a potentially reducing the duration and severity of colds.9 The study neither stated more significant problem. “When someone has an intravenous the upper vitamin C dose limit of the reviewed trials, nor distinguished drip there is always a risk of severe allergic reaction or even Age Intervention Face Cream between the effects of different doses; but it stated that the trials anaphylactic shock,” he says. “There’s a very strong argument that tested doses of at least 0.2g (200mg) per day of vitamin C – the anyone having an IV infusion should be in hospital, and not in an amount available in an average, over-the-counter oral supplement. aesthetic clinic – so there is a safety issue here as well.” New Advanced Formula with intense hydration.

Opposition Notwithstanding these risks, IVMT has an expanding fan base and Recommended for women showing the visible Much of the dispute against IVMT centres on the argument that there is a growing body of anecdotal evidence supporting its use. NEW we ought to get all the nutrients we need from our diet. The The suggestion of a placebo effect may not be without basis: it is signs of ageing skin NEW FOR 2015 recommended daily intake of vitamin C in the US is 90mg for adult said to be a factor in complementary and alternative medicines, males and 75mg for adult females,10 and in the UK it’s 40g for all where the time taken over consultation, the approach of the Age Intervention Face Cream’s patented adults.11 Vitamin C – like many of the others used in IVMT, such as practitioner and the patient’s expectations all affect the impact B1, B2, B3, B6 and B12 – are water-soluble, simply meaning that of a treatment.16 Indeed, the very nature of how the treatment is formula specifically targets changes in the rather than storing them in our cells, our bodies excrete what we delivered – the patient sitting or lying comfortably for 30 to 60 don’t need. Dr John Quinn, former GP, and founder and clinical minutes in a relaxing environment – could itself contribute to the appearance of skin resulting from declining director of Quinn Clinics, suggests the case is clear. “I strongly patient feeling refreshed and vitalised. For people who lead busy, believe that we should be practising evidence-based medicine, stressful lives, the treatment provides a rare opportunity just to hormones and cumulative sun exposure. and I’m not aware of any evidence that giving someone vitamins, stop for an hour, without the usual distractions that prevent them Age Intervention Face Cream will assist in SPECIAL unless they have a deficiency, has any benefit at all,” he says. from winding down. Many argue that if a treatment makes people The National Institute for Health and Care Excellence (NICE) feel better, through whatever means, then it can be considered revitalizing and restoring the appearance of OFFER recommends certain supplements for some groups who have or worthwhile. As the popularity of IVMT continues to grow, it is unlikely are at risk of deficiency,12 including: this debate will subside any time soon. Whether you choose to youthful suppleness and elasticity. INTRODUCING adopt the treatment in your clinic or not, thorough research and safe · Folic acid for pregnant women and those trying to conceive practise are key components to successful treatment outcomes and · Vitamin D for children, the elderly, pregnant and breastfeeding patient satisfaction. women, and people who don’t get enough sun exposure · Specific supplements for medical conditions, such as iron to treat REFERENCES Features & Benefits Key Technologies Ingredients iron-deficiency anaemia 1. Alan Gaby, ‘Intravenous Nutrient Therapy: the ‘Myers’ Cocktail’’, Alternative Medicine Review, 7:5 Designed for women showing Isoflavones (Soy and Red Clover) Water/Aqua/Eau, Dimethyl Sulfone, (2002), 389-403 (p. 389) • • Limnanthes Alba (Meadowfoam) Seed 2. Skobeloff EM, Spivey WH, McNamara RM, Greenspon L, ‘Intravenous magnesium sulfate for the visible signs of skin aging • Topical Interferon (alpha-2b) Oil, Butyrospermum Parkii (Shea) Butter, It can be argued that many patients at clinics or spas offering IVMT the treatment of acute asthma in the emergency department’, The Journal of the American Medical Association, 262:9 (1989), 1210-1213 3. Bloch H, Silverman • Boosts your skin’s ability to repair • Plankton Extract Cetearyl Alcohol, Simmondsia Chinensis do not represent these cohorts, and neither are they typically R, Mancherje N, et al. ‘Intravenous magnesium sulfate as an adjunct in the (Jojoba) Seed Oil, Polysorbate 60, Cetyl treatment of acute asthma’. Chest, 107:6 (1995), 1576-1581 damage for naturally younger people with acute asthma or HIV, or any of the other conditions and • CoEnzyme Q10 (Ubiquinone) Alcohol, Propylene Glycol, Interferon 4. Rowe BH, Bretzlaff JA, Bourdon C, et al. ‘Intravenous magnesium sulfate treatment for acute and healthier looking skin illnesses in which IVMT has been anecdotally shown to provide asthma in the emergency department: a systematic review of the literature’. Annals of Emergency • Methylsulfonylmethane Alpha 2, Butylene Glycol, Glycerin, Trifo- beneficial effects. Certainly, nutrient deficiencies in the general Medicine, 36 (2000), 181-190 Significantly reduces the lium Pratense (Clover) Leaf Extract, Soy 5. Reed JC, ‘Magnesium therapy in musculoskeletal pain syndromes – retrospective review of clinical • (Dimethyl Sulfone) population are not unheard of. “Some people don’t absorb vitamin results’. Magnesium and Trace Elements, 9 (1990), 330 appearance of fine lines and Isoflavones, Sodium Hyaluronate, Hydro- 6. Moorkens G, Manuel y Keenoy B, Vertommen J, et al. ‘Magnesium deficit in a sample of the Belgian Essential Fatty Acids B12; for example, people who don’t eat meat may need to have wrinkles associated with • lyzed Glycosaminoglycans, Ubiquinone, population presenting with chronic fatigue’. Magnesium Research, 10 (1997) 329-337 Lupinus Albus Seed Oil, Rosa Canina their levels checked,” explains Dr Quinn. “Vitamin D deficiency is 7. Ali A, Njike VY, Northrup V, et al. ‘Intravenous Micronutrient Therapy (Myers’ Cocktail) for cumulative sun damage Fruit Oil, Triticum Vulgare (Wheat) Germ also increasingly common and recognised, particularly among the Fibromyalgia: A Placebo-Controlled Pilot Study’. Journal of Alternative and Complementary Medicine, 15:3 (2009) 247-257. • Visibly restores youthful Oil, Saccharomyces/Copper Ferment, immigrant population, so there are some situations where vitamin 8. Harakeh S, Jariwalla RJ, Pauling L, ‘Suppression of human immunodeficiency virus replication by Spirulina Maxima Extract, Plankton supplementation makes sense.” However, diagnosing a deficiency ascorbate in chronically and acutely infected cells’. Proceedings of the National Academy of suppleness and elasticity with Sciences, 87 (1990) 7245-7249 Extract, Tocopherol, Sodium Ascorbate, 13,14 increased hydration relies on blood testing, which, some argue, may not be routinely 9. Hemilä H, Chalker E, ‘Vitamin C for preventing and treating the common cold’. Cochrane Database Mannitol, Tyrosine, Lecithin, Dipalmitolyl carried out as part of the consultation with patients seeking IVMT. In of Systematic Reviews, 1 (2013) CD000980. doi: 10.1002/14651858.CD000980.pub4. 10. National Institutes of Health; Office of Dietary Supplements, Vitamin C factsheet for consumers • Highly moisturizing Hydroxyproline, Beta-Sitosterol, Linoleic the absence of a proper diagnosis, the individual may be paying for (USA: NIH, 2011) [accessed 31 January 2015] • Paraben-free Acid, Tocophersolan, Glycosphingolipids, supplementation they simply don’t need. A 2013 article in the Annals 11. NHS Choices, Vitamins and minerals – vitamin C (London: NHS, 2014) [accessed 31 January 2015] of Internal Medicine, an academic medical journal published by the 12. NHS Choices, Do I need vitamin supplements? (London: NHS, 2014) [accessed 31 January 2015] hexylglycerin, Carrageenan, Sodium 13. NHS Choices, Vitamin B12 or folate deficiency anaemia – diagnosis (London: NHS, 2014) [accessed 31 January 2014] 14. Vitamin D Council, Testing for vitamin D (California: Vitamin D Council) [accessed 31 January 2015] ingredients. Marie Duckett, a nurse and practitioner at London’s 15. Guallar E, Stranges S, Mulrow C, Appel LJ, Miller ER, ‘Enough is enough: stop wasting money on vitamin and mineral supplements’, Annals of Internal Medicine, 159:12 (2013) 850-851, Fiona and Marie Aesthetics, says: “I would be concerned whether doi:10.7326/0003-4819-159-12-201312170-00011 practitioners know if their patients are tolerant to everything that’s 16. House of Lords Science and Technology Committee, Science and Technology Sixth Report JMSR Europe Ltd. www.janmarini.co.uk [email protected] – Complementary and Alternative Medicine, (London: UK Parliament) [accessed on 1 February 2015] Telephone: +44 (0)20 8868 4411

Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015 FREE NEW Age Intervention Face Cream New Advanced Formula with intense hydration. Recommended for women showing the visible NEW signs of ageing skin NEW FOR 2015 Age Intervention Face Cream’s patented formula specifically targets changes in the appearance of skin resulting from declining hormones and cumulative sun exposure. Age Intervention Face Cream will assist in SPECIAL revitalizing and restoring the appearance of OFFER youthful suppleness and elasticity. INTRODUCING

Features & Benefits Key Technologies Ingredients Designed for women showing Isoflavones (Soy and Red Clover) Water/Aqua/Eau, Dimethyl Sulfone, • • Limnanthes Alba (Meadowfoam) Seed the visible signs of skin aging • Topical Interferon (alpha-2b) Oil, Butyrospermum Parkii (Shea) Butter, • Boosts your skin’s ability to repair • Plankton Extract Cetearyl Alcohol, Simmondsia Chinensis (Jojoba) Seed Oil, Polysorbate 60, Cetyl damage for naturally younger • CoEnzyme Q10 (Ubiquinone) and healthier looking skin Alcohol, Propylene Glycol, Interferon • Methylsulfonylmethane Alpha 2, Butylene Glycol, Glycerin, Trifo- • Significantly reduces the (Dimethyl Sulfone) lium Pratense (Clover) Leaf Extract, Soy appearance of fine lines and Isoflavones, Sodium Hyaluronate, Hydro- Essential Fatty Acids wrinkles associated with • lyzed Glycosaminoglycans, Ubiquinone, Lupinus Albus Seed Oil, Rosa Canina cumulative sun damage Fruit Oil, Triticum Vulgare (Wheat) Germ • Visibly restores youthful Oil, Saccharomyces/Copper Ferment, suppleness and elasticity with Spirulina Maxima Extract, Plankton Extract, Tocopherol, Sodium Ascorbate, increased hydration Mannitol, Tyrosine, Lecithin, Dipalmitolyl • Highly moisturizing Hydroxyproline, Beta-Sitosterol, Linoleic Paraben-free Acid, Tocophersolan, Glycosphingolipids, • Citric Acid, Caprylyl Glycol, Hexylene Glycol, Pregnenolone Acetate, Ethyl- hexylglycerin, Carrageenan, Sodium Dihydroacetate, Chlorophenesin, Potassium Sorbate, Phenoxyethanol

JMSR Europe Ltd. www.janmarini.co.uk [email protected] Telephone: +44 (0)20 8868 4411 @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

lateral orbital superficial fat compartments and the ROOF.9,10 The resultant brow ptosis occurs laterally more than medially, mainly due to the weight of unsupported tissue mass over the temporal fossa in association with lateral orbicularis oculi and corrugator muscle activity (brow depressors), lack of frontalis contraction in the lateral brow (brow elevator), and also from gravitational pull of the heavy cheek and lateral facial tissues. Lambros11 has shown the deflator effects of volume loss can cause an illusion of facial soft tissue descent, thus The Anatomy brow descent is often overestimated. Recent studies suggest that eyebrows can actually of the Eye remain level or may even elevate with age.12 Differentiating descent from deflation London-based consultant oculoplastic surgeon Volumetric deflation of the upper-lid and lid- brow junction causes a ‘flatness’ replacing the Mrs Sabrina Shah-Desai discusses the importance ‘convex’ fullness of this zone accompanied by of a thorough knowledge of the periorbital anatomy an alteration in the drape of upper-lid skin. Landmarks for brow position are based upon underlying bony anatomy; the superior The periorbital area (Figure 1) is the The lid-brow junction orbital rim is easily palpable and serves as aesthetic epicentre of the face; its delicate Eyebrows form the lower boundary of the a fixed landmark for the medial head of the critical structures and intricate anatomic upper third of the face. They are often brow. Deflation due to soft tissue volume relations pose a unique challenge for most aesthetically pleasing when they are loss can present as temple hollows, with even the most experienced aesthetic positioned at the superior orbital rim, with a skeletonisation of the lateral orbital rim and practitioner. The thin fragile eyelid skin and gentle arc which peaks at the middle and clipping of the eyebrow tail (Figures 2a mobile orbicularis oculi lend themselves lateral third (this arch being flatter in men). The pre- and 2b post-rejuvenation). Upper eyelid to the possibility of overfilling and Tyndall ideal ‘club-shaped’ female brow is positioned deflation can present as ‘medial A-shaped effect,1 whilst the complex vascularity can 3-5mm above, whilst the ‘T-shaped’ male hollow’ or localised central and lateral result in visible bruising and swelling,2 brow should lie at the level of the supra hollowing of the upper lid sulcus, with the having a negative impact on the patient orbital rim.6 The lid-brow junction is convex development of an extra fold of skin above the experience. Vascular compromise and in youth, due to the retro orbicularis oculi natural eyelid skin crease (Figures 3a and 3b). visual loss2 are devastating complications fat pad (ROOF), the temporal fossa fat pad that must be avoided at all costs. Mid-facial and superficial lateral orbital fat pad, which The lower lids and infraorbital junction ageing is a combination of the ‘gravitational contributes to eyebrow and upper-lid As the infraorbital area is really a continuum theory’ (vertical descent of soft tissues volume.7 When people reach their mid 40’s, of the mid face, treatment of this zone must due to ligamentous attenuation)3 and the there is bony recession of the superior orbital include assessment and treatment of the ‘volumetric theory’ (relative volume loss rim8 and the upper lid orbital sulcus looses related subzones in the mid-face. and gain of neighbouring fat compartments soft tissue volume. This is typically in the On the deep surface of the orbicularis of the face).4 In 2007, Rohrich and Pessa middle third and the entire brow extending muscle, at the superior border of the malar published their seminal study on the facial onto the temple and the lateral orbital area, region, lays the medial compartment of fat compartments.5 This not only serves possibly due to deflation of the superior and sub orbicularis oculi fat (SOOF) and further as a road map to understanding facial ageing, but has also revolutionised how we Figure 1 Figure 2a Figure 2b rejuvenate the ageing face. To successfully navigate the hollows and troughs of the periorbital zone, it is vital to understand how ageing in one sub-zone affects the other, rather than non-specific targeting of the tear trough or cheek. Figure 3a Figure 3b Using an anatomical guide to the deep and superficial facial fat compartments for volume restoration, in multiple key areas, results in a naturally harmonious rejuvenation to lift and fill the central face (eyelid, eyebrow, temple, cheek and mid-face).

Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015 A perfect match.

Sophie Anderton

A complete HA range perfectly designed for your needs

Sinclair IS Pharma. 1st Floor Whitfield Court, 30-32 Whitfield Street, London W1T 2RQ. United Kingdom www.sinclairispharma.com Date of preparation: February 2015 UK/SIPPER/15/0005 @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

Treatment tips from the medial canthus to the medial corneal limbus. 1. Consider restoration of volume in the temple, brow and upper Zone 2: The middle infraorbital groove extends from the medial to lid sulcus at three to four points, with the lateral canthal area as an lateral corneal limbus. optional extra (Figure 4). Zone 3: The lateral infraorbital groove extends from the lateral 2. Use a soft filler, which can be moulded. corneal limbus to the lateral canthus. 3. The superior sulcus area needs very small aliquots injected supra periosteally along the supraorbital rim, above Mid-face sub zones: the orbital septum, staying lateral to the supraorbital notch. Zone 4: The infraorbital hollow lies directly under zone 2 and over 4. The temple hollows need larger volumes, placed into the the infraorbital foramen, which corresponds to the deep medial fat superficial fascia of each temple behind the frontozygomatic compartment. process, to soften the bony contour of the lateral orbital rim. Zone 5: The infrazygomatic or sub malar hollow corresponds to the medial SOOF. Zone 6: The malar mound corresponds to the lateral SOOF. laterally its lateral compartment. The deep medial cheek fat overlies Lateral Canthal area: Where ROOF continues caudally as SOOF. the infraorbital foramen (Figure 5). At the medial infraorbital rim, the tear trough ligament (TTL), attaches to the skin, forming a gentle tear Tear trough treatment tips: trough groove. Laterally this continues as the orbitomalar ligament 1. Treat mid-face zones 4, 5 and 6 first, placing a rigid filler pre (OML). Descent and atrophy of these bony attachments of the periosteal.1 This can decrease the need for treatment in the medial superficial musculo aponeurotic system (SMAS) and SOOF contribute tear trough. to unmasking of the inferior orbital rim and the tear trough. Prolapse 2. Use small aliquots of soft filler in zone 1, place filler pre periosteal of the deep orbital fat, through a naturally weak area of the medial but deep to the muscle. orbital septum, creates eye bags.13 Ageing changes can cause the 3. Avoid over volumisation in zones 1 and 2 as this causes a sausage- inferolateral > inferomedial orbital rim to recede, and loss of the like bulge in what is naturally a gentle depression. maxillary projection (bone) below the orbit14 is a major contributor 4. Palpate the infraorbital bone and place filler below septum (not to laxity and descent of the medial cheek soft tissue. Ageing of the behind or above it), as this will only worsen any eye bag. mid-face is a mix of atrophy and descent of soft tissue, which is visible as a worsening tear trough deformity with a loss of the smooth blend Periorbital vascular anatomy between the SOOF and malar fat pad, leading to an abrupt transition Branches of the external carotid artery (ECA) provide the blood between the lid-cheek junction, cheek flattening and mid-face ptosis. supply to the face with the exception of a mask-like area of the Superficial filler injections in the mid-face can weigh tissues down central forehead, upper eyelids and the upper part of nose, which are further, whilst deep injections with rigid fillers can “lift and fill” the mid- supplied though the internal carotid system (ICA) by the ophthalmic face, so it is important to target appropriate areas in the infraorbital and artery. Vascular anastomoses between ECA and ICA are danger zones mid-face zones (Figure 5). for the aesthetic practitioner as inadvertent intravascular injection can lead to vascular compromise and permanent blindness.14 Infraorbital zone: As the superficial inferior fat pad overlies the infraorbital rim and it Vascular watershed areas (Figure 6) Figure 6 tends to deflate early, it should be assessed and treated in three zones The infraorbital foramen: Infraorbital Zone 1: The tear trough extends inferolaterally vessels arise from maxillary branch of external carotid which anastomose Figure 4 with branches of the ophthalmic artery. The supraorbital notch and glabella: Supraorbital and supratrochlear, infratrochlear and external nasal branches of ophthalmic artery anastomose with branches of the external carotid artery. The temple area: Superficial temporal artery crosses the zygomatic arch and 2cm above the arch divides into anterior and posterior branches. The anterior branch anastomoses with branches of the ophthalmic artery.

Tips to avoid intravascular injection16,17 Figure 5 1. Mark the vascular watershed and inject ‘on the bone’ in that area. 2. Avoid fast anterograde injections and large volumes. 3. Always aspirate prior to injection. 4. Consider cannulas vs needles, unless using a smaller gauge needle. 5. Choose HA filler as hyaluronidase can be used to remove the product, if there is inadvertent intravascular injection.

Conclusions A sound anatomic approach to surgery with thorough pre-operative planning remains the basis for achieving successful cosmetic and

Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015 aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics

Mrs Sabrina Shah-Desai is an expert oculoplastic surgeon well reconstructive outcomes. This should be no different for known for cosmetic eyelid lifts, scarless droopy eyelid correction non-surgical rejuvenation of the eyelids and adjacent areas, (ptosis) and revision eyelid surgery. She is highly experienced in where the injector is well trained with a firm understanding non-surgical aesthetic periorbital rejuvenation with botulinum of the facial vascular anatomy, safe injection planes, toxin and dermal fillers. varied injection techniques and types of filler for achieving REFERENCES pleasing aesthetic results in different anatomical areas. The 1. Jaishree Sharad. ‘Dermal Fillers for the Treatment of Tear Trough Deformity: A Review of Anatomy, Treatment Techniques, and their Outcomes’. J Cutan Aesthet Surg. 2012 Oct-Dec; 5(4): 229–238. hyper dynamic periorbital area should ideally be treated 2. Lafaille P, Benedetto A. ‘Fillers: Contraindications, side effects and precautions’.J Cutan Aesthet Surg. with low molecular weight, high viscosity materials which are 2010;3:16–9. 3. Wulc AE, Sharma P, Czyz CN. ‘The anatomic basis of midfacial aging’, Hartstein ME, Wulc AE, Holck DEE, eds. easier to inject and mould. This area should be assessed Midfacial Rejuvenation, (New York: Springer Science+Business Media, 2012) p.15-28. with non-flash photography, whilst the patient is seated, to 4. Donofrio LM. ‘Fat distribution: a morphologic study of the aging face’, Dermatol Surg, 26 (2000), p.1107-1112. 5. Rohrich RJ, Pessa JE. ‘The fat compartments of the face: anatomy and clinical implications for cosmetic surgery’, assist with patient education by identification of areas of Plast Reconstr Surg, 119(2007), p.2219-2231. deflation. Treating the patient whilst seated upright, after 6. Freund RM, Nolan III WB. ‘Correlation between brow lift outcomes and aesthetic ideals for eyebrow height and shape in females’, Plast Reconstr Surg, 97 (1996) p.1343-8. marking areas of deflation and key anatomic landmarks, 7. Rohrich R, Arbique GM, Wong C, Brown S, Pessa JE.‘The anatomy of suborbicularis fat: implications for allows for injection in the correct plane, using conservative periorbital rejuvenation’, Plast Reconstr Surg 124 (2009) p.946-951. 8. Kahn DM, Shaw RB Jr. ‘Aging of the bony orbit: a three-dimensional computed tomographic study’, Aesthet volumes and avoiding adverse events due to incorrect Surg J, 28 (2008) p.258-64. placement and overcorrection. 9. Kikkawa DO, Lemke BN, et al. ‘Relations of the SMAS to the orbit characterization of the orbitomalar ligament’, Ophthal Plast Reconstr Surg, 12 (1996) p.77-8. Using different injection techniques like retrograde linear 10. Lucarelli MJ, Khwarg SI, et al. ‘The anatomy of midfacial ptosis’, Ophthal Plast Reconstr Surg, 16 (2000) p.7-22. threading for the cheek, lateral brow and lateral tear trough 11. Lambros V. ‘Observations on periorbital and midface aging’, Plast Reconstr Surg, 120 (2007) p.1367–1376, discussion 1377. region (with a cannula or needle), serial puncture technique 12. Matros E, Garcia JA, Yaremchuk MJ. ‘Changes in eyebrow position and shape with aging’, Plast Reconstr Surg, (with a needle) at targeted sites like the medial superior 124 (2009) p.1296-301. 13. Kakizaki H, Jinsong Z, et al. ‘Microscopic anatomy of the Asian lower eyelids’, Ophthal Plast Reconstr Surg, 22 sulcus and fanning technique (with a cannula) for the lateral (2006) p.430-3. cheek and temple area, helps reduce adjacent tissue trauma 14. Mendelson & Wong. ‘Changes in the Facial Skeleton With Aging: Implications and Clinical Applications in Facial Rejuvenation’, Aesthetic Plast Surg, 36 (2012) p.753-760. and minimizes the risk of intravascular injection.1 The primary 15. McCleve D, Goldstein JC. ‘Blindness secondary to injections in the nose, mouth, and face: cause and goal of ‘eye-zone’ rejuvenation is restoration of youthful prevention’, Ear Nose Throat J, 74 (1995) p.182-188. 16. David Funt, Tatjana Pavicic. ‘Dermal fillers in aesthetics: an overview of adverse events and treatment a 3-dimensional periorbital topography, so that the eyelids are proaches’. Clin Cosmet Investig Dermatol. 2013; 6: 295–316. not harshly demarcated from, but naturally blend into the 17. Katie Beleznay, Shannon Humphrey, Jean D.A. Carruthers, Alastair Carruthers. ‘Vascular Compromise from Soft Tissue Augmentation Experience with 12 Cases and Recommendations for Optimal Outcomes’. J Clin brow and cheek. Aesthet Dermatol, 2014 Sep; 7(9): 37–43.

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V-SOFT LIFT can transform downturned mouth corners, eyebrows, smooth the chin and lift the cheeks. It is a simple, speedy way to revitalise and freshen the face, and results show immediately after the treatment and then continue to improve for about four weeks by which time you will notice the skin and the face looking fresher, fuller and more youthful. Results last for one year or more.

For further information about V-SOFT LIFT please contact: Medical Aesthetic Group on 02380 676733 SEE US AT STAND 75 or visit www.magroup.co.uk Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015 MAGROUP V-Soft Lift Half Page Horizontal 125mm x 180mm Aesthetic Journal November 2014 Issue 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 atrophy . Patients treated with therapeutic doses may experience <1/100): Dizziness, Visual disturbances, Vision blurred, Diplopia, haemagglutinin complex) 10 Speywood units/0.05ml of reconstituted exaggerated muscle weakness. Not recommended in patients with Pruritus, Rash, Hypersensitivity. Rare (≥ 1/10,000 to < 1/1,000): Eye solution (powder for solution for injection). Indications: Temporary history of dysphagia, aspiration or with prolonged bleeding time. Seek movement disorder, Urticaria. Adverse effects resulting from distribution improvement in appearance of moderate to severe glabellar lines immediate medical care if swallowing, speech or respiratory difficulties of the effects of the toxin to sites remote from the site of injection seen at frown, in adult patients under 65 years, when severity of these arise. Facial asymmetry, ptosis, excessive dermatochalasis, scarring have been very rarely reported with botulinum toxin (excessive muscle lines has an important psychological impact on the patient. Dosage & and any alterations to facial anatomy, as a result of previous surgical weakness, dysphagia, aspiration pneumonia with fatal outcome in Administration: Botulinum toxin units are different depending on the interventions should be taken into consideration prior to injection. some cases). Prescribers should consult the summary of product medicinal products. Speywood units are specific to this preparation and Injections at more frequent intervals/higher doses can increase the characteristics in relation to other side effects. Packaging Quantities are not interchangeable with other botulinum toxins. Reconstitute prior risk of antibody formation. Avoid administering different botulinum & Cost: UK 1 Vial Pack (1 x 125u) £64.00 (RRP), 2 Vial Pack (2 x 125u) to injection. Intramuscular injections should be performed at right angles neurotoxins during the course of treatment with Azzalure. To be used for £128.00 (RRP), IRE 1 Vial Pack (1 x 125u) €93.50, 2 Vial Pack (2 x 125u) to the skin using a sterile 29-30 gauge needle. Recommended dose is one single patient treatment only during a single session. Interactions: €187.05 (RRP). Marketing Authorisation Number: PL 06958/0031 50 Speywood units (0.25 ml of reconstituted solution) divided equally Concomitant treatment with aminoglycosides or other agents interfering (UK), PA 1609/001/001(IRE). Legal Category: POM. Full Prescribing into 5 injection sites,: 2 injections into each corrugator muscle and one with neuromuscular transmission (e.g. curare-like agents) may Information is Available From: Galderma (UK) Limited, Meridien House, into the procerus muscle near the nasofrontal angle. (See summary of potentiate effect of botulinum toxin. Pregnancy & Lactation: Not to 69-71 Clarendon Road, Watford, Herts. WD17 1DS, UK. Tel: +44 (0) 1923 product characteristics for full technique). Treatment interval should not be used during pregnancy or lactation. Side Effects: Most frequently 208950 Fax: +44 (0) 1923 208998. Date of Revision: March 2013 be more frequent than every three months. Not recommended for use occurring related reactions are headache and injection site reactions. in individuals under 18 years of age. Contraindications: In individuals Generally treatment/injection technique related reactions occur within first week following injection and are transient and of mild to moderate Adverse events should be reported. Reporting forms and with hypersensitivity to botulinum toxin A or to any of the excipients. information can be found at www.mhra.gov.uk/yellowcard. In the presence of infection at the proposed injection sites, myasthenia severity and reversible. Very Common (≥ 1/10): Headache, Injection site gravis, Eaton Lambert Syndrome or Amyotrophic lateral sclerosis. reactions (e.g. erythema, oedema, irritation, rash, pruritus, paraesthesia, Adverse events should also be reported to Galderma (UK) Ltd. Special warnings and precautions for use: Use with caution in patients pain, discomfort, stinging and bruising). Common (≥ 1/100 to < 1/10): with a risk of, or clinical evidence of, marked defective neuro-muscular Facial paresis (predominantly describes brow paresis), Asthenopia, transmission, in the presence of inflammation at the proposed injection Ptosis, Eyelid oedema, Lacrimation increase, Dry eye, Muscle twitching

Date of preparation: March 2013 AZZ/020/0313

26605 Azzalure A4 Ads Rev.indd 4 25/04/2013 14:07 aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics The Importance of Patient Satisfaction It’s every practitioner’s desired result, but how exactly is patient satisfaction measured? Dr Beatriz Molina discusses her role in recent groundbreaking research into the topic

As aesthetic practitioners working in clinics and administering practitioners and the patient’s reaction to the product. In terms of aesthetic treatments, we bear witness to patient reaction and the link between patient satisfaction and patient loyalty, these high feedback with each procedure performed. We witness patients’ percentages speak volumes. delight following treatment with toxin, filler, radiofrequency or laser. In many scenarios, satisfaction and wellbeing are inextricably Sometimes, if a complication has occurred, we witness patients’ linked, as both rely on the idea of a ‘positive mood’. The idea that frustration with a procedure. We talk about patient satisfaction and the use of botulinum toxin can enhance mood, and even in some making a difference to patients’ lives at conferences and meetings cases aid depression, is one that has been explored recently by across the globe. However, measuring this in quantifiable terms is my colleague Dr Doris Hexsel in a study investigating the effect of difficult. How is it possible to measure what kind of difference you treatment with onabotulinumtoxinA for glabellar lines on self esteem make to a patient’s life with the procedure you administer? and depression. Utilising the Beck Depression Inventory (BDI) and The ANGEL study, a multi-centre, prospective, non-interventional Rosenberg Self-Esteem Scale (RSES) to assess depression symptoms observational study carried out in France, Germany, Spain and the and self-esteem, this study found that patients with depression had United Kingdom aimed to do just that.1 This study, for which I was the significant improvement in depression symptoms after injections with lead investigator, looked at the relationship between treatment with onabotulinumtoxinA.2 An additional study conducted by Dr Patrick botulinum toxin type A and patient satisfaction. The first study of its Bowler and Dr Michael Lewis indicated that frowning can actually kind, it documented patient satisfaction following treatment of the make a person unhappy, and therefore treatments that prevent glabellar lines with botulinum toxin type A (Speywood Unit). frowning result in a happier mood, and thus a happier patient.3 In this study, we recruited 559 patients, distributed amongst 66 clinics Research into the topic of patient satisfaction naturally combines in four countries across Europe. Subjects were between 18 and 64 the two fields of clinical practice and psychology. To further aid our years old, with moderate or severe glabellar lines, and were eligible understanding of the subject it is crucial that more studies such as only if the investigator had already decided to prescribe BoNT-A this one are carried out but in addition, it is important to highlight the (s.U), according to the labelling. This meant that no-one was paid significance of psychological training within the structure of aesthetics to complete the study – patients would come in to our clinic for a and core medical training. Exposing medical students to psychological consultation and the practitioner, myself in this scenario, would decide practice and concepts is crucial to secure that only suitable patients whether treatment with BoNT-A (s.U) was appropriate. Only then would who are sound of judgement receive aesthetic treatment. This goes a the patient be offered the opportunity to fill out a questionnaire and be long way to lay the correct foundation for overall patient satisfaction. enrolled in the study. For the next step in our work to learn more about the link between The study lasted for four months, and patients were required to aesthetic treatment and patient satisfaction, I would be keen to carry complete two questionnaires. Subjects completed satisfaction out research looking at treatment of the commissures of the mouth, in questionnaires three weeks and four months following the first this case deploying the combined use of botulinum toxin and dermal injection. 531 (95.0%) completed the questionnaire at week three filler. Many patients I treat day-to-day express a desire to appear on the LOOK HOW YOU FEEL and 485 (86.8%) completed the questionnaire at month four. The outside how they feel on the inside – which is happy. Sometimes, as a analysed population contained 533 patients who had completed consequence of the ageing process, which causes the commissures at least one of the questionnaires. The main reason for treatment in of the mouth to deflect downwards, an aged outward expression can terms of the patients’ motivations and desired results was a “personal give the impression of being unhappy or sad. A study treating this area wish (to enhance) appearance or attractiveness”, with 91.1% of patients could ask whether changing this expression with aesthetic treatment 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 choosing this as their main motivation. would have a significant impact on the patient’s satisfaction and overall atrophy . Patients treated with therapeutic doses may experience <1/100): Dizziness, Visual disturbances, Vision blurred, Diplopia, Presentation: Botulinum toxin type A (Clostridium botulinum toxin A 93.4% and 88.7% of patients enrolled in the study considered that wellbeing. To continue our research inspired by patient feedback is haemagglutinin complex) 10 Speywood units/0.05ml of reconstituted exaggerated muscle weakness. Not recommended in patients with Pruritus, Rash, Hypersensitivity. Rare (≥ 1/10,000 to < 1/1,000): Eye solution (powder for solution for injection). Indications: Temporary history of dysphagia, aspiration or with prolonged bleeding time. Seek movement disorder, Urticaria. Adverse effects resulting from distribution their results “surpassed” or “met” their expectations at week three crucial to ensuring a forward-looking approach to aesthetic treatment improvement in appearance of moderate to severe glabellar lines immediate medical care if swallowing, speech or respiratory difficulties of the effects of the toxin to sites remote from the site of injection and month four, respectively. Interestingly, satisfaction and reaction to that is holistic in nature, and puts the patient, and ultimately their arise. Facial asymmetry, ptosis, excessive dermatochalasis, scarring have been very rarely reported with botulinum toxin (excessive muscle seen at frown, in adult patients under 65 years, when severity of these the treatment did not revolve primarily around the patient’s perceived satisfaction, first. lines has an important psychological impact on the patient. Dosage & and any alterations to facial anatomy, as a result of previous surgical weakness, dysphagia, aspiration pneumonia with fatal outcome in interventions should be taken into consideration prior to injection. some cases). Prescribers should consult the summary of product Administration: Botulinum toxin units are different depending on the level of ‘beauty’ following the procedure. In fact, major reasons for Dr Beatriz Molina is a member of the British College Injections at more frequent intervals/higher doses can increase the characteristics in relation to other side effects. Packaging Quantities medicinal products. Speywood units are specific to this preparation and satisfaction included a natural appearance, a rested look, and comfort of Aesthetic Medicine (BCAM) and founder of the risk of antibody formation. Avoid administering different botulinum & Cost: UK 1 Vial Pack (1 x 125u) £64.00 (RRP), 2 Vial Pack (2 x 125u) are not interchangeable with other botulinum toxins. Reconstitute prior of injection. More than 80% of patients felt they had a more rested Medikas Medispa Clinic. She also teaches techniques to injection. Intramuscular injections should be performed at right angles neurotoxins during the course of treatment with Azzalure. To be used for £128.00 (RRP), IRE 1 Vial Pack (1 x 125u) €93.50, 2 Vial Pack (2 x 125u) for botulinum toxin administration. to the skin using a sterile 29-30 gauge needle. Recommended dose is one single patient treatment only during a single session. Interactions: €187.05 (RRP). Marketing Authorisation Number: PL 06958/0031 appearance after three weeks; a concept that is pivotal to patients’ 50 Speywood units (0.25 ml of reconstituted solution) divided equally Concomitant treatment with aminoglycosides or other agents interfering (UK), PA 1609/001/001(IRE). Legal Category: POM. Full Prescribing expectations and desired outcomes in aesthetics today. into 5 injection sites,: 2 injections into each corrugator muscle and one with neuromuscular transmission (e.g. curare-like agents) may Information is Available From: Galderma (UK) Limited, Meridien House, Levels of patient satisfaction are of course directly linked to patient REFERENCES into the procerus muscle near the nasofrontal angle. (See summary of potentiate effect of botulinum toxin. Pregnancy & Lactation: Not to 69-71 Clarendon Road, Watford, Herts. WD17 1DS, UK. Tel: +44 (0) 1923 be used during pregnancy or lactation. Side Effects: Most frequently 208950 Fax: +44 (0) 1923 208998. Date of Revision: March 2013 loyalty – if a patient receives a positive experience and outcome at 1. B. Molina, Y. Grangier, B.Mole, N. Ribe, L. Martín Diaz, W. Prager, F. Paliargues, N. Kerrouche, product characteristics for full technique). Treatment interval should not ‘Patient Satisfaction after the treatment of glabellar lines with Botulinum toxin type A (Speywood occurring related reactions are headache and injection site reactions. be more frequent than every three months. Not recommended for use your clinic then they will more than likely return when considering Unit): a multi-centre European observational study’, Journal of the European Academy of in individuals under 18 years of age. Contraindications: In individuals Generally treatment/injection technique related reactions occur within Dermatology and Venereology, (2014). first week following injection and are transient and of mild to moderate Adverse events should be reported. Reporting forms and a second treatment. The ANGEL study found that at month four, with hypersensitivity to botulinum toxin A or to any of the excipients. information can be found at www.mhra.gov.uk/yellowcard. 2. Hexsel D, Brum C, Siega C, Schilling-Souza J, Dal’Forno T, Heckmann M, Rodrigues TC., ‘Evaluation In the presence of infection at the proposed injection sites, myasthenia severity and reversible. Very Common (≥ 1/10): Headache, Injection site 93.4% of subjects would recommend the treatment to family and of self-esteem and depression symptoms in depressed and nondepressed subjects treated with Adverse events should also be reported to Galderma (UK) Ltd. gravis, Eaton Lambert Syndrome or Amyotrophic lateral sclerosis. reactions (e.g. erythema, oedema, irritation, rash, pruritus, paraesthesia, friends, and 93.2% would like to receive the treatment again. Of onabotulinumtoxinA for glabellar lines’, Dermatologic Surgery, 39 (7) (2013), pp. 1088-96. Special warnings and precautions for use: Use with caution in patients pain, discomfort, stinging and bruising). Common (≥ 1/100 to < 1/10): 3. Lewis, M, Bowler P, ‘Botulinum toxin cosmetic therapy correlates with a more positive mood’, course, this outcome is related to the product used, the skill of the Journal of Cosmetic Dermatology, 8 (2009), pp. 24-26. with a risk of, or clinical evidence of, marked defective neuro-muscular Facial paresis (predominantly describes brow paresis), Asthenopia, transmission, in the presence of inflammation at the proposed injection Ptosis, Eyelid oedema, Lacrimation increase, Dry eye, Muscle twitching Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015 Date of preparation: March 2013 AZZ/020/0313

26605 Azzalure A4 Ads Rev.indd 4 25/04/2013 14:07 @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

zone. FUE involves the individual removal of follicular Hair Transplant units from the occipital and parietal scalp, with each unit individually transplanted to the recipient area. The procedure was developed to avoid the linear scar that occurs with Strip FUT and has grown in Techniques: popularity over the past decade. Global statistics from the International Society of Hair Restoration Surgery (ISHRS) suggest hair transplants performed using FUE Restoration and accounted for 32.2% of all methods in 2013, compared with 10.8% in 2009.2 However, these figures vary widely between countries. Reconstruction One of the drawbacks with FUE is that the whole donor area needs to be shaved – something not all Hair transplant surgeon Dr Greg Williams patients are keen on, as it makes it more obvious discusses current surgical treatments for that surgery has been performed. Furthermore, the harvesting of hairs needs to be spread out over a Male Pattern Hair Loss and reconstructive much wider area than with Strip FUT, and donor areas approaches to correct previous procedures that look like they have permanent hair in younger men can deteriorate with age. Hairs transplanted from Introduction areas outside of the ’safe’ donor zone may therefore These days, modern hair transplants for Male Pattern Hair Loss (MPHL, also known not be permanent in their transplanted location. as androgenetic alopecia) can produce extremely natural looking results. In the There are several methods of performing FUE – past, hair transplants were problematic, as those with MPHL would frequently manual, mechanical and robotic. The first two use continue to experience hair loss after hair plugs were inserted into the scalp, handheld devices, whereas the only robotic system causing a patchy, ‘doll’s hair’ appearance and therefore requiring further surgery. currently available – known as the ARTAS3 – is Today, hair transplants appear far more natural, and allow for continued hair loss in automated (although it still needs a human doctor a way not previously seen in the field. Furthermore, patients who had previously to set the parameters and to direct it). The ARTAS undergone hair transplant surgery can access newer techniques to correct their allows the surgeon to work with the utmost precision past procedures that may have caused aesthetic disfigurement. when harvesting donor hair follicles and new software technology allows the robotic system to automatically Technique identify the size of follicular units and, therefore, A modern hair transplant technique should follow a specific aesthetic structure. The harvest specific numbers of different sized grafts hairline should be irregularly aligned, with randomised single hairs in front of the required for individual patients’ recipient sites. It also main bulk of the hairline. The angle and direction of the transplanted hairs should removes the element of fatigue and human error in mimic any residual natural hairs and, if an entirely new hairline is being recreated, the incision making. This is because a robot does the then the transplanted hairs should be positioned in a forward direction. Even under actual ‘punching’, or incision making, of the grafts, so close scrutiny, with the hair being combed aside, the untrained observer should not the 1000th graft would be taken with exactly the same be able to differentiate transplanted hairs from naturally occurring ones. precision as the first. It is important to note that the This is demonstrated in Figure 1, which shows the appearance of a hairline prior terms ‘Strip FUT’ and ‘FUE’ only refer to the methods to a hair transplant; the natural growth direction of the hairs post-transplant; and a of harvesting follicular units and do not determine close-up view with the hairs combed back to demonstrate that, on close inspection the final appearance of the hair transplant, as the of the roots of the hairs, there are no tell tale signs that these hairs have been design and incisions are made in the same way for transplanted. Currently, there are two main methods for performing hair transplant both methods. There are pros and cons with both surgery. The first is known as Strip Follicular Unit Transplant (Strip FUT), in which the methods and the most appropriate type of surgery is surgeon removes a strip of hair bearing skin from the back and sides of the head in Figure 1 entirely dependent the area referred to as the ‘donor site’. Under magnification, the strip is separated upon the individual into the naturally occurring groupings of hairs known as ‘follicular units’. These in question. Each consist of grafts that have between one and four hairs which are then re-implanted procedure has in the recipient area – either into pre-made incisions created with a variety of sharp its own risks and instruments, or using implanters that create incisions at the same time as the hairs benefits but both are implanted. The Strip FUT method has been continually refined over the years should deliver and, while it was prone to leaving poor quality, widened scars at the donor site natural-looking when first developed, a good surgeon will now be able to perform the operation results which last a leaving a scar that averages just two-three millimetres in width. The main benefit of lifetime if performed Strip FUT is that the hairs are taken from the most dense part of the scalp, where by a skilled they are least likely to be affected by dihydrotestosterone (DHT) – the hormone surgeon. responsible for male genetic balding. Therefore, not only can large numbers of However, this hasn’t good quality grafts be procured, but the risk of the transplanted hairs deteriorating always been the with time is much smaller than if the other method1 – known as Follicular Unit case. Historical Extraction (FUE) – is used, and hairs are harvested from outside this ‘safe’ donor techniques – such

Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015 Before Aft er 16 weeks use of NeoStrata Skin Acti ve 4 product regimen; an advanced, comprehensive anti aging regimen, to target all the visible signs of aging with state-of-the-art technologies 1

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Aesthetic Medicine Dec14-Jan15_ Glycation-V2.indd 1 12/12/2014 14:13 @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com as flaps and plug grafts – may have provided short-term aesthetic Options include: improvements, but many have failed to stand the test of time. Where hair loss has progressed, these procedures have in some cases left • follicular unit grafting to soften ‘pluggy’ grafts or harsh anterior patients aesthetically disfigured with an unnatural appearance to the flap margins hair, either in terms of looking ‘pluggy’ or having abnormal distribution • total plug graft excision and hair redistribution or growth direction. Reconstructive surgery options are available, but • partial plug graft excision and hair redistribution they must be tailored to the individual’s needs, depending on what the • harsh anterior flap margin excision unnatural appearance looks like and what it has been caused by. • combinations of the above

Conclusion Before CLINICAL CASE ONE This patient had a typical appearance of what Many of these patients have occurs when plug grafts were used to increase experienced significant psychological density. He had a short to medium term distress as a result of their unnatural improvement in appearance but, as his male appearance and resort to wearing hats, pattern hair loss progressed, he eventually lost all wigs or toupés. In the most extreme of his natural hair in the area, with only the plug cases, patients may avoid social grafts remaining. The plug technique was one situations completely. It is imperative of the first methods of hair transplanting, but for that these patients should be made those men who subsequently lost their native hair aware of the complete spectrum of completely, it resulted in this ‘doll’s hair’ or ‘corn reconstructive options available to row’ effect. The patient opted to address this by them. Refined hair transplant surgical having follicular unit grafts interspersed between skills are required in order to carry out After the plug grafts to soften their appearance, giving a these restoration and reconstruction very natural look. Over three procedures spanning techniques, and unfortunately general three years, he had a total of 5,278 follicular units practitioners seldom know where (10,317 hairs) transplanted. to refer individuals for this specialist care. As a result, patients continue to Before CLINICAL CASE TWO suffer, unaware of the modern options This patient had previously had plug grafts, but available to them; they may also be only to boost a receding hairline. As the hairline hesitant to trust a doctor to re-operate continued to recede and all the natural hairs were on them, given their poor experiences lost, the plug grafts remained isolated, limiting his in the past. Along with raising After hairstyle options to having a fringe brushed forward. This was treated by completely removing the awareness of the treatments available, plugs and using the hair within the excised plugs to we should encourage the opportunity create a rejuvenated and natural looking hairline by in our practice for the patient to meet redistributing them and allowing him to brush his hair other patients who have undergone backwards or to the side. hair transplant reconstruction. In this manner we can work to build Before After CLINICAL CASE THREE patients’ confidence and trust in these For ‘pluggy’ hairlines, where the coarse grafts are revolutionary and often life-altering not completely isolated on the scalp or forehead, the procedures. plug grafts can be partially removed, leaving one or is a two hairs behind and then redistributing the rest of Dr Greg Williams hair transplant surgeon the excised hairs in front of and between the plugs to and member of the British create a soft, natural looking new hairline. Association of Aesthetic Plastic Surgeons (BAAPS). With over 10 years of experience in hair restoration for burns and trauma, he also Before CLINICAL CASE FOUR treats hereditary male/female pattern When flaps have been used in combination with plug hair loss and other aetiologies. grafts, an option is to excise a strip of hair bearing skin, along with any scarring, and redistribute the hairs REFERENCES 1. Unger WP, ‘Delineating the ‘Safe’ Donor Area for Hair yielded from this ‘strip’ as follicular unit grafts. In addition, Transplanting’ The American Journal of Cosmetic the plug grafts can be either completely or partially Surgery 11 (1994), 239-243 2. International Society of Hair Restoration Surgery, excised (as in Clinical Cases 1 and 2) to soften the ISHRS Statistics and Research (US: ISHRS.org, 2013) After overall appearance and yield further follicular unit grafts. in the occipital scalp region. This patient’s restorative [Accessed February 11] procedure utilised a combination of methods to achieve a natural reconstruction.

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JMSR Europe Ltd. www.janmarini.co.uk [email protected] Telephone: +44 (0)20 8868 4411 @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com Vitamin C: SkinCeuticals Antioxidant Essentials ADVANCED SKINCARE BACKED BY SCIENCE Renowned for its ability to improve skin health and provide a beautifully radiant complexion, the SkinCeuticals range is built on the philosophy of skincare for life. Developed on an effective regime containing three fundamental elements, prevent, protect and correct their antioxidant collection is designed to optimize skin health all year-round.

Research shows that ageing skin is the result of more than just years on the calendar. A comprehensive SkinCeuticals preventive programme not only addresses natural ageing issues, Phloretin CF but further helps patients to protect their skin against Phloretin CF represents a new class of preventive and corrective topical environmental damage, as well as the onset of more antioxidant treatment. After 5 years of extensive research, SkinCeuticals have serious skin conditions. With nearly three decades of developed a patent-pending breakthrough technology combining the newly- research, SkinCeuticals has pioneered the industry discovered, broad-range power of Phloretin with Vitamin C and Ferulic Acid in in antioxidant technology, and their range of Vitamin a bio-diverse formulation to divide and conquer sources of damage at every C-based formulations have been scientifically proven level of the skin. With a winning combination of 2% Phloretin, 10% L-Ascorbic to deliver superior results, helping to reinforce the Acid and 0.5% Ferulic Acid, it not only protects against free radicals but also skin’s natural protection against free radicals. defends against a vast range of other factors known to cause skin damage and DNA mutations. Simultaneously, Phloretin CF will work to correct existing damage Why Vitamin C? Though the skin naturally protects by stimulating the synthesis of essential proteins and fibres and accelerating itself with antioxidants, as it is bombarded with cell turnover. The result? A strengthened support structure on the inside and a environmental aggressors its natural supply is quickly more youthful, firm, radiant appearance on the outside. Recommended for oily, depleted and requires supplemental protection. problematic and normal skin, Phloretin CF is the ideal solution for diminishing Vitamin C has been proven to successfully reinforce hyperpigmentation, improving skin laxity and accelerating cell renewal. the skin’s natural protection against the free radicals generated when skin is exposed to environmental C E Ferulic aggressors. SkinCeuticals’ award-winning antioxidant C E Ferulic is a revolutionary antioxidant combination that delivers advanced range, which consists of Phloretin CF, C E Ferulic, and protection against photoageing - neutralising IRA, UV-induced and endogenously AOX+ Eye Gel, is formulated in a way which combines, produced free radicals. More protection means more youthful looking skin and stabilises and delivers key antioxidants, including better defence against environmental ageing. Containing 15% pure L-Ascorbic Acid Vitamin C, into the skin. “Skin is naturally built for repair. and 1% Alpha Tocopherol, the addition of Ferulic Acid doubles the already synergistic When bombarded by environmental assaults, skin benefits of the original high-potency formula, Vitamin C+E, transforming C E Ferulic must focus on neutralizing oxidative damage, limiting into a super-antioxidant combination. Suitable for dry and normal skin types, its capacity for reparative functions. Daily use of C E Ferulic has proven highly effective on fine lines, skin elasticity and wrinkles. pure antioxidants, when properly formulated to penetrate skin, protect against damage, enhancing AOX+ Eye Gel self-repair to reduce signs of ageing,” says This breakthrough eye serum-in-a-gel helps to protect the delicate eye Dr Sheldon Pinnell, M.D, founder of SkinCeuticals. contour area from oxidative stress, while targeted actives revive under-eye Only SkinCeuticals’ antioxidants have been proven skin and reduce the appearance of puffiness. A triple antioxidant treatment, to perform synergistically, providing superior which works to combat photoageing and signs of fatigue, preventing signs of results to single antioxidant formulations. Combine accelerated ageing and correcting existing visible sun damage. With Phloretin, a SkinCeuticals antioxidants formulation with L-Ascorbic Acid and Ferulic Acid, the AOX formulation is a vital addition to sunscreen to achieve a truly comprehensive help patients see improved drainage and congestion of fluids around the protection against UVA, UVB, IRA and pollution eye-area, using caffeine to effectively reduce the look of under-eye bags. allowing the skin to self repair and correct visible A state-of-the-art gelifier suspends the ingredients in an acidic solution signs of ageing. within an open matrix delivery system for controlled and precise delivery.

Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015 aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics

A summary of the latest clinical studies

Title: Nasal alar necrosis following hyaluronic acid injection into remains resistant to available therapies. The aim of the present study nasolabial folds: a case report was to evaluate the efficacy of erbium:YAG lasers in the treatment Authors: A Manafi, B Barikbin, A Manafi, ZS Hamedi, S of refractory melasma and investigate the histopathological and Ahmadi Moghadam ultrastructural changes between melasma skin and adjacent control Published: World Journal of Plastic Surgery, January 2015 skin before and after surgery. Fifteen Egyptian female patients with Keywords: Alar necrosis, hyaluronic acid, injection, soft tissue melasma unresponsive to previous therapy of bleaching creams and Abstract: Injection of synthetic fillers for soft tissue augmentation chemical peels were included in this study. Full-face skin resurfacing is increasing over the last decade. One of the most common using an erbium:YAG laser was performed. Clinical parameters materials used is hyaluronic acid (HA) that is a safe and temporary included physician and patient assessment, and melasma area and filler for soft tissue augmentation. We present a case of 54-year- severity index score were done. Adverse effects after laser resurfacing old female who experienced vascular occlusion and nasal alar were recorded. Biopsies of lesions and adjacent healthy skin were necrosis following HA injection to the nasolabial folds. She suffered stained using hematoxylin-eosin, immunohistochemically marked from pain, necrosis, infection, and alar loss that finally required a for Melan-A, and evaluated by electron microscopy. The amount of reconstructive surgery for cosmetic appearance of the nose. The melanin, staining intensity, and number of epidermal melanocytes case highlights the importance of proper injection technique by an are increased in melasma lesions as compared to normal skin. anesthesiologist, as well as the need for immediate recognition and Electron microscopic analysis revealed an increased number of treatment of vascular occlusion. mature melanosomes in keratinocytes and melanocytes, with more marked cytoplasmic organelles in melasma skin than in biopsy Title: Analysis of Incidence of Bulla Formation After Tattoo specimens from normal skin, suggesting increased cell activity. After Treatment Using the Combination of the Picosecond Alexandrite surgery, the number of melanocytes and concentration of melanin Laser and Fractionated CO2 Ablation decreased in melasma skin, and the mean melasma area and severity Authors: S Au, AM Liolios, MP Goldman index score decreased dramatically. In conclusion, Erbium:YAG Published: Dermatology Surgery, January 2015 laser resurfacing effectively improves melasma; however, the Keywords: Tattoo treatment, Laser, Fractionated CO2 almost universal appearance of transient postinflammatory Ablation, Picosecond hyperpigmentation necessitates prompt and persistent intervention. Abstract: The picosecond Alexandrite laser has shown increased efficacy in tattoo removal in comparison to Q-switched lasers. Title: Optimizing the use of topical brimonidine in rosacea However, bulla formation is a well-known and expected side effect management: panel recommendations of this novel treatment and causes patient discomfort. The objective Authors: EA Tanghetti, JM Jackson, KT Belasco, A Friedrichs, F was to analyze the incidence of bulla formation after tattoo Hougier, SM Johnson, FA Kerdel, D Palceski, HC Hong, A Hinek, treatment using the combination of the picosecond Alexandrite MJ Cadena laser and fractionated CO2 ablation. This is a retrospective chart Published: Journal of Drugs in Dermatology January 2015 review to determine the incidence of bulla formation after laser Keywords: Rosacea, brimonidine, treatment tattoo removal in 95 patients who were treated with either with Abstract: Rosacea is a chronic inflammatory disease with the picosecond Alexandrite laser alone or in combination with a complex pathophysiology that manifests with central facial fractional CO2 ablation. Twenty-six patients (32%) treated with the redness with or without papulopustular lesions. Often, patients picosecond laser alone experienced blistering, whereas none of the with rosacea present with a constellation of signs and symptoms; patients treated with the combination of the picosecond laser and for best results, the treatment plan should take into account all fractionated CO2 ablation experienced blistering. The difference symptoms manifesting in the individual patient. The first available in incidence of bulla formation between the 2 groups was found to pharmacologic treatment to address the redness associated with be statistically significant (p < .05). This study shows a significant rosacea is topical brimonidine. In the United States, brimonidine decrease in bulla formation associated with tattoo treatment when topical gel 0.33% is indicated for persistent facial erythema of rosacea; fractionated CO2 ablation is added to the picosecond Alexandrite approval was based on clinically significant efficacy and good safety laser, which is consistent with observations from a previous case data from large-scale clinical trials. Use of brimonidine in routine series. This is important because decreasing extensive blistering clinical practice has yielded new insights that elaborate on the likely results in increased patient satisfaction and willingness to findings from clinical trials. For example, real-world use has shown return for future treatments. that a percentage of patients (in our experience, approximately 10 to 20%) treated with brimonidine experience a worsening of erythema Title: Melasma treatment using an erbium:YAG laser: a clinical, that has been called “rebound.” Our routine use of this agent for immunohistochemical, and ultrastructural study 1 year has yielded strategies to set patient expectations, optimize Authors: E Attwa, M Khater, M Assaf, MA Haleem treatment initiation, and minimize potential problems; this article Published: International Journal of Dermatology, January 2015 details those strategies. Because we believe that the term “rebound” Keywords: Melasma, laser, erbium:YAG laser, hyperpigmentation has been used to describe several physiologically distinct events, we Abstract: Melasma is a common pigmentary disorder that have also proposed more specific terminology for such events.

Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015 @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

straightforward enquiry should be passed on to the doctors or therapists in order for them to provide more in-depth answers. This immediately gives the impression of a much more personal service; the one thing that most patients are looking for. Telephone calls are a priority in our clinic, with phone lines open from 9am to 7pm every weekday and 9am to 1pm on a Saturday. There is nothing more off-putting to a potential patient than an answerphone, so calls should be answered as efficiently as possible. Our present phone system gives five choices that are simple and clear, allowing important Dr Hilary Allan looks at the factors that work together patient enquiries or potential bookings to be prioritised over marketing or sales calls. All to ensure the perfect patient experience new patient enquiries are handled by clinical treatment advisors. Their approach is friendly and cheerful yet highly informative, and, having impeccable telephone skills, they Enhancing the ensure a consistent 95% conversion rate of telephone enquiry to booking. On arrival at your clinic, patients should be Patient Journey greeted with a friendly face and made to feel as comfortable and as at ease as possible. Ways to optimise positive patient experience My patients’ journeys have changed idea of what they are looking for. In terms of could include offering refreshments and over the years as much as my journey providing online content (in the form of blogs seating them in a welcoming waiting room, as a medical practitioner has changed. and social media posts) they will spot work which may be enhanced with a vase of Confidence and expertise gained through that has been cut and pasted a mile off – so flowers. Ensure there is information available many patient interactions, treatments don’t insult their intelligence and begin the on all the relevant and current offers at your and masterclass training events have journey on the wrong foot. clinic, and create tasteful displays of your sharpened the sword of my skills and my Investing in a marketing strategy is one way chosen skincare range to stimulate their ability to handle different personalities and, to make sure the patient experience you appetite for what is available. Contact forms occasionally, difficult expectations. This offer is as comfortable and easy as possible should be completed at this time, asking for training and experience has also worked for your patient. Our own clinic is fortunate information about other treatments already to sharpen my view and understanding of enough to have a dedicated marketing undertaken, and their skin care regime, to the importance of the patient journey in team and a large part of their daily work ensure you are completely up to date with aesthetics. These days, patients have – quite is updating the website, posting on social their aesthetic history. rightly – high expectations of the service on media and writing relevant blogs relating We introduced free consultations with offer, and every single piece of that patient to current trends, new treatments or simply either doctors or therapists a few years journey jigsaw must be in place to ensure everyday life at our clinic. They are also an ago. Free consultations are extremely the best outcome for that particular patient. integral part of designing and writing our attractive to potential patients, and most Nowadays, most patient journeys usually own bespoke patient leaflets and creating patients like to see the practitioner who start with some research on the internet. a patient information pack full of relevant will actually perform the treatment, in order Making an impact with your online information and advice that can be sent to to attain their opinion on their perceived presence is key. In regards to your website, all enquirers, promising a comprehensive concern before proceeding with treatment. potential patients will quickly dismiss patient experience from the beginning. This reassures the patient and is a perfect the unremarkable or worse, clunky and The size of your clinic may determine your time for the practitioner to fully assess the inefficient. It’s not difficult to see that time marketing budget, but, for any practice, patient and discuss all aspects of their and money spent on optimising your online relevant information packs and keeping treatment, whilst formulating a treatment presence will be invaluable in guiding those an updated website are the first steps to plan. Some patients will go ahead with enquirers securely in your direction. This is increasing patient retention rates. a simpler procedure, such as a toxin the first step. Making sure your website is Further enquiries, either by email or by treatment, straight away, whilst more classy, attractive, friendly, informative, easy telephone, will hopefully follow this initial complex treatments, such as volumising to navigate and, most importantly, up to browsing. I would always advise that a fillers, may need to be planned in advance date and full of original material, is crucial in clinic ensures all emails are answered and require a more thorough consultation. order for it to be effective. Never doubt how immediately, or at least on the same day, and The use of clinical assistants is one way savvy patients are; they will have done their information packs sent where appropriate. to enhance the patient journey and research and they will mostly have a good Anything more complicated than a ultimately ensure patient satisfaction.

Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015 Patients should receive Mesotherapy HAIR COCKTAIL PLUS MESOLIFT COCKTAIL the appropriate empathy ANTIAGING COCKTAIL FCE COCKTAIL and support with suitable SLIMMING COCKTAIL LOCALIZED CELLULITE COCKTAIL guidance on what could ANTICELLULITE COCKTAIL RADIANCE COCKTAIL PURIFYING COCKTAIL be the next step REGENERATING COCKTAIL TOSKANI are manufacturers and suppliers. Working alongside the doctors and aesthetic therapists to look We o er training and comprehensive protocols after the welfare of the patient at all times, with repeated visits these assistants build up a valuable rapport with the patient that Peels is both welcoming and reassuring. This could be complemented PHOTO AGING PEEL by encouraging patients to contact the clinical assistant after the SALICYLIC 14%, LACTIC 14%, CITRIC 8% procedure with any concerns they may have. In return, patients REJUVENTATING PEEL should receive the appropriate empathy and support with suitable PYRUVIC 40%, LACTIC 10% PURIFYING PEEL guidance on what could be the next step. SALICYLIC 20%, AZELAIC 20% Consultation is a crucial stage in the patient journey. I suggest GLYCOLIC PEEL 20% - 35% - 50% - 70% encouraging your patients to vocalise their concerns and LACTIC ACID 30% - 40% - 50% motivation for seeking treatment. This will aid in building a trusting MANDELIC ACID 30% - 40% - 50% relationship, and will also give you the essential opportunity to SALICYLIC ACID 2% - 10% - 20% - 30% assess whether the patient is seeking treatment for the right PYRUVIC ACID 30% - 40% - 50% TCA 35% reasons. Recent relationship breakdowns or serious illnesses SPOT OUT Whitening Treatment commonly lead to the request for aesthetic work. Intricately linked NOTE: Peels available in cosmetic and medical pH to loss of self-esteem and low confidence, an improvement in appearance can provide an amazing development in wellbeing. Pistor Mesotherapy Guns My approach is cautious and supportive – I call it the ‘slow burn’. O er the most comprehensive Before and after photos should be taken to allow for future menu injection settings available evaluation of the patient’s progress, reinforcing the success of the in the present market. The gun’s treatments. This can be useful as many patients forget how they lightness and ergonomic design looked to begin with. facilitates handling. The increased power enables use of active When treatments are finally undertaken, any discomfort should solutions with a high viscosity be minimised by providing reassurance – and the occasional index. The gentle andsilent use of anaesthetic cream. Severe pain will be remembered action enhances patient and and should not be repeated, so it’s helpful to always be aware practitioner well-being. of how your patient is feeling during the treatment session. Any obvious marks afterwards are also a source of discomfort Carboxytherapy & Oxygen Needling and Infusion and embarrassment and will put people off. Trying to minimise Carboxytherapy uses localized bruising in any feasible way is vital, as some patients will likely microinjections of medical seek a different practitioner if they experience bruising as part CO2 to increase the skin tone, of their treatment. If there are visible signs following treatment, increase skin elasticity and offering mineral make-up, which can be applied by the clinical increase skin brightness. As assistant, can help to conceal any blemishes. CO2 is naturally occuring, the treatment is perfectly safe for Follow-up appointments should always be booked to ensure that the patient. Oxygenated the end result is as it should be, and that the patient is happy with Needling combines oxygen the result – this is, after all, only the start of a long relationship. infusion with needling and Regular surveys canvassing feedback from patients can be utilised achieves amazing results when to check you are doing things right, or to highlight where needs compared with needling improving, and these are essential for good practice. Creating alone. Oxygen infusion has no contraindications, is a clear strategy, supported by an effective team at your clinic, perfect for all skin types, is is integral to the success of dealing with the concerns of every used in Orthopaedics, patient, whilst securing the format for an excellent patient journey Physiatrics, sport medicine, that will guarantee future business and a loyal patient base. aesthetic medicine and dermatology and as a way of Dr Hilary Allan qualified as a medical doctor at St applying homeopathic Bartholomew’s Hospital. Dr Allan practiced as a GP medicines. until 2000 when she decided to devote herself to the Tel: +44 (0)1306 646526 thriving aesthetic clinic, Woodford Medical. Dr Allan [email protected] has been named in the top 10 cosmetic doctors in the www.vidahealthandbeauty.com UK by the Evening Standard and The Daily Telegraph. @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

Whilst each practitioner will have a slightly different approach, the most important thing to consider when dealing with both kinds of communication is good structure and clear objectives. Although these occasions do arise, this article will focus on sharing knowledge and information specifically via presentation to an audience.

Preparation Without question, the most important step in the process of effectively sharing knowledge is planning. The art of As the old adage states – ‘fail to plan and you’ll plan to fail’ It’s my ‘must-do’, no matter where I’m presenting or which audience is scheduled to listen. I really can’t sharing knowledge underline enough the importance of good prep. As much as it’s about the attention to detail when Dr Kieren Bong uncovers the best looking after my patients in a clinical environment, detail is key when researching for a presentation. methods of delivering and sharing Knowing your audience is vital. Look at exactly who information in aesthetics is attending. If the information is given, pore over who does what and where. Know how many candidates will be present, and look at their levels of experience and Each year, my diary contains a number of key engagements which see me knowledge. As the first step when preparing for a new swapping my Glasgow-based clinic treatment room with venues all over the presentation, I will set out my objectives in list-form, world. In these venues – and these can range from university lecture theatres and prepare an outline of a talk based on these aims. to exhibition halls and seminar rooms – I wear a different hat from my usual That initial draft may bear no resemblance to the end one of cosmetic doctor. I take on a new role as lecturer, trainer and key opinion result – but it will provide me with a working document leader, prepared to cover an extensive range of topics and techniques on that keeps me focused on what I need to deliver. I call advanced non-surgical facial aesthetics. The art of sharing accrued knowledge it my ‘work in progress’. and expertise is one I’ve honed and fine-tuned over the last five years or so. When the occasion or setting calls for a PowerPoint This craft has taken me to international venues including those in Sweden, presentation, I am a great believer in ‘less is more’ – Kazakhstan, Monaco, Malta and Cyprus. More recently, I have been fortunate to formulate the content on each slide with just enough to take up a role with one of Norway’s most respected universities where I lecture deliver the audience the key information. Because you on the topic of dermal fillers six times a year to students on the Masters degree will be well-prepared and rehearsed, these will provide equivalent of a postgraduate diploma in cosmetic dermatology. In this varied more than enough information as aides-memoires work, my audiences can change from a group of just 10 such students in a to keep you on the correct path and on-message. classroom-like setting, to almost 1,000 delegates at an international conference. Before each presentation, I always take a close look For me, however, the requirements are near identical. As a result of my interest at the actual venue and the facilities available. Thanks in developing how best to share the specifics of any presentation or training nowadays to search engines such as Google and session, I aim to ensure that those on the receiving end of my information the wonders of the web, it is often possible to have receive maximum benefit. a 360 degree virtual tour of the venue. There is no In this article I would like to share some of the presentation skills that I have point turning up with a presentation in a format that’s learnt over the years, outline some dos and don’ts, and highlight the pitfalls to not compatible with the venue’s equipment. It can avoid if you too embark on the wonderful journey of sharing your knowledge also be useful to find out the lighting options in a and expertise. venue, as light can sometimes determine the style of In my opinion, there is a clear difference between training and presenting. It’s presentation to adopt. Some event organisers provide worth focusing on this difference and making it clear in your mind in order to additional external lights for the live demonstrations, correctly determine the content of what’s to be shared or communicated. especially when videographers are on-site to film the Training: This is something that can occur in an every-day clinic setting, procedures for live broadcast throughout the venue. especially whenever a new team member joins. Training typically focuses on On the other hand, there have been occasions when assisting a person or group to learn through activity, discussion and inclusion. I have had to make do with the existing lights in the Presenting: This is best described as the provision of information to an auditorium. A trainer should always be prepared to audience. adapt to the facility that has been provided. Both sound straightforward enough, but the art of engaging with each focus group can present its own challenges. Engaging with your audience Of course, there are times when the types of sharing – presenting and training In cases where my audience is located in an – can cross over and blend together. For instance, the advanced full-face overseas venue, I carry out some local research contouring and volumising treatment requires complex mapping of the face and, where relevant, will work in some local prior to the actual procedure, and the drawing of landmarks and imaginary references. These references will help you connect guide lines are both presented and demonstrated live, during the same session. with your audience and will work to better spark

Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015 Grow Your Practice by Offering Postpartum Treatments to Your Patients!

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*The VelaShape III is indicated for non-invasive treatment for body contouring via temporary cellulite and circumference reduction. This brochure is not intended for use in the U.S. market. ©2014. All rights reserved. Syneron, the Syneron logo, VelaShape, UltraShape, Sublative and elōs are registered trademarks of Syneron Medical Ltd. and may be registered in certain jurisdictions. Candela is a registered trademark of the Candela Corporation. PB85751EN @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com their interest. It also clearly demonstrates to the audience your commitment to preparation and your respect for their time. My top 10 tips on presenting: If, for example, the presentation is going to involve a technique • Plan and prepare demonstration – perhaps a new advanced filler technique – then securing a model or several models is key to its success. To do • Work out scope and format this, work closely in advance with the event organiser and product • Research your audience distributor to ensure models are fully briefed on what will be involved, and to ensure that all consent protocols are satisfied. This will include • Research your venue – especially for suitable both verbal and written consent. You will need your model to be as equipment prepared and relaxed as you are when working under the spotlight. • Rehearse, rehearse and rehearse again Recently at a one-day seminar and technique demonstration in • Ensure any live model is available and well briefed London, the model I’d booked for the presentation fell sick so, at the in advance last-minute, we were facing a crisis. No model meant I’d not be able to deliver a practical demonstration of the theory I was planning to • Be prepared for potential cynicism, fear or present. Thankfully, the product distributor and I worked together resistance and managed to secure a volunteer from one of the delegates • Use case studies or personal experience to boost who’d travelled from Belgium. After volunteering and signing the audience engagement necessary consent forms, she gave me the green light to complete • Encourage participation my presentation in the most effective way possible. In the event of working with a medical company, I find the preparation steps on many • Be happy to answer questions occasions to be simplified, as not only will the aims be made very clear at the outset, but in most cases the local product distributors will help to source the necessary model(s). In my personal experience, although approaching my mid-30s, I have been told in the past that I appear younger, and so a cynic in the Participation audience might question age and, therefore, gravitas and industry No matter the type of presentation or training masterclass you are experience. It is my job at the outset to ensure that the audience not delivering, it is crucial to promote participation. This might be in the only understands my qualifications for speaking to them, but to build, form of half-time practise sessions and/or workshops, or staging a point by point, a confidence in my skills and abilities so they appreciate questions/answers session. This kind of participation has a dual- my right to stand before them for that particular session. This is benefit for you as a presenter and a trainer. Within minutes it’s achieved through clear communication and thorough preparation. possible to ascertain how successful your delivery has been, and just how switched on the audience has remained. If there’s a hint A multimedia approach of any failing in one or the other aspect of your presentation, then One very important point to be made is related to your content. conducting any kind of participation sessions gives you the chance I strive to personalise the topic at hand by example, whether by to redress the balance and get your audience back on track and using personal experience or with case study illustration. Few engaging with your content. Due to the aforementioned forward of us in today’s aesthetics profession work exclusively among planning and research you should rarely find this to be the case, and text books and the world of academia, so we will usually have your audience should be given multiple opportunities to engage via a wealth of personal stories to share, or access to effective the mix of PowerPoint presentation slides or live demonstrations. before and after images. Mixing the use of still photography with good video footage enriches any presentation. This multimedia Potential pitfalls approach helps to generate engaging content, and this kind of So what are the things to look out for when sharing knowledge in this delivery improves the chances of the information and technique way, be it training, presenting or running a workshop? First of all, you displays sticking in the audience’s memory. may well need to handle resistance from your audience. Don’t be over Lastly, aim to be as relaxed as possible before your appearance. alarmed – it does happen. This will manifest either through immediate Get a good night’s sleep. Have a reasonable meal ahead of the criticism of a point you’re making, insincere agreement, silence or in- engagement. Nerves are normal, and some say these nerves your-face defiance! help keep the mind focused. Even after years of experience and Don’t be swayed by any of the above. Be prepared. By being so, appearances before audiences small and large, I’ll still experience you’ll be able to tackle that resistance which may be caused by fear, nervousness. In my experience, deep breathing helps to calm misunderstanding, cynicism or a mixture of all three. nerves, along with the knowledge that you have prepared 100% The element of fear may stem from the audience’s concern they’ll for the session. All in all, these factors should add up to be unable to develop the skills and competencies. Our job is to a well-delivered presentation and an effective and fluid sharing instil the necessary knowledge and boost their confidence in order of knowledge. to overcome such fear. In some cases – such as in a more intimate Dr Kieren Bong is clinical director of Essence Medical training environment – one-on-one contact may be a solution. Today, Cosmetic Clinic in Glasgow, Scotland. He prides himself the sharing of presentations or training notes via technology is so in his innovative approach to non-surgical facial simple and can, itself, allay fears. treatments, and is well known for his unique methods of achieving beautiful yet natural results with minimal Cynicism may arise, as an audience can comprise different levels of pain and downtime. Dr Bong is a sought after international trainer, experience, background and training. There may be questions arising speaker and key opinion leader, teaching other doctors and surgeons about choice and availability of different brands or grades of products. advanced facial aesthetic procedures.

Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015

@aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

examine your budget to see what you can feasibly offer. Once you have noted all of these elements, you will have a far better idea of the person you need to recruit. If you still have doubts after this, then ask for help – fellow aesthetic professionals with past experience of hiring staff will be able to offer you valuable advice.

Update your adverts, interviews and employee packages When did you last revise your job specifications, your interview questions and your employee packages? If you haven’t reviewed any of these in the last few months, then you must make time to do so before you begin the hiring process again. You may be well versed in the latest aesthetic trends, but does that include industry salaries? It is not sufficient to simply offer the same remuneration year after year, as this may mean you are not Hiring Staff keeping up with your direct competitors. Similarly, it could mean you are offering more than you need Aesthetic recruitment brand manager to, raising your costs unnecessarily. Before you advertise for a new employee, check what other Victoria Vilas shares her advice on choosing clinics in your region are offering to ensure you are the right employees for your clinic not losing key personnel to other clinics. You should also ensure that your job specification is in line with current requirements within the The process of hiring new staff members for your practice has the potential aesthetic and cosmetic surgery industry. As noted, to be time-consuming and costly. However, careful planning and research into before advertising you must know the minimum industry recruitment trends can save you time and money, as well as providing requirements for this role, both in terms of essential potential employees with confidence in your knowledge and practice. Before skills and also in terms of legalities. If you advertise you begin recruiting, make sure you’ve considered these key points, to ensure for an aesthetic practitioner who is to perform laser the process runs smoothly. treatments, but you do not state that they need to have completed their NVQ3 in Beauty Therapy and Start the recruitment process only when you know what you need the Laser Core of Knowledge course, then you are As highlighted, the main hurdle of hiring new staff is that it can be time likely to receive applications from underqualified consuming. Planning your recruitment process is crucial to making this process practitioners who want to develop their skill set. more time-efficient. For example, if you’re unsure whether you want to hire an Unless you are willing and able to offer, and aesthetician or an aesthetic nurse to carry out particular treatments, then list sometimes fund, training for such applicants, then the essential requirements of the role you have in mind. Consider all aspects you will either waste time sifting through unsuitable of the role and match these up with the required experience or training. Your applications, or hire someone who will not meet the clinician may need to have training and practical experience in laser hair minimum requirements for your clinic’s insurance. removal, but does that clinician also need to be a trained nurse and, if so, why? Speak to your insurer if you are in any doubt about Perhaps your clinic’s USP is that treatments are only carried out by medical the criteria for cover. If you are about to launch a professionals who are qualified doctors or nurses. But, if not, then consider start-up venture, contact a specialist insurer for the that a fully-qualified aesthetician, with the relevant skills and experience in cosmetic industry, as they will be able to tell you performing the skin treatments you offer, could also be a fit for the role. which treatments you can and should be covered Such factors should be noted, discussed and decided on before you advertise for, and the minimum requirements for practitioners. the role available, and certainly before you begin to interview, or you could waste days reading CVs and interviewing candidates who don’t meet your Choose suitable recruitment methods demands. If you think you know what you want, but are not entirely sure what When managing the recruitment process yourself, you need, make a list dividing essential and desired skills and qualities. Look it is important to factor in costs for advertising fees at the average salaries being offered for similar vacancies in your region, and for job boards, local press and other classifieds, as well as the time spent on preparing adverts, reading CVs, arranging interviews, and managing You may be well versed in the any contract negotiations. If you use a recruitment agency, you will usually pay one fee for these latest aesthetic trends, but does tasks. A recruitment agency will have access to a wide network of industry professionals, so they can that include industry salaries? proactively headhunt candidates when you have a

Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015 aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics specific person in mind for your vacancy. Give new staff members the Though agency fees can seem expensive at first sight, if you add up the cost of your in-house recruitment process, you may find that time to learn your processes agency fees are cheaper when all is taken into account. However, that isn’t to say that it is always advantageous to use an agency to and protocols recruit every new member of staff; this is very much dependant on the kind of candidate and the type of role you are looking to fill. that you do everything you can to make new employees feel at Before making your decision on whether to recruit in-house or ease, and have the confidence to do their job to the best of their outsource, think about your vacancy. Is the role for someone with a abilities. Make sure you have an induction process that helps very specific and uncommon skillset, or are the skills required easy your new employees understand their role and responsibilities, as to find in a wide range of applicants? If you are looking for a junior well as your company culture. Give new staff members the time receptionist who does not need to have vast industry experience, to learn your processes and protocols before you leave them on for example, you may receive a high number of applications for their own, and be there to answer any key questions they may that role and, out of those, you are likely to find some candidates have. If you start off on the right foot, your new employee should worthy of an interview. If you are looking for a senior manager with get into their stride quickly and feel confident they have made a lot of industry experience and a detailed set of skills, you may the right decision in joining your clinic’s team. Taking a thorough end up spending a lot of time searching for your perfect employee, approach to hiring new members of staff for your clinic will ensure and possibly waiting longer than you desired to get that new staff efficacy in the long-term. Research and planning is key to finding member in place. While you may not need an agency to assist with the right candidate and ensuring a streamlined process for filling junior roles within your company, it may be advantageous to use the both current and future roles within your practice. help of a recruiter for roles that require specific skills and attributes. Victoria Vilas is brand manager at ARC Aesthetic Establish a comprehensive induction process Professionals, a recruitment consultancy specialising Once you have gone through the recruitment process and in the aesthetic medicine and cosmetic surgery sector. Since 2008, managing director John Sellers and his successfully hired your ideal employee, you need to make sure team have helped numerous organisations within the they stay. Don’t take it for granted that your staff members will industry grow their businesses by hiring the most talented aesthetic settle in and feel comfortable straight away; you need to ensure professionals in the UK.

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to leave. You believe you are being asked to leave unfairly and, in any event, even if you were to leave you would want to secure your financial future to some extent; after all, surely you are due something back from the practice into which you have invested a large chunk of your life. Aren’t you? However, you have no partnership agreement in place. There is nothing which spells out what your share of the practice’s or the business’s profits are; there is nothing that spells out the circumstances in which the other partners can ask you to leave; you wonder if you could be protected in employment law; you seek advice; you realise that employment law does not always necessarily treat Why Do You Need partners the same way as employees and this means you have no legal claim to compensation for dismissal.4 So much could have been avoided if only you had A Partnership put an agreement in place. The consequence is you become embroiled in a lengthy and acrimonious dispute with your partners as to what you think you should be owed. The legal costs start to add up from Agreement? this point onwards until a resolution is found. Apart from the financial impact there is also the Solicitor Shuba Nath explains how psychological impact and stress that is imposed investment in a partnership agreement on all when a dispute arises; business owners are best left to running their businesses, not wasting can protect you and your business valuable management practice time in trying to resolve disputes. Other key provisions under the Partnership agreements are akin to marriages; when things are going well partnership agreement will revolve around the there are likely to be no complaints – however, when things do not live up to decision making process, partnership premises, the a partner’s expectations, business tensions arise which can result in an ugly partner’s shares of profits and liabilities, a valuation and expensive divorce of the partnership. Time and money spent in having a of the partnership if the others are to buy a partner carefully crafted and bespoke agreement, which takes account of the various out, partner targets, restrictive covenants to stop needs of the partners and provides solutions to those often tricky questions or exiting partners setting in competition with an existing disputes can, on any analysis, only be viewed as an investment. If the parties business within a defined geographical area and involved choose not to put an agreement in place, the provisions of the Partnership time frame; retirement, expulsion, holiday, absence Act 18901 will apply automatically. Unfortunately, these provisions may not always leave and, finally, provisions for dealing with dispute be suitable for the parties’ needs. The upfront costs involved in paying for a resolution. Partnerships, like any other business, partnership agreement pale significantly when compared to the costs involved evolve. A partnership agreement is a valuable asset; in managing a partnership dispute; the dispute may end up in litigation (a non- it’s your responsibility to ensure that the agreement confidential and public process) if no proper arbitration or mediation provisions does not become a toxic asset. If you do have an (both confidential processes) are contained in the agreement. The old adage existing partnership agreement in place you should ‘prevention is better than cure’ applies equally to partnerships as to any other get it reviewed regularly, perhaps every three to five area of life. Some professions – in particular the GP sector – are very fortunate. years (depending on your business), to ensure that the The GPs have specific guidance provided to them in the form of the British agreement that was initially put in place still reflects the Medical Association’s (BMA) Partnership Agreements 2014.2 Yet despite the realities of your business and its needs. availability of this resource, it is still surprising how many GPs either have no partnership agreement in place or if they do, it is likely to be outdated and not Shubha Nath is a solicitor and the managing director of Nath Solicitors fit for the needs of the modern practice. However, GPs are not alone; there are Limited; she has spent more than many businesses, including private aesthetic clinics, where parties team up to 20 years practising partnership and work together, completely oblivious to the liability that they may attract through company law and learning first-hand operating on a partnership basis. The Partnership Act 1890 is very clear that a about partnership agreements and setting up and running of companies. partnership is formed when: “Partnership is the relation which subsists between persons carrying on a business in common with a view of profit.”3 REFERENCES 1. Legislation.gov.uk, Partnership Act 1980 (UK: legislation.gov.uk, 1890) Imagine you are a partner; you have been working in a practice or with your [accessed business partners for a considerable number of years. You have had some 4 February 2015]. 2. British Medical Association, Partnership Agreements (UK: British Medical ups and downs over the years but you have generally gotten on well with your Associations, 2014) [accessed 4 colleagues. One day, to your surprise, your colleagues tell you they do not February 2015]. 3. Legislation.gov.uk, Definition of partnership(UK: legislation.gov.uk, 1890) think you are performing as well as you used to. This underperformance is the [accessed reason why your colleagues would like you to leave the partnership; they are 4 February 2015]. 4. Tiffin vester L Aldridge EWCA Civ 35 (2012), British and Irish Legal keen to keep things amicable and will help you and support you but you have Information Institute, 2012

Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015 Untitled-2 1 05/02/2015 18:22:43 aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics

accessible, understandable and engaging manner. If a user faces difficulty accessing information because your website is not optimised for mobile (for example, if they are having to pan around a mass of information and zoom in and out to read key parts) they will simply navigate away and find a better resource of information. It is not only important from an accessibility perspective to be mobile ready – new mobile and web technologies have made it easier to offer a wider range of services for patients. Online booking, appointment management, and access to specialists via ticketing and chat systems, all The Mobile Revolution help patients make an informed decision on whether your service is right for them. Tracey Prior highlights why having Technological development has allowed for the increased use of new and often a mobile-friendly website is crucial in 2015 under-utilised techniques for capturing a potential audience. With the roll out of 4G it In recent years, access to faster, cheaper home or a mobile device on the move, an is becoming more viable to present video mobile technology and more accessible optimised web solution ensures you are on information to consumers; a great way to data hotspots, WIFI and reliable 3G/4G the right track to capture and capitalise on this capture attention. Having a mobile solution connections has meant a surge in mobile growing tech-savvy clientelle. for your web presence also improves the usage across the world. Once businesses Statistics collected from a selection of our share-ability of information on social networks. could simply provide an online portal for clients’ cosmetic aesthetic websites, as of 60% of social network access is via a mobile3 customers to find their address or contact December 2014, show that on average 50% – and the majority of people have social details (and this on an unoptimised web of users are visiting websites via mobile, which network accounts directly linked to their page), but this is no longer viable. Forward- equates to an increase of 10% from 2013. mobile devices. This increases the chances thinking companies now adopt the use of This increasing trend is further confirmed by that a consumer could share information responsive web design (RWB), a design which OfCom official statistics.1 If, therefore, your that is useful to them (or potentially the adapts to whichever interface the user is website is not optimised for mobile use, it people within their network) on social media, deploying, ensuring that it is always formatted becomes difficult for approximately half of increasing your reach and promoting your and functional to the size of that particular your patients to find what they require in a clinic. There are many ways to tackle this screen, be it a desktop, tablet or mobile. quick and accessible manner. As we know, evolving trend. It could be a responsive Others have a dedicated mobile website, the average attention span of consumers is website, a dedicated mobile website or a with design and function built purposefully for waning, whilst the speed and accessibility of mobile application. All methods focus on a mobile use, or craft apps that deliver content information is creating a mindset of, “Instant similar and unified goal – to ensure the user efficiently and directly. gratification and quick fixes”, according to is getting the best possible experience and One sector that has witnessed a growth Rob Weatherhead, head of digital operations level of service possible. Statistics show a in mobile usage is the aesthetic sector. at leading media agency MediaCom.2 In this definitive increase of companies deploying Patients used to purchasing food and other digital revolution, an online presence is not mobile solutions over recent years – with no necessities online now expect a similar level enough. Your web and mobile presence impression of slowing down. of service in all areas of their life. Whether has to secure the attention of a potential Tracey Prior is the operations a consumer is using a tablet device in their patient by providing key information in a fast, manager for Blow Media, a creative, design and digital agency which caters to the aesthetic Capitalising on the mobile boom industry. Having been a sales When considering how to become mobile friendly, assess the content that you currently director for 12 years prior to joining Blow have on your website and imagine (or try out) how this displays on a mobile device – is Media, Tracey Prior is very much commercially there scrolling/panning to find information? Do images make up the bulk of the content minded and knows the value creating a strong and do they bury the informative text at the bottom of the page? Your aim is to de-clutter digital footprint can add to your clinic. and simplify information displayed on the screen, ensuring there is a clear hierarchy REFERENCES to the information being presented, and that it is delivered in captivating yet bite-sized 1. Ofcom, Facts and Figures (UK: ofcom.org.uk, 2014) [Accessed 4 February 2014] sections. There are many services out there that will allow you to begin your journey to 2. Rob Weatherhead, Say it quick, say it well – the attention becoming mobile ready. For example, you can utilise free website builders that supply span of a modern internet consumer (UK: The Guardian, 2014) a functional web presence that just needs updating, or if you require an online overhaul, [Accessed 4 February 2014] calling on the experience of a design/digital agency is key. Digital development is an 3. Emily Alder, Social Media Engagement: The Surprising Facts About How Much Time People Spend On The evolving process and digital agencies are at the forefront of ensuring their clients see a Major Social Networks (UK: Business Insider, 2014) . [Accessed 4 February 2014]

Reproduced from Aesthetics | Volume 2/Issue 4 - March 2015

Untitled-2 1 05/02/2015 18:22:43 @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

“Don’t let anyone tell you that you can’t do what you have your heart set on” Nurse Independent Prescriber Emma Davies talks to us about co-founding the BACN, and her unwavering passion for growth, learning and regulation

Emma Davies has achieved many milestones in a career as highlighted in the Keogh report, for an independent register of spanning 28 years. From co-founding the British Association of accredited professionals. “I think we’re all agreed that we will be in Aesthetic Nurses (BACN), to her current clinical director position at a better place when there are accredited standards and pathways the newly-formed Save Face, her work has served as an important to education, and when the consumer has a means to navigate to building block for a generation of practitioners campaigning for an independently verified, safe and accountable service provider.” better regulation in aesthetic medicine. For industry newcomers, she insists research is key. “Reading Qualifying as an NHS nurse in 1987, Davies recollects how she fell journals such as Aesthetics is hugely valuable, as is making time in love with the profession at a young age. “I had kidney disease to get a feel for the field before jumping in,” she advises. when I was a child and spent a lot of time in hospital, so grew up Reflecting on her career and on how she has learnt from mistakes, wanting to be a nurse. Those nurses who looked after me inspired she says candidly, “I would think the mistakes and the wrong me,” she explains. turns, and there have been a few, have had so much more value Her interest in aesthetic work wasn’t sparked until 1998, when than things that went right the first time, and I wouldn’t be where a colleague mentioned that a nurse who had treated her with I am today if I hadn’t made and learnt from them. I wouldn’t collagen injections was looking to expand her practice – and change anything.” was offering training in the field. The aforementioned nurse was AestheticSource director Lorna Bowes. “I was fortunate because she mentored me and helped me find my feet. I haven’t really What treatment do you enjoy giving the most? stopped since,” says Davies. “The more I find there is to learn – Dermal fillers. It’s a skill that allows you to be fairly artistic, and it which is what I love – the more I love my work.” provides that instant wow-factor for the patient. In the beginning, Davies experienced a very gradual learning curve. “At the time there weren’t many reference points – if any,” What technological tool do you think best she recalls. “It was a slow learning curve for me, it was such a complements your work? foreign world.” However, she focused on building her skills by The syringe or the needle. Having a good quality syringe – and following her personal motto, ‘plough your own furrow’, which the types do vary – and a very sharp needle, are the main things means don’t be distracted by what other people are doing – that complement my work. focus on doing what you do, and doing it well. Since 1998, Davies has worked in independent and national chains in London and What’s the best piece of career advice you think the South West, before establishing her own clinic in Somerset you’ve been given? and courses for vein-care training in 2003. She now also works “Don’t let anyone tell you that you can’t achieve something alongside a plastic surgeon in Bristol. “I’ve never just focused on that you have your heart set on.” When I had big ideas, it would one thing, I’ve always had two or three different hats,” she says. have been easy to ‘park’ them, the voice of doubt saying, “Well, Davies feels the BACN is her biggest achievement to date. Before if that’s such a good idea, why hasn’t it been done?” I might its creation in 2010, turning to other professional bodies had left have played safe and simple, but I didn’t, and have thoroughly her disappointed. She felt their services were no longer adequate enjoyed and grown from all the challenges I’ve faced. for the aesthetic nurse profession. “The BACN was really needed to take up the baton, celebrate our role, and bring aesthetic Do you have an industry ‘pet hate’? nurses together in a community. It was needed to develop our When role models brag about treating large numbers of patients selves further,” she says, adding, “I was completely hooked on every day, as though seeing a patient every 15 minutes is a the journey.” Though it didn’t seem likely at the time, the BACN measure of success. All I’m thinking is, what is that experience eventually grew to be much more than Davies and her fellow like for the patient? We have to remember there’s a person on founding members had ever imagined. “I don’t think people fully that couch, and they’re paying a lot of money, so they shouldn’t appreciate how important it’s been, and how important it’s going to be treated like something in a factory. Where is your job continue to be for those nurses that are passionate and committed satisfaction when you’re working with that attitude? to it,” she says. After retiring from her post as BACN Chair in 2014, though still What aspects of aesthetics do you enjoy the most? actively involved in the association, she has since become the I love meeting with professionals who have a passion for the clinical director of voluntary accreditation register Save Face. craft, care about their patients, and love what they do – and “I was planning to have a quieter life, but this was far too exciting there are lots of them. to say no to,” she says. Davies acknowledges the requirement,

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clinic. Acne scarring is another example of an aesthetic concern where there are little treatment options available within the NHS. Sound knowledge of other treatments can really help guide patients to make safe and effective choices. From an aesthetic practitioner’s perspective, skin lesion recognition is a valuable skill to bear. I advocate that all aesthetic practitioners should have basic training and understanding of how to recognise malignant or premalignant lesions. Many patients with aesthetic concerns have signs of ageing, most commonly from their 40s onwards, which is often associated with sun damage. As we know, solar-related skin lesions such as basal cell carcinomas, actinic keratosis, Bowen’s disease and melanoma are more common within this group. In my experience, The Last Word many patients who seek aesthetic treatments are sun-bathers or use sun beds, which increases the risks of solar damage and raises Dr Paul Charlson argues the value the incidence of these lesions. Being able to use a dermatoscope, of dermatological training for in particular to aid recognition of lesions, is very helpful in planning lesion management. This is often crucial if a surgical procedure is aesthetic practitioners required and, with the correct diagnosis, can also ensure you avoid advising or performing unnecessary surgery. Aesthetic medicine and dermatology are interrelated specialties An understanding of dermatology can also help the practitioner and, as such, it is harder to practise aesthetics effectively without choose suitable topical cosmeceutical agents for patients – further a thorough understanding of the skin and how it functions. guaranteeing an effective treatment outcome. Similarly, when Conversely, having knowledge of aesthetics is complementary complications arise as a result of aesthetic treatments, it is really to modern dermatological practice. For this second point, it is helpful for practitioners to understand how the skin might react important to note that the boundaries between what the state and have the knowledge to correct the problem with confidence. provides through a taxation-funded NHS and the private medical Complications are inevitable, thus handling them correctly and sector are becoming increasingly blurred – and this is particularly having the understanding of how to treat them effectively can avoid noticeable in dermatology. We no longer live in a society where potential medical litigation arising in the future. people are content with the options that the NHS provides. From Traditionally, dermatology has not been a particularly well- both my own experience, as well as that of colleagues, it has been taught subject at undergraduate level and, as a consequence, noted that patients are increasingly consulting us on what aesthetic many doctors and nurses entering aesthetic practice will have procedures are available, how they work and where they can go to significant gaps in their knowledge of skin function and care. receive treatment. However, NHS clinicians working in dermatology Considering each of the points made in this article, I argue that and primary care, who also work as aesthetic practitioners in the anyone considering a career in aesthetics should also gain basic private sector, regularly encounter the difficulty of this multifaceted dermatological training at an early stage in his or her career. As and interlinking interface. In order for our patients to make informed dermatology is a visual subject, where pattern recognition is treatment choices, it is reasonable to advise them of all the options crucial, spending time in a dermatology clinic is very helpful. Most available. Whilst consulting within the NHS, good practice dictates practitioners are happy to welcome colleagues into their clinics so that we should endeavor to answer patients’ direct questions about I would certainly recommend contacting consultants in their local aesthetic treatments not available on the NHS reasonably and briefly. Trust or community clinics. Many dermatology courses are also It is ethically prudent of NHS doctors and nurses to suggest patients available, and organisations such as the Primary Care Dermatology do their own research, especially when they receive direct enquiries. Society (PCDS) and the British Association of Dermatologists This is frustrating as we are aware of the variability of quality (BAD) run excellent short courses. I found the diploma in Practical within the aesthetic industry, and want to ensure our patients seek Dermatology particularly beneficial to my understanding of skin treatment from a practitioner who is clinically and ethically sound. function and care. Although these courses require a significant Dermatology and aesthetic medicine are natural bedfellows. In investment in time and money, they do provide an excellent my NHS practice as a GP and as a GPSI in dermatology, I am often dermatological grounding for aesthetic practitioners. In the future confronted with conditions that can also be classed as aesthetic I believe a module on dermatology – specifically tailored to concerns. A typical example of this is melasma, which is often aesthetics – should form part of all diplomas in aesthetic medicine. distressing for patients and cannot be comprehensively treated The purpose of this piece is not to claim that dermatology training by an NHS prescription for Azeliac acid, a retinoid and sun block. is absolutely essential to becoming an aesthetic practitioner, but Whilst being beneficial, these treatments only form part of a range of to highlight that it is complementary to an aesthetic practice. The accessible options. There are excellent effective alternatives, which benefits to both the patient and to the practitioner are worth the would be denied to a patient if the practitioner had no knowledge of effort from a clinical, as well as a commercial, point of view. their efficacy and indications. Furthermore, from the point of view of NHS clinicians, rosacea is Dr Paul Charlson is an NHS GP and GPSI in another distressing condition, characterised by facial telangiectasia, Dermatology. Joining aesthetic practice in 2002, he is now the president of the British College of Aesthetic which can be easily treated by vascular laser. It can be very helpful Medicine and medical director of Skinqure Clinic. if practitioners are able to advise a patient of how lasers work and Previously Dr Charlson was a GP trainer and partner, how they can aid the treatment of rosacea in a private aesthetic with 20 years experience in a dispensing practice.

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