Book your ticket to The Aesthetics Awards 2014 Today VOLUME 1/ISSUE 10 - SEPTEMBER 2014

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Treating Hair Aesthetics Collagen Radiofrequency Loss Awards supplements Leading figures share The finalists for the Practitioners discuss CPD article their methods for prestigious Aesthetics the benefits and Lee Brine explores the science behind RF hair loss treatment in Awards 2014 are limitations of orally in medical aesthetic procedures patients announced ingested collagen

Aesthetics Journal Neoretin FC.indd 1 11/08/2014 17:07 Syneron Candela Launches Breakthrough Technology. Again. Introducing PicoWay.

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

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

And PicoWay has the reliability and low cost of ownership physicians want.

PicoWay Launch @ CCR Expo, Olympia London October 10th & 11th, 2014 STAND #E10

www.syneron-candela.co.uk | [email protected] | Tel. 0845 5210698

©2014. All rights reserved. Syneron and the Syneron logo are registered trademarks of Syneron Medical Ltd. and may be registered in certain jurisdictions. PicoWay and Candela are registered trademarks of the Candela Corporation. PB83214EN Contents • September 2014

INSIDER

06 News The latest product and industry news 17 News Special A look at social media in aesthetics CLINICAL PRACTICE 18 Conference Report Radiofrequency Dr Raj Acquilla reports on his recent work at international congresses Page 26 CLINICAL PRACTICE

21 Special Feature: Treating Hair Loss We ask leading aesthetic practitioners to share their methods for treating patients with hair loss 26 CPD Clinical Article Syneron Candela Launches Breakthrough Technology. Again. Lee Brine explores the science behind radiofrequency in medical aesthetic procedures Introducing PicoWay. 30 Clinical Focus IN PRACTICE Dr John Quinn looks at the avoidance and management of potential Local Marketing dermal filler complications Page 54 35 Techniques PicoWay is a remarkably innovative dual wavelength Dr Sotirios Foutsizoglou discusses hair restoration surgery for picosecond laser from Syneron Candela, the most younger patients Clinical contributors trusted brand in lasers. With both 532nm and 1064nm 39 Clinical Focus wavelengths, PicoWay can treat a very broad range of Fleur-Louise Newsom explores changes in the skin associated Lee Brine is a qualified engineer from the aero indus- try, with a career in medical technologies. He works tattoo types and colors and pigmented lesions on any with the menopause predominantly with lasers and radiofrequency energy skin type. 42 Treatment Focus sources, covering a range of surgical specialities. Rebecca Treston provides an overview of laser hair removal Dr John Quinn is an Irish qualified general practitioner with over 9 years experience in 44 Spotlight On cosmetic medicine. He is a full member of the PicoWay has the highest peak power and the shortest British College of Aesthetic Medicine. Practitioners discuss the benefits and limitations of orally ingested pulse duration of any picosecond laser for superior Dr Sotirios Foutsizoglou is the founder of collagen efficacy, safety and comfort. Proprietary PicoWay SFMedica. He specialises in cosmetic surgery 46 Abstracts and aesthetic medicine, and is a member of the International Society of Hair Restoration Surgery. technology creates the purest photo-mechanical A round-up and summary of useful clinical papers interaction available to most effectively impact tattoo Fleur-Louise Newsom is a skincare specialist at 49 Aesthetics Awards Special Focus Forme Laboratories. With 20 years experience in ink and pigmented lesions, without the negative skincare and healthy living, Fleur works closely with The finalists for The Aesthetics wardsA 2014 are announced the product development team at Stratum C. thermal effects of other lasers. IN PRACTICE Rebecca Treston is a laser specialist and a member of the American Academy of Anti-Ageing. Rebecca’s Dubai clinic, Rebecca Treston @Euromed, offers the 54 Marketing And PicoWay has the reliability and low cost of latest cutting-edge anti-ageing treatments. Jill Woods highlights the importance of considering local ownership physicians want. demographic and competition in your marketing strategy NEXT MONTH 58 Law • IN FOCUS: Lasers • Special focus: Tattoo removal PicoWay Launch @ CCR Expo, Olympia London Expert witness Liz Bardolph looks into the possibilities for damage • CPD: Laser complications • Engaging your audience October 10th & 11th, 2014 limitation with unhappy patients STAND #E10 62 Business Process Gilly Dickons on the benefits of collecting statistics to boost your Voting is open for the most business prestigious celebration 66 In Profile in medical aesthetics Dr Rita Rakus shares her experiences as a cosmetic practitioner in Visit the UK www.aestheticsawards.com 68 The Last Word today to vote in www.syneron-candela.co.uk | [email protected] | Tel. 0845 5210698 Mr Dalvi Humzah argues for clarity and unity within the medical aesthetics profession The Aesthetics Awards 2014

©2014. All rights reserved. Syneron and the Syneron logo are registered trademarks of Syneron Medical Ltd. and may be Subscribe to Aesthetics, the UK’s leading free-of-charge journal for medical registered in certain jurisdictions. PicoWay and Candela are registered trademarks of the Candela Corporation. PB83214EN Subscribe to Aesthetics aesthetic professionals. Visit aestheticsjournal.com or call 0203 096 1228 The Science of Great Skin

NeoStrata: Scientifically advanced, clinically proven dermatologist developed skincare to target specific patient needs.

NeoStrata professionals: Leading medical aesthetic clinics. Practitioners requiring effective skincare. Building successful business solutions.

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We deliver: Comprehensive training and support. Focussed marketing and PR campaigns. Skincare you and your clients will love:

Meeting the needs of your business, delivering high satisfaction to your patients Call us on 01234 313130 [email protected] www.aestheticsource.com Editor’s letter

August and September represent the start of analysing where you are performing well and where improvements the academic year for many. I am sure with our can and should be made. Our local marketing feature addresses wide range of readers at Aesthetics we will have how important considering your demographic and local competition ages across the board, with parents of four- is in determining your marketing strategy. Is this something that you The Science of Great Skin year-olds starting school for the first time, new are currently assessing and evaluating? Education is king throughout Amanda Cameron secondary schools, right up to those getting our lives so let’s not slow down the momentum in continuing to Editor A-level results and going to university or into strive for better results for our businesses, and for our patients. an apprenticeship or business. We live in a society of continuous Hair is the focus of this month’s journal, and in our special feature NeoStrata: measurement and each measurement leads us to another step in we ask leading practitioners to discuss effective methods for life. But how often do we subject our own businesses and practice treating hair loss. Conversely, laser hair removal specialist Rebecca Scientifically advanced, clinically proven to the same scrutiny? Do we set objectives when we start our Treston gives an overview of the technology and considerations for dermatologist developed skincare businesses? And do we review and evaluate these as we progress, implementing this as a treatment in your clinic. An excellent indication such as at end of year assessments and points of promotion, of our progress and success is commendation through awards to target specific patient needs. growth and expansion? I believe it is crucial to undertake detailed and honours. I’m sure you will all have been eagerly anticipating assessment of where we stand annually, if not more frequently. I am the announcement of the finalists for The Aesthetics Awards 2014, sure all your accountants ask for your accounts on a regular basis which are revealed in this issue. The standard of entries this year NeoStrata professionals: but take this opportunity to review every aspect of your business. was even higher than in previous years and I’d like to congratulate all Aside from complex financial analysis, we should also remember finalists for such a fantastic achievement. Now the voting and judging Leading medical aesthetic clinics. to go back to basics – think about who your customers are, what process will begin to determine the winners and highly commended they need and whether you are fulfilling those needs successfully and commended finalists ready for the ceremony on December 6th Practitioners requiring effective skincare. and effectively. In this issue, Gilly Dickons discusses the statistics in London. Building successful business solutions. that you should be recording and how this can aid your business in Happy reading and best of luck to all the finalists!

Aesthetic Source: Editorial advisory board We are honoured that a number of leading figures from the medical aesthetic community have joined Aesthetics journal’s Multi award winning UK distributor. editorial advisory board to help steer the direction of educational, clinical and business content

World renowned proven skincare options Dr Mike Comins is president and Fellow of the British Dr Raj Acquilla is a cosmetic dermatologist with over 11 years College of Aesthetic Medicine. He is part of the cosmetic experience in facial aesthetic medicine. UK ambassador, global for professional aesthetic clinics. interventions working group, and is on the faculty for the KOL and masterclass trainer in the cosmetic use of botulinum toxin 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, We deliver: 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 Comprehensive training and support. 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 Patel Focussed marketing and PR campaigns. surgeon in the NHS for 15 years, and is currently a member of the is passionate about standards in aesthetic medicine and still British Association of Plastic, Reconstructive and Aesthetic Sur- participates in active learning. Dr Patel gives presentations at Skincare you and your clients will love: geons (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 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 also the founding editor of the Journal of Cosmetic Dermatology based therapies. and has authored numerous scientific papers and studies.

PUBLISHED BY FOLLOW US EDITORIAL ADVERTISING @aestheticsgroup 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 [email protected] [email protected] Aesthetics Suzy Allinson • Associate Publisher Andrew Grant • Administration and Production T: 0207 148 1292 | M: 07500 007 013 T: 0203 096 1228 | [email protected] ARTICLE PDFs AND REPRO [email protected] MARKETING Material may not be reproduced in any form without the Amanda Cameron • Editor Jenna Earl • Marketing Manager publisher’s written permission. For PDF file support please T: 0207 148 1292 M: 07810 758 401 T. 0203 096 1228 contact Craig Christie; [email protected] [email protected] [email protected] Betsan Jones • Journalist Helen Batten • Events Manager © Copyright 2013 Aesthetics. All rights reserved. Aesthetics T: 0207 148 1292 | M: 07741 312 463 T: 0203 096 1228 | [email protected] Journal is published by Synaptiq Ltd, which is registered [email protected] DESIGN as a limited company in England; No 3766240 Chloé Gronow • Journalist Peter Johnson • Senior Designer T: 0207 148 1292 M: 07788 712 615 T: 0203 096 1228 | [email protected] [email protected] Chiara Mariani • Designer Meeting the needs of your business, delivering high satisfaction to your patients DISCLAIMER: The editor and the publishers do not necessarily agree with the views 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. Insider News @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

Industry Talk Aesthetics Allergan file lawsuit against What you’ve been tweeting about this month

Dr David Eccleston /@DavidEccleston Valeant ‘Eartox’. Nothing to do with Botox, but involves Global pharmaceutical company, Allergan, has filed a lawsuit against putting filler in the earlobes to plump them Valeant Pharmaceuticals and Pershing Square Capital accusing them of and reduce sagging, so earrings hang better. insider trading. They claim that Valeant, Pershing Square and its CEO, William

Ackman, violated federal security laws, engaged in fraudulent practices and Pam Underdown / @AestheticGrowth failed to disclose legally required information. Allergan said that they decided Price is never the most important thing to file the lawsuit to, “Ensure that all of its stockholders have the opportunity according to statistics and research. 14% of to make decisions regarding their investment in the company based on buying public only ever buy the cheapest compliant, full and fair disclosures, and to ensure that any stockholders voting

on corporate matters acquired their shares in accordance with the law.” Sharonbennettskin / @sharonbennettuk Between February and April this year, Pershing Square purchased Allergan Learn about bio identical hormone treatment stock and securities, then valued at more than $3.2 billion, from company @BACNurses confs oct 3/4 Brighton. stockholders. Allergan claim that they did so fully aware of Valeant’s non- public takeover intentions – depriving the selling stockholders of value Dr Jenna Burton / @DrbJenna appreciation, worth approximately $1.2 billion, upon Valeant’s initial offer on Natural Vitamin E in avocados, green leafy April 22. Under federal law, it is illegal to buy shares if you have knowledge of veg and vegetable oil will provide much more such a takeover. Allergan said they believe that, “It is important that the rights nutrient than synthetic vitamin E in a tablet of the company’s stockholders not be infringed by the actions of one hedge fund that significantly profited (to the detriment of other stockholders and Dr Raj Acquilla / @RajAcquilla the market) by trading in Allergan securities, while in possession of material Excellent day @RATPMasterclass then dinner non-public information regarding Allergan.” In a joint statement, Valeant and with @aestheticsgroup for our exciting live Pershing Square said, “Allergan’s true purpose in bringing the litigation is an symposium plans #ACE2015 @drtapanp attempt to interfere with shareholders’ efforts to call a special meeting.” They @pdsurgery said this intention was made clear in a separate letter, which noted that bylaws provide that any meeting requests are considered ineffective if the requester Dr Roshini Raj / @DrRoshiniRaj has violated the law. Pershing Square, Allergan’s largest shareholder, had Argula is highly #alkaline, helping your previously called a board meeting with Allergan, in which it was expected that body to regain its pH balance & preventing William Ackman would replace six out of nine Allergan directors. Mr Ackman inflammation, one of the causes of #acne claimed that Allergan is threatened by Valeant’s takeover progress and said, breakouts. “Allergan’s determination to waste money on a baseless lawsuit against its largest shareholder further demonstrates why this board of directors should be Emma Davies / @daviesemma5 removed.” CEO of Valeant, J. Michael Pearson said, “We are disappointed that @aestheticsgroup really impressed with Allergan continues to stand in the way of its shareholders’ right to voice their quality of articles old dogs CAN learn new views on a transaction with Valeant. Despite Allergan’s attempted roadblocks, tricks! we remain committed to pursuing this compelling combination, which will create an unrivalled platform for growth and value creation.” In its complaint, To share your thoughts follow us on Twitter Allergan is seeking a declaration from the court that Pershing Square and @aestheticsgroup, or email us at Valeant violated insider trading and disclosure laws. The company also want [email protected] Pershing Square to revoke the Allergan shares that they claim Mr Ackman acquired illegally.

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1. BEL-DOF3-001_01. 2. Tran C et al. in vivo bio-integration of three Hyaluronic Acid fi llers in human skin: a histological study. +44 (0) 333 200 4140 Dermatology DOI:10.1159/000354384. 3. Taufi g A.Z. et al., J Ästhet Chir 2009 2:29 – 36. 4. Prager W et al. A Prospective, Tel: Split-Face, Randomized, Comparative Study of safety and 12-Month Longevity of Three Formulations of Hyaluronic Acid [email protected] Dermal Filler for Treatment of Nasolabial Folds. Dermatol Surg 2012, 38: 1143 – 1150. 5. Buntrock H, Reuther T, Prager Email: W, Kerscher M. Effi cacy, safety, and patient satisfaction of a monophasic cohesive polydensifi ed matrix versus a biphasic nonanimal stabilized hyaluronic acid fi ller after single injection in nasolabial folds. Dermatol Surg. 2013; 39(7):1097-105. www.belotero.uk.com BEL093/0314/FS Date of preparation: April 2014

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Conference News in Brief

Brand new conference Mesoestetic launches mct injector Mesoestetic Pharma Group has launched the experience unveiled for mct injector, a device uniting mesotherapy and carboxytherapy to allow practitioners to complete ACE 2015 treatment with one device. The mct injector allows for mesotherapy and carboxytherapy to The Aesthetics Conference and Exhibition steering committee have revealed be performed in the same session or alternate exciting details about the innovative educational conference experience sessions, with precise directional lighting to planned for ACE 2015. This cutting-edge conference experience will be aid treatment. The injector is CE marked and tailored for delegates looking to further their practice in medical aesthetics compatible with all needles and syringes. in 2015 and beyond. With a novel format and style representing a first of its kind for our profession, Anti-ageing warming cleanser the main agenda will comprise four highly interactive educational modules. and cooling masque launched by Delegates will be able to choose to attend individual three-hour learning Innovative Skincare experiences or the full two-day programme. Each session will take the form Innovative Skincare has launched two new of a virtual clinic environment, following the patient journey from consultation, anti-ageing skincare products: Warming Honey through live treatment techniques, to post-treatment results and follow-up. Cleanser and Coolmint Revitalizing Masque. Comprising both surgical and non-surgical methodology, the content will be Combining natural honey with papaya enzymes non-promotional and chaired by leading experts, supported by a panel of and green tea extracts, the Warming Honey eminent practitioners in each individual field. The prime Saturday afternoon Cleanser aims to cleanse the skin and protect and Sunday morning sessions will take the form of a two-part injectables its natural ceramide barrier. Innovative Skincare masterclass led by Mr Dalvi Humzah, Dr Raj Acquilla and Dr Tapan Patel.These recommends using the Coolmint Revitalizing two sessions will cover all the essential elements of an injectables masterclass, Masque after cleansing to soothe skin. supported by multiple live video feeds and interactive audience technology and are guaranteed to provide delegates with the very best learning LoveLite launches Lipoglaze Callista experience. Saturday will feature the full remit of pan-facial beautification, cryolipolysis device with injection techniques for specific anatomical areas covered in detail on Lovelite announced the launch of the new Sunday. Surrounding this important injectables masterclass will be sessions Lipoglaze Callista, an extension of its existing covering other key growth areas for the broader, successful practice of cryolipolysis portfolio. The Callista gives medical aesthetics. The Saturday morning session will feature experts covering practitioners the ability to treat two areas simultaneously, and has the option of six attachments, with sizes to treat four different areas.

Athena Cosmetics promotes breast cancer awareness Athena Cosmetics will give 10% of its profits from the sale of each limited edition Revitalash Advanced Eyelash Conditioner to cancer research during the month of October. The company continues its annual Pink Ribbon Promotion to reaffirm its commitment to compassionate business practices, giving a portion of proceeds fat, including weight loss and fat augmentation and reduction, as well as from year-round sales of all products to breast body skin, including treatments for lifting and tightening, cellulite and stretch cancer research. marks. In the final session on Sunday afternoon, delegates will be able to learn more about skin health through presentations related to both pathology and SkinBrands partner with ABC Lasers physiology. A distinguished panel will explore the identification and treatment Partner to distribute CoolTech of dermatological conditions, the latest skin treatments and explanation of SkinBrands @ Cosmeceuticals have partnered cosmeceutical ingredients. In place of traditional lecturn presentations, ACE 2015 with ABC Lasers to distribute cryotherapy has been designed around a programme that utilises exciting new technology treatment, CoolTech. CoolTech is a method of to allow videos and apps to engage and educate delegates through enhanced reducing unwanted subcutaneous fat using demonstration methods and full interaction. Alongside the main conference a controlled cooling system. Tracy Parkin, agenda, the Aesthetics Conference and Exhibition will feature the return of SkinBrands managing director, said, “We the popular Expert Clinic, now running in two parallel sessions, as well as the have partnered with ABC, who are specialists Business Track and sponsored Masterclasses. in laser and RF equipment sales, to provide ACE 2015 will be held on Saturday 7 March and Sunday 8 March at the customers with the highest level of customer Business Design Centre in London. Visit www.aestheticsconference.com to service and support.” find out more details about the conference and exhibition.

Aesthetics | September 2014 7 Insider News @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

Acne Conference PicoSure Focus cleared BACN to hold conference in by FDA for acne scar October

treatment The British Association of Cosmetic Nurses (BACN) annual conference will be held at the Hilton Brighton Metropole, Brighton on October 3 Aesthetic manufacturer Cynosure announced that it has and October 4. The event, called “All Things Bright ‘n’ Beautiful”, will host a received FDA clearance to market PicoSure Focus for variety of speakers discussing the latest aesthetic topics and techniques. On the treatment of acne scars. Friday, speakers include botulinum toxin expert, Professor Andy Pickett and The treatment uses laser technology that claims to chair of the BACN, Sharon Bennett. Saturday will see Dr Raj Acquilla give a revitalise and rid the skin of imperfections in just 30 live demonstration on using Botox and Juvederm Vycross in the periorbital minutes. Where other lasers use a photo-thermal action area, whilst Mr Brian Leatherbarrow will present on periorbital rejuvenation (heat), Picosure Focus’ ultra-short pulse aims to create an for facial ageing. CEO of the BACN, Paul Burgess, said, “The 2014 BACN intense photomechanical impact, known as PressureWave. Conference comes at an exciting and important time for the industry. It will Cynosure claims that this creates shockwaves in the have the usual top class speakers and practitioners making presentations but dermis, generating collagen and elastin and resulting in will also include the launch of the BACN Strategy Plan for the next three years dramatic improvements, without the associated downtime. and lots of exciting news for member services.” Sharon Bennett adds, “It’s As well as being recommended for acne scarring and a fantastic opportunity to meet up with friends from across the UK, network, revitalisation, PicoSure Focus can be used for toning, share and take away some new skills and learning and all that’s needed to texture, wrinkles and fine lines. In 2012 it was granted FDA run a safe, successful aesthetic practice.” Dr Acquilla said, “I am delighted approval for the removal of tattoos and pigmented lesions. to be presenting the Peri-orbital Symposium at the BACN conference, and looking forward to sharing my latest experience and techniques from around Décolletage the world with the UK’s aesthetic nurses.” Julian Popple, marketing manager at Galderma said, “Galderma are delighted to sponsor the BACN conference Ultherapy receives again this year. Over the years the BACN has emerged as one of, if not the, leading aesthetic organisations promoting excellent clinical practice, training FDA clearance for and education throughout the UK.” A dinner dance will be held on the Friday décolletage treatment evening, with wine tasting and a live band. Skin The Ultherapy Décolletage Treatment has become the first non-invasive procedure to be specifically indicated by the Aesthetic Source launches FDA to treat lines and wrinkles on the décolleté. The Ulthera system is an ultrasound platform device, The Skin Fitness Roadshow previously cleared to lift the neck, brow and beneath the chin. The treatment purports to stimulate the natural production of Aesthetic Source is launching an educational workshop series to support collagen and elastin in the skin to gradually smooth wrinkles, aesthetic practices. Led by Lorna Bowes and a team of experienced with results visible at around three months post treatment. trainers, the one-day Skin Fitness workshops will be held at locations Matthew E. Likens, president and CEO of Ulthera, said, “Now, across the UK in the autumn and spring of 2015. The sessions will cover skin the Ultherapy Treatment addresses four total treatment areas physiology, extrinsic and intrinsic skin ageing processes, typical skin concerns – from the brow to the chest – making it apparent that our such as photodamage and hyperpigmentation, and treatment options for investment in clinical advancements and dedication to R&D is improving skin health using cosmeceutical and nutraceutical options. The Skin producing results for our customers.” Fitness workshops will be supported by published clinical data.

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Business Vital Statistics Medisico Aesthetic Medicine Non-invasive procedures launches Body Face Couture in Glasgow are estimated to be worth £10 million by This month sees the launch of Body Face Couture, a new aesthetic the end of 2014 Azimuth Healthcare Solutions business model for UK clinics launched by Medisico Aesthetic Medicine, a subsidiary of Medisico PLC. The model offers Body Face Couture branded aesthetic treatments, all based on radiofrequency and laser light technologies, whilst allowing clinics to maintain their own identity. Patients are able to choose their treatments via the Body Face Couture website, which then directs patients to their nearest clinic. The Body Face Couture brand is directly responsible for standards and patient satisfaction, including the management of sales and marketing. All Body Face Couture treatment equipment includes a three-year warranty, and Facial scarring due to acne clinics are required to undergo a rigorous accreditation process, including aff ects up to 20% of people. a financial and clinical assessment, as well as an assessment of each BBC health news clinic’s approach and values.

Microneedling Normal hair loss is Lutronic launches new considered to be 100 hairs per day tip for Infini The Belgravia Centre

Lutronic has announced the The psoriasis therapeutic market... launch of a new ...was worth ...and is forecast 16 microneedle $3.6 billion to grow to $6.7 tip for its Infini in 2010... billion by 2018 radiofrequency Global Data microneedle system, which it claims will offer more precise treatment for smaller areas, such as the peri-orbital region, as well as being less expensive than the standard 49 microneedle version. 11,874,937 Infini claims to work faster than competing systems by eliminating damage nonsurgical aesthetic procedures to the surface of the skin and delivering RF energy directly to the dermis. were performed worldwide in 2013. ISAPS Its proponents insist that Infini produces reliable results with reduced downtime when compared with similar devices. In 2013, 87.2% Journal of people undergoing cosmetic procedures Dr Tapan Patel joins the globally were women. Aesthetics editorial board ISAP

Dr Tapan Patel this month joins the Aesthetics journal Editorial Advisory In 2014 there will Board. Founder and medical director of VIVA and PHI Clinic, Dr Patel brings be an estimated over 14 years of clinical experience to the role, and joins seven other leading 139,870 new cases of figures from within the aesthetics profession. melanoma in America American Academy of Dermatologyv “Having worked closely with the Aesthetics editorial team on numerous occasions in the past I am extremely pleased to be joining the journal’s editorial advisory board,” said Dr Patel. “I hope my contribution will aid the journal to continue to thrive and flourish and maintain an editorial ethos The global acne market which is now firmly grounded in science and education. In addition to my is estimated to reach work on the journal, I will also continue to hold my position on the Aesthetics revenues of $3.02 Conference and Exhibition (ACE) steering committee. This work sees billion by 2016. Research and Markets exciting plans already in place to ensure next year’s conference is a truly cutting edge presentation of the very latest developments in aesthetics.”

Aesthetics | September 2014 9 Insider News @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

Accreditation Gynaecology First clinic receives New academy launches for accreditation as Save laser gynaecology techniques

Face register prepares A new academy has been launched to promote the use of minimally- invasive laser techniques to treat gynaecological problems. to launch The British Academy of Laser Gynaecology (BALG) will provide its members with education and training in the techniques, which have been A Buckinghamshire clinic, developed by Fotona Lasers, and claim to offer rapid, pain-free treatment Appearance Based Medicine, for issues such as stress incontinence, vaginal laxity and vaginal atrophy. has become the first clinic to Kevin Rendell, director of Beehive Solutions Ltd, UK distributor for Fotona receive accreditation from the Lasers, described the new Academy as a “unique patient information newly launched Save Face centre and key learning facility for laser professionals looking to offer initiative. Save Face launched the best treatment”. He said, “For too long, because the old treatments in June in response to the Keogh Review, and claims to be were aggressive and painful, women have suffered in silence with these the first register of its kind in the UK aesthetics industry, with debilitating and often embarrassing conditions. Now there is a treatment every applicant being rigorously checked and interviewed option that gives long term, pain free, relief.” before receiving accreditation. The register of accredited practitioners from across Great Britain will go live at the end Rosacea of August, with application only open to registered doctors, dentists and nurses who can demonstrate that they are Act on Red campaign insured and have received certified training. Appearance Based Medicine, which has been open since 2004, is run by supports Rosacea sufferers Clare McLoughlin RGN INP. Clare said: “Save Face is filling a huge gap in the non-invasive cosmetic treatment market. A rosacea awareness programme, Act on Red, has launched For years, the industry has desperately needed some form of alongside new research that assesses the effect the condition has regulation and guidance. We are an independent clinic and so on sufferers. The data from Face Values: Global Perceptions Survey, it was refreshing to see Save Face working with us to ensure demonstrated that nearly two thirds (62%) of people with facial redness our policies and procedures are up to the highest standards.” agreed it embarrasses them and nearly half (46%) believe their rosacea “We are very proud to be the first clinic to be accredited. I changes others’ perception of them. The survey also found that rosacea know that many more have already followed our example and affects 77% of people emotionally, 67% socially, 63% at work and 53% in that’s a very positive move for the industry.” Ashton Honeyball, their relationships/dating behaviour. director at Save Face Ltd, said, “We’ve had a phenomenal In addition, researchers analysed how other people perceived rosacea response to the register. It demonstrates the very real need sufferers. They found that they were judged to be less intelligent, there was for accreditation in this market. When the register reliable, successful and trustworthy compared to people without goes live later this month, it will provide patients with a new- redness. They were also more likely to be perceived as sick, tired, found confidence in the non-surgical cosmetics industry. They unhealthy and stressed, as well as less likely to be in a relationship or know that every practitioner on the register is experienced professional job. and has had their qualifications checked, had their premises These results align with psychological studies that show a single glance inspected and operates to the highest standards. It is of a face is enough for people to make automatic judgements. becoming a new benchmark for the industry. We’re delighted Act on Red, supported by Galderma, aims to provide information, with the positive response and the willingness from the educational resources and where to get to help to people affected by industry to demonstrate their professionalism.” facial redness associated with rosacea.

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Mob: +353 (0)85 711 7166 | Tel: +353 (0)1 676 9810 Email: [email protected] | Skype: ivanlawlor Web: www.adareaesthetics.com Insider @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com News

Data Spire Liverpool Hospital offers warning to patients as numbers Andrew60 Morris, country operations travelling abroad for surgery soar director of Sinclair Is Pharma Why has Sinclair Pharma A study by private healthcare search engine WhatClinic.com has revealed that the chosen to make acquisitions number of patients choosing to undergo cosmetic surgery abroad has more than recently? doubled in the past two years. Sinclair Pharma’s long-term Cheap air fares and lower surgery costs seem to be fuelling the rise in medical objective is to become a first tier tourism, with Eastern Europe seeing the biggest influx – there has been a 304% player in aesthetic dermatology; we now have a increase in nose job enquiries in the Czech Republic in the past year, with Poland portfolio range built around the market’s needs, experiencing a 57% rise in those looking for breast enlargements. both now and in the future. In light of this, surgeons from Spire Liverpool Hospital have issued a warning to How does this affect your position within the the public about the dangers of travelling abroad. Spire plastic surgeon, Mr Azhar marketplace? Iqbal, said, “It is clear from these figures that medical and cosmetic surgery tourism We have a unique position with a complimentary is on the rise. Cosmetic surgery like any other surgery requires post-operative product range which is focused on various follow up, the frequency of which can vary on individual basis.” forms of collagen stimulation, including Sculptra, He added, “Many places have different regulations to the UK. Standards and providing gradual collagen stimulation, and safety procedures vary dramatically depending on where you go so research and Ellansé, for immediate and longer-term bio planning is vital.” Mr Iqbal explained that another common problem with patients stimulation. Silhouette’s unique patented travelling overseas for their surgery is that recovery time can often be lengthy. products (Silhouette Lift® and Silhouette Soft®) are “Realistically you would have to remain abroad until you were fully recovered. It is resorbable collagen-stimulating cones on sutures important to ask about aftercare plans and what happens if something goes wrong (‘threads’) which offer a minimally invasive facelift. during, or after, the procedure,” he said. The acquisition of Silhouette offers an exciting opportunity to launch several new indications for He noted that is was also important to remember that the NHS will only cover the body currently unserved by injected fillers, and medical emergencies and will not cater for cosmetic needs. Ellansé offers longer-term solutions for the hands, deep and sub dermal soft tissue augmentation Plasma of the facial area. These products sit alongside a strong offering in the HA filler segment, with Plexr launched in the UK Perfectha™, an ideal complement to our collagen stimulators in the rapidly growing dermal filler Aesthetics distributor Fusion Gt has launched a new non-invasive lifting device market, adding a complete hyaluronic acid (“HA”) in the UK. According to Fusion GT, Plexr can perform all types of non-ablative filler range to our portfolio. Marketed as a ‘soft surgery without risk to either the practitioner or patient. What benefits does this bring to surgery device’, Plexr uses the ionisation of the gases in the air, forming plasma, practitioners and patients? which creates a small electrical arc that treats problem areas – without spreading Sinclair Pharma’s comprehensive product range unwanted heat to the surrounding skin. Plexr is a wireless device, described by the enables us to become the business partner of manufacturers as ergonomic. Plexr can be used for numerous aesthetic concerns, for choice for the clinic. The products in our range face and body lifting, treating acne and scarring, and to perform blepharoplasty. After offer the patient the most comprehensive and initial success in Italy, Fusion Gt are now launching the product in the UK along with natural-looking solution to anti-ageing. They also free training courses for practitioners. The next course will take place in October. provide the most cost effective solution in terms of longevity of results.

Botulinum toxin What does the future hold for Sinclair? We believe the future of the market is based Botulinum toxin tops non- around natural anti-ageing through collagen stimulation, and Sinclair Pharma now have invasive procedure ranking the products and organisation to support this growth. The recent build-out of our aesthetics A report published by the International Society of Aesthetic Plastic Surgery (ISAPS) business significantly enhances Sinclair’s has shown that botulinum toxin still tops the rankings of non-invasive aesthetic technological position and growth prospects in collagen stimulation. Our enlarged aesthetics procedures around the world, with 5,145,189 injections having been carried out portfolio provides us with the platform to worldwide in 2013. Fillers came next on the list, with 3,089,686 procedures in 2013, outperform this fast growth market. We expect and laser hair removal (1,440,252) was third. America still leads the way with the to benefit in the near and most cosmetic surgical and non-surgical procedures performed – 3,996,631 in total. long term from accelerating However, Brazil has overtaken the United States this year for the first time ever in growth and significant terms of the number of cosmetic surgical procedures performed – 1,491,721 surgeries operating leverage. in Brazil last year compared to 1,452,356 in America.

Aesthetics | September 2014 11 Insider News @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

Events diary Topical

12th - 13th September 2014 HealthXchange launches F.A.C.E.2f@ce Conference, Cannes Obagi360 www.face2facecongress.com/en HealthXchange Pharmacy, the 20th September 2014 UK distributor of Obagi Medical, British College of Aesthetic Medicine - has launched the Obagi360 BCAM Conference 2014, London range. Aimed at a younger www.bcam.ac.uk market, Obagi360 has been designed to encourage the idea that prevention is better than cure th th 25 - 26 September 2014 when it comes to the signs of The British Association of Aesthetic Plastic ageing. The range contains three Surgeons - BAAPS Meeting 2014, London products: Exfoliating Cleanser, www.me .baaps.org.uk Retinol 0.5% and HydraFactor, a daily moisturiser containing broad-spectrum SPF protection. One key point 3rd-4th October 2014 of difference with Obagi360 is that the products contain entrapped polypore British Association of Cosmetic Nurses - retinol technology, which it’s claimed releases retinol 0.5% slowly into the skin to tone and refine texture. BACN Meeting 2014, London www.cosmeticnurses.org Psoriasis 6th December 2014 Trial results positive for new The Aesthetics Awards 2014, London www.aestheticsawards.com psoriasis treatment

7th - 8th March 2015 Research published in the New England Journal of Medicine has shown The Aesthetics Conference and Exhibition that injections of the antibody secukinumab could significantly improve the symptoms of psoriasis. The study, which was funded by Novartis and headed 2015, London up by Dr Richard Langley, professor of medicine at Dalhousie Medical School, www.aestheticsconference.com Halifax, involved more than 2,000 patients at 200 sites across the world. In two separate trials, patients with moderate to severe psoriasis were injected with Landmark a subcutaneous dose of secukinumab (either 300 mg or 150mg) once weekly for 5 weeks, then every four weeks thereafter, for 52 weeks. In both trials, Lynton celebrates 20 around 80% of patients showed a 75% reduction in skin lesions associated with psoriasis. A quarter displayed no sign of the disease after 12 weeks of treatment. years in aesthetics and Dermatologists with no connection to the study have said that it is good news for psoriasis sufferers. Langley said it is likely that patients will need monthly injections prepares to launch the of the antibody over the long term to control their symptoms. “We’re not curing the ProMax Plus disease,” he said. “We’re simply halting its progression in some cases.” Pollution Lynton Lasers marked 20 years in the UK aesthetics industry Study shows Clarisonic more at its annual conference, held at the Didsbury Hotel in effective than manual cleansing Manchester. Jonathon Exley, managing director at Lynton for removing external pollutants Lasers, commented: “As we have a nationwide based team, it’s always great to L’Oreal has published the results of a study into pollution and its effects get together and discuss new ideas for the future, on the skin, which it claims show that atmospheric pollution can have a and this year, reflect on 20 years within the aesthetic significant impact on hydration, oiliness and desquamation. technologies market.” The study was carried out as part of a promotional campaign for the One new launch being discussed at the conference Clarisonic cleansing device to investigate the cleansing efficacy of was the ProMax Plus, due to be unveiled in October. Clarisonic compared to manual cleansing, at removing small particulate Marketed as “the instant facelift”, ProMax Plus is a matter and cleansing dirt, sebum and oil trapping pollutants. According to radiofrequency skin tightening and wrinkle reduction L’Oreal, results show that Clarisonic is 30 times more effective than manual treatment, designed for use on the face and neck. cleansing.

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Botulinum toxin Skin Research conducted into Study links smell with skin the role of botulinum healing

toxin in fighting cancer A recent study, published in the Journal of Investigative Dermatology, explores the effect of specific synthetic sandalwood Botulinum toxin may have a role in the treatment of stomach oil on the process of wound healing and skin regeneration. ‘A cancer, according to recent research on animals. Scientists Synthetic Sandalwood Odorant Induces Wound-Healing Processes at the Columbia University Medical Centre, New York, and the in Human Keratinocytes via the Olfactory Receptor OR2AT4’, led Norwegian University of Science and Technology in Trondheim, by cell physiologist Dr Hanns Hatt at the Ruhr University Bochum in looked at the important role of nerves in tumorigenesis. In a study Germany, looks at the link between olfactory receptors and wound published in Science Translational Medicine, nerves connected healing. The authors report the identification of ORs as a “novel to tumours were silenced in mice models of gastric cancer, type of chemoreceptors in human keratinocytes”. After cloning the either with surgery or via local injection of botulinum toxin. In the cutaneous OR – OR2AT4 – the study recognised Sandalore (a synthetic study, the authors describe the method as working to “markedly sandalwood oil sold commercially) as the most potent in activating reduced tumour incidence and progression, but only in the targeted OR. In a Dermatology Times article, Dr Hatt reflected on the denervated portion of the stomach.” Experts have warned that this findings: “Perhaps we will be able to add a sandalwood oil odorant research is still in early stages, and cannot yet be considered a to a topical cream to make wounds heal faster,” he said, “or use it to treatment for patients. regenerate aging skin.”

Laser Awards Cynosure launches Allergan receives three Prix RevLite to UK market Galien nomination

Cynosure’s RevLite Q-switched Nd:YAG laser has launched in Allergan research and development department has been recognised the UK, claiming to be the new market leader for skin lightening with three nominations for the 2014 US Prix Galien Awards. The and the treatment of pigmented lesions, such as birth marks Prix Galien Awards acknowledge excellence within the biomedical and freckles. RevLite uses pulsed beams of light and Cynosure’s industry, recognising the technical, scientific and clinical research skills proprietary PhotoAcoustic technology to shatter dark pigment, necessary to develop innovative medicines and devices. The Allergan with reportedly minimal damage to the outer layers of the skin, as products nominated are: BOTOX for Migraines (Best Biotechnology compared to more traditional photothermal treatments. Product nominee); OZURDEX (Best Pharmaceutical Agent nominee) “This treatment is a newcomer to the market,” said Dr Maria and SERI Surgical Scaffold (Best Medical Technology nominee). “For Gonzalez, of The Specialist Skin Clinic in Cardiff. “Even though more than 64 years, Allergan has remained committed to developing I have a CO2 laser I believe the RevLite treatment provides a innovative products to address unmet medical needs,” said David E.I. superior result with less pain and less downtime. It is also much Pyott, Allergan’s Chairman and chief executive officer. “We are proud safer in patients with pigmented skin in whom we do a less to be recognised for our R&D efforts by the Prix Galien Committee and aggressive treatment known as ‘laser toning’, providing safe and especially honoured to be the only company to receive nominations in effective rejuvenation and improvement in pigmentation.” all three of the 2014 Prix Galien Award categories.”

Topical NeoStrata launch Skin Active Triple Firming Neck Cream

NeoStrata has launched a new neck cream to add to its Skin Active line of advanced anti-ageing skincare products. Skin Active Triple Firming Neck Cream is formulated with NeoStrata’s proprietory active ingredients NeoGlucosamine and NeoCitriate, as well as pro-amino acid and swiss apple stem cell extract, and aims to address the three main issues associated with ageing – loss of elasticity, wrinkles and pigmentation. Dermatologist Dr Sandeep Cliff says, “NeoStrata Skin Active Triple Firming Neck Cream is an essential skincare product to improve the look and appearance of the neck and décolletage areas which can be tricky to treat. With growing awareness of premature ageing skin caused by sun damage, my patients lavish care on their faces but more often than not, tend to overlook their necks and décolletage. As we age, we produce less collagen and pigmentation becomes more mottled resulting in sagging, discoloured skin. Skin Active Triple Firming Neck Cream helps rebuild the skin’s matrix, encouraging the production of collagen and hyaluronic acid to improve skin health and quality.”

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With the news that the FDA have released draft botulinum toxin online,2 but as Medical PR Tingy guidelines for pharmaceutical companies Simoes notes, “Social media in our sector is still in its infancy. It’s skyrocketing in popularity but still used using character and space-limited social media clumsily. Reputations can be badly damaged at the sites, Aesthetics investigates how the UK is click of a button.” responding to these changes An MHRA spokesperson explains that the MHRA operate a targeted approach to action on clinics, Using social media in aesthetics and other services, offering treatments involving botulinum toxin products and other POMs. This In 2013, allegedly incorrect focus however, is primarily on the home pages advertising of prescription only of clinic websites, and not on Twitter posts or ESSENTIAL medicines (POMs) via social sponsored links. With Twitter, along with other social media accounted for more than networking sites, being increasingly used as a 10% of complaints received by promotional platform, the character space limitations the Medicines and Healthcare it encompasses can make it difficult to know how to ANTI AGEING products Regulatory Agency use it effectively, and most importantly, legally. (MHRA) in the UK.1 Aesthetic doctor, Dr Sarah Tonks, acknowledges Responsible for monitoring online these challenges for clinics, and suggests a potential medical advertising, the MHRA’s alternative to Twitter. “Google+ is underused,” she PROTECTION & annual report recorded 283 says, “But it provides plenty of character space.” complaints, and, consistent with Most importantly, she says, there is room to post previous years, a high proportion any potential risks or side effects the medicine of these complaints related may have. The APBI Code of Practice states that PREVENTION to the advertising of botulinum toxin to the public. Despite the MHRA setting when pharmaceutical companies discuss POMs stringent guidelines for digital communications in general, 2013 saw an increase online, only factual and balanced information must of complaints about advertising on social media, as well as the first complaint be distributed. The PMCPA published informal Medigrade skincare management relating to advertising via Twitter. 1 guidance last year on these digital communications of the complete spectrum of daily Meanwhile in the US, the Food and Drugs Administration (FDA) recognised for the pharmaceutical industry, including a section communication problems with character space limitations on social media sites specifically on social media.3 skin-ageing challenges and internet platforms by releasing draft guidelines. Suggestions include that the In their new draft guidelines, the FDA has suggested prominence of risk information should be comparable to the benefit information the use of hyperlinks to allow direct access to a more PROTECTS featured within each individual character-space-limited communication. An FDA complete discussion of risk information about the A unique combination of clinically researched filters protect against the spokesperson, says, “Character-space-limited internet or social media platforms product in question. AJ Barroso, digital marketing complete spectrum of environmental challenges that we face all year may pose challenges for firms in providing a balanced presentation of both risks manager at digital healthcare agency emotive, round – UVA, UVB, IR-A and visible light and benefits of medical products. This draft guidance aims to aid the industry in says, “The way people access information on the PREVENTS effectively communicating benefit and risk information in product promotion.” web is constantly evolving, and the suggestion to Based in the US, global aesthetics industry consultant Wendy Lewis believes incorporate the use of hyperlinks is a good first step. Powerful prevention of ROS / free radical the guidelines will encourage pharmaceutical companies to embrace social However, more can be done to govern the use damage with Fernblock® FC, a natural, patented, clinically proven skin anti-oxidant media, who have until now, been hesitant to engage online because of unclear of social media in this industry. This could include guidelines. She says, “Some companies have taken a one-way approach to greater moderation of social content by governing REPAIRS social; they have a presence, as in a page or a Twitter account, but do not bodies, and even the development of a tweeting Helps prevent the effects of skin cell DNA engage, share, respond to, or otherwise interact, with the general public. Clearly template to aid clarity and consistency in the damage with evidence-based DNA repair enzymes this defies the very essence of what social is all about.” messages published.” Acknowledging the new guidelines, an MHRA CARES UK guidelines relating to the use of social media and digital advertising in the spokesperson said, “We have recently laid Silky, smooth, moisturising, every-day use health and aesthetic industry are supplied by the MHRA, Association of the regulations to amend the law to permit companies skin-loving formulations British Pharmaceutical Industry (ABPI) and the Prescription Medicines Code to include a link to the summary of product of Practice Authority (PMCPA). However the use of social media for aesthetics characteristics, in place of the prescribing information is further complicated by the fact that some aesthetic companies will not be currently required.” governed by the ABPI, depending on whether they supply prescription only He added, “We will continue to investigate complaints medicines POMs, and so companies need to address whether these rules of received and take action where a potential breach of practice apply to them. Worry lies in the misrepresentation of POMs on social the legislation is identified.” media. Advertising POMs to the public is prohibited in accordance with the ASK US ABOUT CPD CERTIFIED TRAINING WORKSHOPS REFERENCES The skin; anatomy & physiology, functions & mechanisms, WORKSHOPS Human Medicines Regulations 2012, and, as the MHRA report demonstrates, 1. MHRA, Delivering High Standards in Medicines Advertising Regulation botulinum toxin is of paramount concern for the aesthetics industry. Publicising (MHRA, 2013) Evidence-based skincare ingredients and products ACROSS THE UK POMs is subject to the ABPI Code of Practice, administered by the PMCPA, 2. CAP, Advice and Training (London, CAP, 2014) 0800 0195 322 heliocare.aestheticare.co.uk [email protected] @aestheticareuk facebook.com/aestheticareuk Aesthetics | September 2014 17

© AesthetiCare® 2014 6730/08.14

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Aesthetics worldwide Dr Raj Acquilla’s work as injectables teacher, global key opinion leader and international mentor takes him across the globe. We speak to him about aesthetic themes worldwide

Tell us about your recent international of the world, such as the popularity of of 3500 with four live interactive feeds experiences. lip and cheek enhancement in Europe showing cadaver dissection, anatomy and RA: Over the past three months I have & USA, nasal contouring in the Middle physiology slide deck, podium and of course presented at congress and Masterclass East, body reshaping in South America live injection (which had six camera angles). tours in Europe, the Middle East, Singapore, and skin lightening in the Indian sub- The engagement and feedback from such a Hong Kong, Australia, New Zealand and the continent. Different territories tend to base large audience was amazing, and confirmed USA. Each continent or country possesses their aesthetic ideal around popular local that the visual component of a congress a unique aesthetic ideal and market, trends eg. Asian skin tends to be of very now plays a huge role in the delivery of clear which makes delivering medical aesthetic good quality and resistant to ageing, so educational messages. education extremely challenging and the demand in Japan, Korea & China is rewarding. usually for structural augmentation such What was the most exciting as forehead, brow, eyelids, nose, chin and presentation or demonstration that you What have been your favourite jawline. saw? countries? RA: Definitely the guru of beautification RA: I have worked in Australia four times What experience do you bring home Dr Arthur Swift performing a live pan-facial now and find the AUS/NZ market very to your UK clinic after attending beautiPHIcation when we worked together exciting. They are where we were 10 years international conferences? in Brisbane. Live injection in front of a large ago but with high levels of regulation, RA: The sharing of knowledge and audience is always challenging but he which drives quality and excellence. techniques amongst peers is a great delivered something truly exquisite and Furthermore, they have experienced huge feature of our industry and I am fortunate impactful whilst remaining gentle, precise economic growth in recent years, which to be able to work with, and learn from, and with an honest desire to share with has accelerated their industry and appetite the best in our profession at these humility. for knowledge and success. I really see international events. This certainly helps Asia Pacific as being an area of significant me to treat my patients with a holistic and Where are you planning to teach next? growth over the next 5-10 years. balanced approach. What’s more the UK, RA: I’m off to present at AMWC Brazil and particularly London, is a global melting next week, then DASIL / Cosmedica South What are the themes that have pot of genotypes, therefore the clinical Africa, Spain, Singapore, Russia, Turkey, emerged over the course of recent presentation and their aesthetic needs Colombia and India. I will be bringing global congresses? can be complex. I apply my experience in my experience back to the UK for a RA: The past 3-5 years has been the most injecting patients of different geographic Masterclass series, the CCR Expo, BCAM exciting time in the global industry. Now we origins to achieve optimum beauty whilst and the BACN conferences. We also have know more about facial anatomy, ageing respecting ethnicity and regional aesthetic very exciting plans for an impressive live and injection technique than ever before. I ideals. injection symposium at ACE 2015, which see each continent embracing a culture of will encompass the latest knowledge and re-education and application of the latest How have congresses differed in their injection techniques with cutting edge AV approaches to help grow their individual format, presentation and technology? delivery. practices and overall domestic market. RA: The modern cosmetic medical congress usually encompasses the latest How do you follow up with the Have different trends been highlighted in audiovisual (AV) technology to make international audiences you teach? in specific regions? for a highly engaging interactive learning RA: Sometimes I won’t visit the same country RA: Yes! This is what makes my work so experience. The most impressive show I again for over a year so it’s difficult to offer interesting. There seems to be a unique participated in was in Melbourne, where we mentorship and continue to give educational aesthetic model favoured in each region had an IMAX-style screen for an audience support to the delegates. My colleagues in this country will offer local training to follow up their progress and I often welcome international trainees to my clinic in the UK for internships or Masterclasses. I recently launched an online academy, which allows delegates to view injection techniques as a series of webinars, to use as a supportive tool. This form of remote education has been Ageing of the Asian face compared to the Caucasian model very well received around the world.

18 Aesthetics | September 2014 n

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person has. There’s an obvious relationship between general health and hair loss, so I look to see if there are any underlying problems. If so, I advise that these are addressed before treatment starts. I also ask about any family history. Then I examine the patient and ask about any earlier treatments and whether these made any difference.” Dr Knoll, who sees around 20 patients a week, explains the protocol of mesotherapy treatment to her patients and details the ingredients. She checks for severe autoimmune disease and whether patients have allergies to the ingredients or signs of infection on the scalp. She also takes photographs for comparative purposes. She explains, “First we do an examination and take a medical history – we need to know what kind of treatment has been carried out before. We also need to know if there has been a laboratory check and everything Hair loss treatments is okay with the blood and hormones. We clean the skin and give a mixture of specific According to the NHS, male-pattern baldness bio revitalisers that are composed for mesotherapy.” (androgenic or androgenetic alopecia) affects half CEO of Dermagenica Dr Gabriela Mercik, of all men by the time they turn 50, whilst female- who typically uses the Dermaheal HL hair pattern baldness affects an estimated eight million growth programme containing nano-peptides before hair transplants, to improve hair women in the UK. David Jacobs asks practitioners condition, establishes the pattern and type how to best treat these patients. of hair loss, the level of vitamin D and the patient’s genome to diagnose the problem. Dr Sherif Wakil, a cosmetic doctor and hair surgeon at the Wimpole Clinic, as awareness transplant surgeon at the Royale Skin Clinic, of new procedures has grown, so too has Mesotherapy treatment says the number of patients attending his public confidence. This, he believes, has not First described by the physician Michael clinic for hair loss therapies is increasing. only encouraged more patients to visit clinics, Pistor, mesotherapy is an injection treatment “Over the past 10 years, hair loss treatment but has also prompted more clinics to open. that nourishes layers of the skin where has grown dramatically. The recession meant there is cell repair and growth. Treatment a lot of redundancies, and men in their late The initial consultation is primarily carried out on the top of the 40s or 50s or even 30s [with hair loss] look Dr Wakil, whose treatment of choice is head and only works if the hair bulbs are much older than their age. These people PRP and AQ growth factor, explains his still alive. Compared to other techniques, have found themselves competing with a approach: “I undertake a hair analysis and Dr Knoll finds that the main advantage of younger generation who have hair on top a full history. I examine the patient’s hair mesotherapy is that it is a gentle treatment, of their head and skin that looks better. At under a microscope and a special camera. involving little pain. “We very rarely see a disadvantage, these guys started having This gives an indication of how many hairs a any side-effects. Patients may have some Botox and fillers, and Platelet Rich Plasma patient has per square centimetre, and their bruising or itching, and if there are only a (PRP) injections for hair loss.” hair loss. Then I test the hair at the back of few hairs left they must take care not to Dr Wakil suggests that there may be another the head and check the health of the scalp go out in the sun – micro-injection points reason for the increase in demand. “In the to see if there’s dandruff or other problems, create hyper-pigmentation when in contact past, people depended on shampoos or such as psoriasis. with the sun. Patients have to cover their moisturisers. But numbers have increased “The history is very important, it gives an heads and wash their hair before they come because patients understand that other indication about the type of alopecia the for treatment but then avoid washing or treatments are now available, both surgical and non-surgical.” A similar explanation is offered by Dr Britta Knoll, president of the German Society of Mesotherapy, “There’s growing interest because of more information regarding the possibility of treating these forms of hair loss with mesotherapy,” she says. According to Mr Michael May, a specialist Treating hair loss with mesotherapy. Images courtesy of Dr Britta Knoll

Aesthetics | September 2014 21

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not only benefits the patient but also the practitioner, since you don’t have to buy expensive equipment and lasers. In my opinion, because the market changes so quickly, it’s best to invest in a product with Our NEW training will help a proven track record in order to minimise your risk.” put a smile on your face Hair transplant surgery As Dr Wakil explains, “Sometimes hair transplant surgery is a must if a practitioner Treatment with Dermaheal HL. Images courtesy of Dr Gabriela Mercik is to meet a patient’s expectation. However, ® SILHOUETTE SOFT is the latest colouring for three days after.” is a simple non-surgical treatment even in these cases, improving the quality or innovative thread technology Dr Knoll explains that the treatment comprising a series of shallow injections prolonging the life of existing hair with other protocol is once a week for six weeks in the scalp that, according to Dr Mercik, non-surgical treatments can help, meaning a which both lifts and regenerates and then monthly. Although a long-term can be repeated for several trials without shorter hair transplant session.” treatment, individual sessions take less adverse effects or complications. “The According to transplant surgeon Mr May, • Immediate natural lift: than five minutes, making it convenient for two-pronged approach of stopping hair the current situation is positive. “We’ve been - Progressive restoration of collagen most people. Whilst the long-term nature loss and stimulating hair growth makes through some fairly tough times but things of the therapy might put some patients off, it a complete”, she says. She describes seem to be getting a bit better now,” he says. - Entirely re-absorbable component Dr Knoll has found it produces very good it as, “A treatment that can be performed Typically seeing seven or eight cases a week, - No incision results that regenerate the hair scalp and before hair transplants to improve hair he believes that the success of the procedure fight against the atrophy of the hair bulb; condition and wound healing; it shortens is due to the fact that people believe it is a • 30 minute procedure with long lasting she encourages her patients to follow the downtime after transplants. It can worthwhile procedure to undergo. effect for up to 18 months through with the procedure, saying that also be used for women with greasy hair Mr May uses two extraction methods and 80-90% of those she sees are happy with because the treatment improves the pH advises each patient what would be best: • FDA submitted. CE marked the results. of the scalp. Furthermore, Dermaheal either Follicular Unit Extraction (FUE), where With many mesotherapy products on the blocks the conversion of testosterone to a group of two or three hairs are taken out • NEW comprehensive training workshops market, Dr Knoll and others are clear that dihydrotestosterone (DHT) in the scalp individually using a small 1mm punch, or practitioners looking to use them should and delays the process from anagen (hair Follicular Unit Transplantation (FUT), where find a good manufacturer, a good product growth) to catagen (cessation of growth).” a narrow strip is taken from the back of to inject and use the right technique. But, as The procedure is supported by the use the head. From a patient’s point of view, a note of caution, Dr Wakil advises patients of shampoo and conditioners that contain although it is more expensive, FUE offers the and practitioners to be careful what they nano-peptides. In the first month there advantage of no downtime and no scarring use, emphasising, “Not everything does is a set of weekly injections followed by at the back of the head, although there are exactly what it says…” three bi-weekly sets of injections. A top-up often little marks and scabs where each graft Workshops running from September 2014 Dr Knoll explains that she finds Toskani of one set of injections is recommended is placed and, as with any minor surgery, and open to aesthetic physicians, products produce the best results. after six months although, according to there can be some bleeding. As there’s no However, she adds, “There are other Dr Mercik, “One course of treatment will long-term scarring, Mr May feels it is often dermatologists and cosmetic surgeons: products on the market – some generally improve the patient’s hair to the most suitable procedure for younger - Full day training practitioners undertake the treatment with the desired extent.” She explains, “The men who may want a short haircut or to - World class expert PRP, which has good results too – but in my injection protocol is based on findings that shave their scalps. trainers opinion there is more preparation work. By suggest specialised nano-peptides act as Patients undergoing FUE have a large contrast, mesotherapy is quicker and very growth factors in the applied areas and numbers of grafts, around 2,500, and this - Live model demo - effective. The first results may be after three this counteracts the gradual reduction of can take as long as seven or eight hours. gain hands-on or four treatments; initially patients may see endogenous growth factors.” Whilst not a complicated procedure, Mr May less hair loss, then after around two months Asked what advice she would offer other explains, “Every member of the team has to experience new hair appears. Initially small or weak, by practitioners, Dr Mercik counsels, “The best be meticulous in their contribution, so it does - Includes one box of the next month they will be stronger and treatment is the least invasive. Simplicity take time.” But it’s usually worth it: “Results threads thicker with good volume.” Asked if there are there any patients “SILHOUETTE ENHANCED unsuited for the procedure, Dr Britta THE CONTOURS OF MY FACE E-mail: silhouettetraining explains, “In the case of total hair loss in males the alternative is a hair transplant. AND PUT A SMILE UPON IT” @sinclairpharma.com In patients with total or sub-total hair loss for dates, booking and more caused by alopecia areata that’s very Valérie Kaprisky Bidirectional resorbable suture difficult to treat, we do a natural holistic French Actress with cones without incision information treatment for the immune system to try to for face and neck get it functioning normally.” Another mesotherapy solution, Dermaheal Hair transplant surgery. Images courtesy of Mr Michael May www.silhouette-soft.com Date of preparation: August 2014 UK/SIPGEN/14/0001 Aesthetics | September 2014 23 Clinical Practice Special Feature @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

are very good: we give a man a very nice, natural cover. In Images courtesy of Tracie Giles the years I’ve been doing it, hair transplants have moved from that rather strange look of 20 years ago, to being almost undetectable, which is what everyone wants.” Asked to share some advice, Mr May highlights a common professional problem: “You have to go to a clinic or join a doctor where you can do almost an apprenticeship. This isn’t easy. As it stands at the moment there’s no formal training for doctors in most cosmetic procedures – you have to get someone to show you how to do it or assist someone.”

Platelet Rich Plasma (PRP) The treatment of choice for Dr Wakil is PRP. “It’s something that has been around since the 1970s and was first used in 1987 in an open heart surgery procedure to promote healing,” he explains. “The platelet has growth factors and each growth factor helps Medical tattooing/permanent makeup Tracie Giles is a London-based medical tattooist. Although her work also includes permanent cosmetic makeup, she treats patients with alopecia, those undergoing chemotherapy, and people with distressing hair pulling disorders. Tattooing eyebrows, but not the scalp, Ms Giles uses a normal cosmetic pencil, or uses pigment and a very fine paintbrush, to draw symmetrical eyebrows before applying a gentle topical anaesthetic to the area. Ms Giles then tattoos the area using an acupuncture needle and/or permanent make-up needles to create a 3D effect to the eyebrow. She says that infection and allergic Treating hair loss with PRP. Images courtesy of Dr Sherif Wakil reactions are rare – an allergy test is performed before the process begins. Afterwards, patients are advised to keep the area clean and in cell regeneration of a certain place in the body,” explains Dr dry, and use Vaseline as a barrier cream. Wakil. “I don’t think it’s as precise as it could be, but we know more now and scientists are able to reproduce the specific Giles, like other practitioners interviewed, stresses the positive growth factor that helps the hair follicle and offer it as a hair psychological impact her work can have on her clients. “You can solution to use at home.” empower somebody to take some control over conditions they Dr Wakil usually combines PRP with AQ growth factor. “The otherwise have no control over. It’s such a lovely thing when someone response varies: some patients come and they’re thrilled; with sits up and cries because they’re so happy they’ve got eyebrows others, results take a little more time. There’s no rule to how back again. You definitely get the feel-good factor.” fast hair will grow. The most remarkable thing I’ve seen is with patients who lose their hair constantly: when they wash it, immune-compromised patient you can actually create infection with the when they sleep, when they brush it. The first thing they tell me smallest amount of bacteria in the air. For this reason I don’t treat immune- is that their hair has stopped falling out. That’s what I want to compromised patients.” hear when they come back.” Dr Wakil’s advice to his peers is to find the cause of the hair loss. “This is As far as long-term results are concerned, Dr Wakil explains, very important because you won’t get good results otherwise. Secondly, “Hair in men aged 30 plus is under constant pressure. I try to take a proper history and immerse yourself in hair loss treatments. For avoid the need for a hair transplant. I make patients aware that some, it’s something extra they do in a clinic, but it’s actually a whole world. it’s not like having a ‘nose job’; I’m not fixing a nose that’s going So if you want to do it, do it properly and benefit your patient by offering to be fixed forever.” different treatments. If you’re just using one treatment your patient may Dr Wakil prefers PRP to mesotherapy and sometimes miss the chance of having thick hair. A good medical practitioner is one combines it with carboxytherapy as part of his total “attack that, if they don’t know something, they refer it to a colleague. My first theory”. As he explains, “The problem with mesotherapy is priority is the patient. That’s my first and most important principle. I think we that it’s the practitioner’s responsibility to check what’s in the should all act in this spirit.” cocktail. Every company comes up with a solution, but you need to investigate this because your patient trusts you.” The future of hair loss One of the reasons Dr Wakil enthuses about PRP, he According to Mr May, “At the moment we’re just relocating existing hair explains, is that, “It’s extremely safe and requires little and that’s a finite resource. University departments and pharmaceutical aftercare. The important thing is to advise patients not to companies are all looking for ways of growing hair using stem cells/tissue drink alcohol the night before or take aspirin – these thin engineering – after all, it’s a billion dollar product. However, it’s still some the blood and can cause the patient to bleed a little more. time away. This is a sentiment echoed by Dr Wakil: “We are all waiting for Afterwards I tell patients not to touch their hair until their the stem cell research that has been going on for over 30 years; waiting hands have been properly cleaned. The only thing I worry for the miracle of taking hair follicles from the patient, replicating it, and about is the risk of infection in a patient who’s immune- injecting it into the scalp to produce hair everywhere. This is the future compromised. The procedure is very sterile, but with an everybody’s waiting for.”

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1. BEL-DOF3-001_01. 2. Tran C et al. in vivo bio-integration of three Hyaluronic Acid fi llers in human skin: a histological study. Dermatology DOI:10.1159/000354384. 3. Taufi g A.Z. et al., J Ästhet Chir 2009 2:29 – 36. 4. Prager W et al. A Prospective, Split-Face, Randomized, Comparative Study of safety and 12-Month Longevity of Three Formulations of Hyaluronic Acid Dermal Filler for Treatment of Nasolabial Folds. Dermatol Surg 2012, 38: 1143 – 1150. 5. Buntrock H, Reuther T, Prager W, Kerscher M. Effi cacy, safety, and patient satisfaction of a monophasic cohesive polydensifi ed matrix versus a biphasic nonanimal stabilized hyaluronic acid fi ller after single injection in nasolabial folds. Dermatol Surg. 2013; 39(7):1097-105. BEL092/0314/FS Date of preparation: April 2014

MZ021 A4 AESTHETICS JOURNAL ADVERT.indd 1 09/05/2014 14:43 Clinical Practice one CPD point @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com Radiofrequency Lee Brine explores the science and application of RF in non-invasive aesthetic procedures

The use of radiofrequency (RF) in surgical applications is far from is the principal factor in determining what reaction is created new, with records of early work in basic surgical cutting going with the various body structures. An example is CO2 laser; this back some 50 years. Radiofrequency energy exposure is a well- wavelength is highly absorbed by water and thus it is absorbed as established method for generating heat in tissue to incise, excise, soon as it strikes the skin and creates a very superficial reaction ablate or coagulate the targeted tissue for a vast array of surgical and thus is used for resurfacing the skin. Another example would applications. However, in the last 10 years there has been an be frequency double YAG at 532 nanometers (Green) which explosion of RF applications in non-invasive aesthetic applications has an absorbtion peak in Oxyheamaglobin and thus is very leading to many conflicting and confusing elements surrounding useful in surgical applications, such as prostate surgery, where RF. In order to understand this widely used energy form the a greater degree of heamastasis is required. RF delivers heat following review will discuss: to tissues based on the properties of the tissue itself and is not • Technology dependent on chromophores; thus the tissue effect does not • Applications seem dependant on skin colour as with lasers and IPL, i.e. light • Tissue response application. • Methods of tissue application • Clinical results Applications Laxity is a skin disorder that occurs with natural or accelerated Technology aging and is structurally linked to diminished collagen production. Radiofrequency is an oscillating current of electricity. Whereas The number and vitality of fibroblasts decrease, and both the electricity from your domestic outlet operates at around 50 Hz, dermis and the fibrous septa undergo partial loss of their natural the RF used in various clinical and surgical applications oscillate ability to replace themselves. The morphological changes that at rates between the frequencies ranges of 3 to 24 kHz, with the appear are a consequence of diminished biosynthesis of collagen whole band of radiofrequency being between 3 kHz to 300 GHz. and elastin and abnormalities of the extracellular environment It is these oscillations that cause vibrations and collisions between with a decrease in the concentration of hyaluronic acid.2 charged molecules and charged ions that create controlled heat.1 Skin laxity is an aesthetic problem that usually occurs between RF current is simply an electrical current, and acts in similar ways the ages of 35 and 40 years, although it generally only starts to to our common understanding of the properties of electricity, become visible from age 40 onward. Issues with skin laxity and with the fundamental principle of note being that if the passage quality can start to appear in younger people due to pregnancy of energy meets resistance it will create heat. Consider a tiny or sudden weight loss. The impact of these problems on the light bulb filament that is highly resistive, which is why it heats patient’s self-esteem can become important enough to affect up to give light. The main idea behind using RF on the skin is its quality of life in psychological terms.3,4 The demand for treatment ability to deliver heat to tissue non-specifically. Lasers are able to of skin laxity is growing rapidly across the globe.5 generate heat, but when controlled, they do so in a chromophore- Skin laxity is associated with lack of physical exercise and specific manner (selective photothermolysis). To expand upon rigorous dieting, and often appears in combination with cellulite. this part of the theory we need to look at laser light and tissue Cellulite is an inflammation of the subcutaneous adipose tissue interaction. Lasers are unique from normal light in that they and has several causes. It occurs mainly on the legs, buttocks, consist of a single wavelength whereas white light is a mixture of hips, breasts, arms, and neck.6 The fibrous structure of the a whole spectrum of wavelengths. The wavelength of the laser interlobular septa that divide female subcutaneous cell tissue Absorption into compartments is arranged perpendicular to the skin surface. HPS Diode Nd: YAG Thulum Ho: YAG This structure enables fat lobules in each septum to move toward (532nm) (980nm) (1064nm) (2013nm) (2120nm) 1000 the skin surface, which is the only structure that contains them. ) -1 100 Some authors consider that cellulite visible to the naked eye is caused by lengthening and weakening of connective tissue fibers 10 accompanied by fat protrusion.7,8 1 0.1 Tissue response 0.01 The basic premise of RF devices is electrical resistance causing heat. There is initial collagen contraction and destruction through IE-3 both mechanical and biochemical pathways. As a result of the Absorption Coe cient (cm Coe cient Absorption IE-4 400 800 1200 1600 2000 energy delivered deeply into the skin, collagen remodelling Wavelength (mm) Oxyhemoglobin Water through a controlled wound healing response occurs over time Graph illustrating the different absobtion levels various lasers in with associated neocollagenesis. This collagen remodelling also water (tissue main component) and oxyhemoglobin yields the desired tissue tightening that is seen with RF devices.

26 Aesthetics | September 2014 Clinical Practice @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com CPD

RF devices typically Before After are not intended to resurface the skin but rather to induce thermal damage to dermal collagen while Dermal remodelling and neocollagenesis following radiofrequency treatment at pre-treatment (A) and 10 weeks post treatment (B). sparing the epidermis At 10 weeks, dermal thickness was increased over pre-treatment and subcutaneous interstitial collagen also was thickened. Both Appropriate cooling is also required for these devices, since the observations can be attributed to dermal remodelling and ongoing neocollagenesis following radiofrequency treatment. energy delivered needs to penetrate to the deep dermal and subcutaneous fat layers without damaging the more superficial structures.9 Histology pre treatment After RF can be used for the heating and reduction of fat by inducing apoptososis (cellular death) in the fat structure. By raising the temperature of the fat cells to at least 46 degrees the process of cell destruction will commence.9 Global incidence of obesity is at an all-time high.10 This growth is in line with the rapid increase in the methods that can be used to non-invasively remove these pockets of fat. Multiple non-invasive Histology post four applications of RF clearly demonstrating healthy fat cells in the top slide with visible destruction of the cellular structure in modalities to induce adipocyte apoptosis in pockets of fat are the right slide now widely used. These modalities primarily aim to target the properties of fat that differentiate skin from muscle, thus resulting The released fatty acids and triglycerides are processed through in the selective removal or dissolution of fat, otherwise known the normal metabolic pathway. 11 as lipolysis. As seen in the table below, fat is highly resistant (i.e. RF devices typically are not intended to resurface the skin but less conductive by a factor of up to 30 times) compared to other rather to induce thermal damage to dermal collagen while sparing structures in the body. As a result, RF heating occurs irrespective the epidermis. Resistance and the resultant degree of thermal of chromophore or skin type and is not dependent on selective damage is determined by the depth and composition of the treat- photothermolysis. Depending on the level of accumulated fat, ed tissue. When applied over a period of time, thermal energy devices can target the fat at different levels. RF-generated tissue contracts and thickens collagen fibres, disrupts hydrogen bonds, heating has different biological and clinical effects, depending on and alters the conformation of the collagen triple helix. It also in- the depth of tissue targeted, the frequency used, and the cooling duces a more prolonged wound-healing effect that is associated of the skin to prevent discomfort. The different effects range with sustained remodelling, reorientation, and formation of new from reducing the extra cellular fluid, heating the dermal layers to collagen bundles over subsequent months.12 Because RF energy disrupt collagen or heating subcutaneous fat to induce apoptosis uses an electrical current rather than a light source, it does not affect epidermal melanin; therefore, patients of all skin types, Tissue’s Ease of including darker skin types and those with a predisposition to de- Tissue Type Tissue’s Conductivity Polarization velop post-inflammatory reaction due to a rise in skin temperature can be treated with RF. Relative Permittivity; ε; Conductivity; σ [S/m]; As discussed, the heating of the fat is due to the fact that the fat (higher number means (higher number means more that material is more easily is far more resistant to the passage of the radiofrequency, this conductive) polarized) resistance is what generates controlled heat. The table quantifies this level of resistance to RF in fat compared to other structures. Fat 0.032909 8.4678 The basic principal of physics is that resistance to the passage of electrical energy creates heat. The table to the left represents the 1.158 (35 times more than 126.96 (15 times more than Blood differences in conductivity in the various tissue structures. in fat) in fat)

0.3283 (10 times more than 165.59 (20 times more than Methods of application Skin in fat) in fat) Radiofrequency current can be applied to the skin in various manners. Monopolar devices have a single electrode that is 0.654 (20 times more than 95.947 (11 times more than Muscle in fat) in fat) placed on the treatment area. A grounding pad is placed in an area distant from the treatment area, generally on the back of the Values measured at radio frequency and tissue temperature 37°C. patient. The depth of penetration of monopolar radiofrequency

Aesthetics | September 2014 27 Clinical Practice CPD @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

depends on the impedance of the tissue and on the size of the the space between the two poles. For effective treatment of fat, electrode. Depth of penetration of monopolar systems can easily deeper penetration of heat is needed, hence a monopolar system reach the subcutaneous fat at some settings, typically for a large would seem to be more efficacious. However, where less depth of applicator approximatly 100 watts is sufficient. thermal zone is required, for example when remodelling the dermal Bipolar devices consist of two electrodes placed over the layer, then bipolar will have sufficient depth of penetration for tissue treatment area. The depth of penetration of the RF is based on the tightening and collagen production. A number of devices will use tissue impedance and the distance between the two electrodes. some form of suction in order to pull the tissue into the delivery The further the distance between the electrodes, the deeper the head in order to allow deeper penetration of the bipolar energy penetration. Bipolar RF is more superficial than monopolar RF. than one would achieve by normal application.13 To summarise the difference between monopolar and bipolar, It is imperative that tissue temperature of 42 degrees in the dermis we must understand that electricity will seek the path of least and 45 degrees in the fat are achieved and maintained for a period resistance. Monopolar: the energy passes from the applicator of time in order to invoke the structural changes discussed above.14 through the body to a return grounding pad, thus enabling the In early RF devices, the incidence of pain was reportedly quite heating of deeper structures. Bipolar: the energy passes between high. However, in the very latest systems one will find a variety the negative and positive pole within the applicator head, the of technical solutions to artificially cool the skin whilst raising the depth of penetration is determined by the distance between temperature of the structures below.15 these two poles. The depth is approximatly half the distance of Conclusion Results There are many different types of RF systems currently in use globally for both body contouring and skin tightening. Depending Porcine model demonstration volume fat reduction after RF application on your requirements in your clinical setting, consideration should be given to the following key components depending on what you are trying to achieve. In treating deeper layers of fat, consider monopolar over bipolar in order to create deeper thermal profile increases in temperature. In achieving therapeutic temperatures some form of cooling at the application interface should be employed to improve patient comfort. To achieve consistent results the skin temperature should be measured to ensure that the therapeutic temperature has been reached. Prior to this the indication of erythema was the only endpoint, which varies from patient to patient.

Lee Brine is a qualified engineer from the aero industry, with a career in medical technologies. Lee works predominantly with lasers and radiofrequency energy sources, covering a wide range of surgical specialities. Pre four applications of RF Post four applications of RF Lee is currently a consultant for BTL aesthetics, advising on the clinical applications of the latest developments in RF for aesthetic procedures.

REFERENCES 1. Curtis, Thomas Stanley, High Frequency Apparatus: Its Construction and Practical Application, (USA: Everyday Mechanics Company, 1916), p. 6 2. Uitto J, ‘The role of elastin and collagen in cutaneous aging: intrinsic aging versus photoexposure’, J Drugs Dermatol, 7 (2 Suppl) (2008), S12–S16. 3. Sarwer DB, Magge L, Clark V, ‘Physical appearance and cosmetic medical treatments: physiological and sociocultural influences’. J Cosmet Dermatol, 2 (2003), pp. 29–39 4. Hexsel D, de Oliveira Dal’Forno T, Cignachi S, ‘Social impact of cellulite and its impact on quality of life’. In: Goldman MP, Bacci PA, Leibaschoff G, Hexsel D, Angelini F, (editors), Cellulite: Pathophysiology and Treatment, (New York: Taylor & Francis; 2006), pp. 1–5 5. Body Contouring Devices Market - Global Industry Analysis, Size, Share, Growth, Trends and Forecast, Transparency Market Research (2013 – 2019) 6. Avram MM, Avram AS, James WD, ‘Subcutaneous fat in normal and diseased states: 1. Pre and post application of three non-contact RF applications Introduction’, J Am Acad Dermatol, 53 (4) (2005), 663–670. 7. Nürnberger F, Müller G. ‘So-called cellulite, an invented disease’. J Dermatol Surg Oncol. 4 (1978), pp. 221–229 8. Piérard GE, Nizet JL, Piérard-Franchimont C, ‘Cellulite: from standing fat herniation to hypodermal stretch marks’, Am J Dermatopathol, 22 (2000), pp. 34–37 9. Vander Vorst, Andre; Rosen, Arye; Kotsuka, Youji, RF/Microwave Interaction with Biological Tissues, (New Jersey: John Wiley and Sons, Inc., 2006) 10/07/2013 13/07/2013 26/07/2013 10. WHO. Obesity: preventing and managing the global epidemic. Report of a WHO Consultation. WHO Technical Report Series 894, (Geneva: World Health Organization, 2000.) 11. M. Berg, Jeremy; L. Tymockzo, John; Stryer, Luber, Biochemistry 7th Edition (New York: W.H Pre four applications of RF Post operative four applications of RF Freeman, 2011) 12. Hsu TS, Kaminer MS. ‘The use of nonablative radiofrequency technology to tighten the lower face and neck’, Semin Cutan Med Surg, 22 (2003), pp. 115–23 13. Hollmig, S. Tyler; Hantash, Basil M., Radiofrequency in Cosmetic Dermatology: Recent and Future Developments , Cosmetic Dermatology, 26 (2011), p. 568 14. Welch, Ashley J., van Gemert, Martin JC (Eds.), Optical-Thermal Response of Laser-Irradiated Tissue, (New York: Springer Science & Business Media, 2011) 15. Fitzpatrick R, Geronemus R, Goldberg D, Kaminer M, Kilmer S, Ruiz-Esparza J, ‘Multicenter study of noninvasive radiofrequency for periorbital tissue tightening’, Lasers Surg Med. (2003), pp. 33:232

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Dr John Quinn addresses the vein and supraorbital vein, runs obliquely downward, on the side complications that can occur when of the root of the nose, to the level of the lower margin of the eye treating patients with dermal fillers socket, where it becomes the anterior facial vein. Branches of the facial vein frequently run along the marionette fold and this is a very common area for noticeable bruising, in my experience. For this reason, this is an area where I almost exclusively use a cannula. Filler When augmenting the lip, it is important to remember that the labial artery runs deep in the body of the lip. Thus injection on the wet dry border is likely to bruise. complications Usually, swelling will settle within a few days. Certain products tend to swell more, related to their hygroscopic properties.3 The lips Complications are, unfortunately, inherent to any medical are a particularly common place to see noticeable swelling, and procedure. When they occur in the NHS, there is a degree of therefore I warn patients of this. My standard practice is to use no understanding amongst patients and medical professionals. In the more than 1ml in an initial lip enhancement, and I frequently use a private sector where cosmetic medicine exists, complications are less 0.5ml syringe. My experience is that patients often prefer their lips accepted and there is a propensity for the incident to become a story when swollen. I then retreat the area, at least two weeks later. Using in a daily newspaper. With so much of our education being sponsored an ice pack post procedure is sensible and oral steroids for early by drug companies, complications have previously been glossed swelling are sometimes used. However, bruising is hard to predict. over and many of us have personal experience of insufficient or no I try to ensure that my patients have no major social engagements support at all in the event of a poor outcome. for a week post procedure. When severe bruising occurs, it is possible to hasten the resolution by use of a vascular laser. This has General considerations been looked at using a pulsed dye laser4 but I have also had some There are some simple steps that a practitioner can take to reduce success in my clinic using my Lumenis One IPL. the risk of complications. My personal view is that dermal filler The most catastrophic potential complication is intravascular procedures should be done in a regulated healthcare setting, ideally injection of filler, leading to tissue necrosis and potential scarring. a Care Quality Commission regulated clinic. Adherence to aseptic This is not an issue that was spoken about on any early dermal filler and ‘no touch’ techniques is essential. The importance of hand course that I attended. A sound knowledge of the surface anatomy washing cannot be overstated. I use a sterile pack, swabs and gloves is essential when injecting dermal fillers. However, as previously for each procedure I perform. I cleanse skin with chlorhexidine. There mentioned, there is very considerable variation and so awareness of is evidence that this provides better, more prolonged anti-microbial the danger areas and some simple tips can reduce your risk. action than with alcohol.1 Either way, I advise using an additional The most common problem areas are the glabella, the nasolabial substance other than the one you use to remove the patient’s folds and the nose.5 The glabella is an issue because the makeup. I personally use multiple needles or cannulas per procedure, supratrochlear and supra orbital arteries, both branches of the and this is of particular importance with deep, volumising injections. internal carotid artery system, are end arteries. This means that On training days, I frequently see practitioners touch or wipe their there is little collateral circulation in the event of cannulation and needle with a swab before injection. This is not sensible and should inadvertent injection. There is also little distance between the skin be avoided. If I touch my glove with a cannula, I change the cannula. and periosteum of the frontal bone in this area. The patients with the In terms of injection technique, go slowly and inject small amounts per deepest frown lines are the patients most at risk. These are the very injection point. Slow injections are less uncomfortable for the patient patients who are often less impressed with initial toxin treatment and and reduce the risk of bruising and swelling and will likely make late thus request fillers. My practice is to try and identify these patients complications less frequent.2 After the procedure, I have my patients pre treatment. I communicate to these patients that their static lines apply some alcohol gel to their hands, instruct them not to rub their will improve but will not be eradicated by one toxin treatment. The face and, ideally, avoid makeup for the rest of the day. If they must use of photographic documentation is extremely important here, apply make up (I am a realist!), then I ask them to make sure that it is and is a practice that should be applied to all aesthetic procedures. brand new and therefore does not harbor any bacteria. I tell these patients that their lines will improve on repeated treatment as per the original FDA approval study for Botox in the Early complications USA demonstrated. If the patient remains unhappy after three Early complications – within a few days of the procedure – are treatments, then filling only becomes easier as the glabellar lines will generally related to the physical act of injection itself. Bruising and be less deep after treatment with toxin. It is also possible to create swelling may be seen as side effects rather than as complications. a problem by compression of the glabellar arteries, as well as by I consider them a complication if the patient has to avoid social cannulation and embolisation.6 This is again because of there being events. This is somewhat arbitrary, as patients will obviously differ. little space between the skin and periosteum in this area. These To reduce the risk of bruising and swelling, I try to use the smallest patients will later present with signs of necrosis, a point discussed needle possible and, in danger areas, I choose a blunt tipped micro later in this article. cannula to place my product. An awareness of vascular anatomy The nasolabial fold is one of the first areas that we learn to inject as aids in locating where large vessels may sit and is important, cosmetic practitioners. As previously mentioned, the facial artery, a but in reality there is considerable variation. The facial artery branch of the external carotid artery, runs a tortuous course, usually runs a tortuous course just lateral to the nasolabial fold, where just lateral to the fold. It gives off labial branches, upper and lower, it changes its name to the angular artery. The angular vein is a just lateral to the oral commissure. At the base of the nasolabial small vein near the eye. It is formed by the junction of the frontal fold, the nasal ala, there is frequently a branch that passes medially.

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Sinclair IS Pharma 1st Floor Whitfield Court, 30-32 Whitfield Street London W1T 2RQ. United Kingdom www.sinclairispharma.com Date of preparation: April 2014 UK/SIPPER/14/0003 Clinical Practice Clinical Focus @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

and patients should be warned of this. Prompt intervention with I am always bacteriocidal antibiotics is essential. Sensible options are macrolide antibiotics such as clartihromycin 500mg bd or ciprofloxacin 750mg watching for bd. Treatment is for two weeks, at least. Medium term complications After a few weeks, hyaluronic acid fillers should be integrated signs of arterial into the host dermis. Palpability of product at this stage is possible but may indicate a problem. Over injection into an area compromise, can produce palpable nodules. These may simply be massaged if they are small and not inflamed. Any sign of infection should prompt early treatment with antibiotics. Hyaluronidase may namely; pain and be used to dissolve hyaluronic acid filler if it is visible or unacceptable from a cosmetic point of view. Common areas that I am asked to treat include the lip, the tear trough and cheeks. pallor. Injections into the body of the lip frequently lead to unevenness. Inadvertent injection into this artery can potentially cause embolism Presumably muscular contraction of orbicularis oris compounds and produce an infarction affecting the nose.7 It is also possible to this problem and collects the product into pockets. It may simply compress the artery. As with the glabella, this will tend to present be injection related also. Bluish discolouration can occur with slightly later. I always warn my patients that pain is not normal any HA filler. This tyndall effect is related to refraction of light post fillers, and to call the clinic if they have any concerns. An off the HA particles. I have seen this with all the fillers that I use, emergency contact number is essential. apart from Belotero.10 I now use this as my first line product for Recently, nose reshaping has become a not uncommon procedure. superficial injections. The discolouration can last for years, long My personal opinion is that this should be done by specialists, past when one would expect the filler to have been degraded and not by a practitioner following a one-day course. Nasal tip by the patient. My experience has been that the more superficial necrosis can occur post fillers; this relates to the compression of the filler is placed, the longer it tends to last. I have used vessels in the area.8 Proximal embolisation can occur, particularly at hyaluronidase several years after implantation and resolved the the nasal bone, which can cause permanent blindness.9 Practical tyndall effect in a number of referred patients. Most recently, I considerations include injecting slowly and to constantly move saw a patient with swelling under her right eye, which she’d had the tip of the needle. Avoid bolus injections in these areas. I have for four years. Her practitioner had told her that she was allergic seen some practitioners advocate aspiration but I have never to the filler. After three sessions with hyaluronidase, she felt felt dexterous enough to be positive that my needle tip stays in happy to be photographed on holiday again. the exact same position post aspiration. Also, although it may be When using hyaluronidase, it is important to discuss with the possible, I don’t think that it is easy to withdraw blood with a 30g patient that it is unlicensed for dissolving filler. It is an animal needle. Despite this, I always aspirate when injecting a bolus. I tend product so there is a risk of hypersensitivity. There is debate, to do this in the midface only. In this situation I use a 27G needle, but standard practice is to patch test on the forearm before advancing towards the periosteum. I steady my syringe with my injecting into the face. Hyalase is a commercially available left hand and aspirate. I inject very slowly and tend to avoid any product in the UK. It comes in 1500 iu vials and is used mainly more than 0.2ml of product per site. I am always watching for signs in anesthesia. To dissolve HA filler, 10-15 units are usually of arterial compromise, namely; pain and pallor. If the catastrophic sufficient per 0.1ml of HA. I add 1.5ml to the vial, then withdraw event of vascular compromise is apparent, treatment includes 0.1ml and draw this up to 1ml. This gives me 10 units of hyalase massage, heat, topical GTN (if available) and hyaluronidase. If per 0.1ml. I allow 24 hours between patch test and treatment. I arterial emobilisation has occurred, then hyaluronidase is unlikely to tend to start with small amounts as there have been reports of be of great benefit, but I would still advocate its use. Early referral the product dissolving the patient’s innate HA.11 I haven’t seen to a plastic surgeon is essential. Superficial areas of necrosis may this in my practice however. Repeated treatments may sensitise heal well but appropriate wound care is paramount. I would not the patient, so I try to do what is required within a small number patch test in this situation – it is an emergency. of treatments. I always have hyalase in my clinic in case of an Blindness post dermal fillers has been reported in the literature emergency, as discussed previously. This is crucial to have on- in recent years.9 In reality, most of the cases have been related hand, in my opinion. to fat injections but it is possible with most materials. The bulk of the arterial supply of the face comes from the external carotid Late complications artery system. The exceptions are, as previously mentioned, the Thankfully the risk of late reaction to commercially available non- arteries of the glabella, supratrochlear and supraorbital. These permanent fillers is very low.12 There is really no reason to use emerge from the orbit as branches of the internal carotid artery. permanent fillers in my opinion. Apart from the difficulty in removing They thus communicate with the retinal artery. There are multiple them, should there be a problem, the fact that facial ageing is a anastomoses between the external and internal carotid systems dynamic process means that anything permanent may not be as in the areas of the base of the nose, the temple and even the tear aesthetically attractive several years later. trough. These are all areas where I urge extreme caution. It is increasingly recognised that late reactions to dermal filler Infection is a risk post implantation of any medical device. Fillers are related to low-grade infections known as biofilms.13 These are no exception. Increasing tenderness or erythema are signs entities are well known in medicine and dentistry. They consist

32 Aesthetics | September 2014 Clinical Practice @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com Clinical Focus

of aggregations of, usually, relatively low pathogenic bacteria, collected onto a matrix of implanted material. The foreign body Dr John Quinn is an Irish qualified general practitioner with over 9 years experience in cosmetic medicine. acts as an anchor for colonisation and subsequent secretion He is a full member of the British College of Aesthetic of protective polysaccharides. This shields them from antibiotic Medicine and has completed the Post-graduate diploma treatment. Patients presenting with late nodules should be in Clinical Dermatology at Queen Mary University, empirically treated with high dose bacteriocidal antibiotics. London. He has a clinic in Bristol and Greenwich. REFERENCES Otherwise the biofilm becomes more resistant and difficult to 1. Edwards, PS, A Lipp, A Holmes, Preoperative skin antiseptics for preventing eradicate. It is often required to remove the implanted material for surgical wound infections after clean surgery (Review), (onlinelibrary.wiley. com, 2004) < http://onlinelibrary.wiley.com/store/10.1002/14651858.CD003949. resolution of the problem. This is why, now, I only use hyaluronic pub2/asset/CD003949.pdf;jsessionid=74C4104CC225C8A110CFC110400AD6F0. f03t03?v=1&t=hyvmz0gq&s=9266307ef6dc10089cbf77181867901df2bbc7c1> acid fillers for facial revolumisation. 2. Boulle, K De, ‘Management of complications after implantation of fillers’,Journal of cosmetic In my practice, I have seen two cases that I have treated as biofilm. dermatology, (2004) 3. Kablik, Jeffrey,et al., ‘Comparative physical properties of hyaluronic acid dermal fillers’, Both presented several months after cheek enhancement with Dermatologic Surgery, 35.s1 (2009), pp. 302-312 4. DeFatta, Robert J, Srinivasan Krishna, and Edwin F. Williams, ‘Pulsed-dye laser for treating slight swelling and discomfort in the treated areas. I prescribed ecchymoses after facial cosmetic procedures’, Archives of facial plastic surgery, 11.2 (2009), clarithromycin 500mg bd for 4 weeks and used hyaluronidase pp. 99-103. 5. Glaich, Adrienne S., Joel L. Cohen, and Leonard H. Goldberg, ‘Injection necrosis of the while on antibiotic cover. Both settled on this regime. Dr K De glabella: protocol for prevention and treatment after use of dermal fillers’, Dermatologic surgery, 32.2 (2006), pp. 276-281 Boulle from Belgium has suggested using ciprofloxacin 750mg bd 6. Narins, Rhoda S., et al, ‘Clinical conference: management of rare events following dermal for one month in the first instance.14 There is a risk of tendonopathy fillers—focal necrosis and angry red bumps”’, Dermatologic surgery, 32.3 (2006), pp. 426-434. 7. Grunebaum, Lisa Danielle, et al., ‘The risk of alar necrosis associated with dermal filler with this so patients must be warned against vigorous physical injection’, Dermatologic Surgery, 35.s2 (2009), pp. 1635-1640 8. Humphrey, Clinton D., John P. Arkins, and Steven H. Dayan, ‘Soft tissue fillers in the nose’, activity. Others have advocated using dual therapy. Either way, a Aesthetic Surgery Journal, 29.6 (2009), pp. 477-484 prolonged course of high dose antibiotics is indicated. 9. Kim, Young Jun, et al., ‘Ocular ischemia with hypotony after injection of hyaluronic acid gel’, Ophthalmic Plastic & Reconstructive Surgery, 27.6 (2011), e152-e155 Given the trend for deep volumising injections and the variation 10. Kühne, Ulrich, et al., ‘Five-year retrospective review of safety, injected volumes, and longevity of the hyaluronic acid Belotero Basic for facial treatments in 317 patients’, Journal of Drugs in in training/ability and inappropriate venues for treatment, there is, Dermatology, 11.9 (2012), pp. 1032-1035 unfortunately, every likelihood, that we will see an increase in these 11. Brody, Harold J, ‘Use of hyaluronidase in the treatment of granulomatous hyaluronic acid reactions or unwanted hyaluronic acid misplacement’, Dermatologic Surgery, 31.8 (2005), pp. biofilm reactions in the future. As discussed, complications are 893-897 12. Andre, P., et al. “Adverse reactions to dermal fillers: a review of European experiences.” sometimes inevitable, but taking a stringent approach to technique Journal of Cosmetic and Laser Therapy 7.3-4 (2005): 171-176 and delivery will ensure that any unnecessary complication in an 13. Rohrich, Rod J, et al., ‘Soft-tissue filler complications: the important role of biofilms’,Plastic and reconstructive surgery, 125.4 (2010), pp. 1250-1256 aesthetic procedure is avoided. 14. CODE Meeting, Toulouse, France, September 2013 IRESOLVEI

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Aestheticare Trade Ad Master.indd 1 11/08/2014 17:12 Clinical Practice @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com Techniques

Hair Transplantation in Younger Patients

Dr Sotirios Foutsizoglou discusses the benefits, limitations and controversy associated with performing hair restoration surgery on younger patients

For years, hair transplant surgeons have debated scalp, whereas in women it more commonly presents in a diffuse pattern in the whether young balding individuals could be crown, with or without sparing of the frontal fringe. Patients who go bald at a candidates for a hair restoration procedure, and very young age (i.e. under the age of 25 years) are prone to developing more the effects of Follicular Unit Extraction (FUE) and extensive and occasionally non-pattern hair loss than those who thin later in life. Follicular Unit Transplantation (FUT) on their donor Diffuse un-patterned alopecia (DUPA) is a contraindication for hair restoration zone. The problem lies in that it is very difficult, if not surgery as the instability of the donor area increases the risk of scarring impossible, to identify the safe, permanent donor becoming visible (whether it is the linear scar of FUT or the small, round scars area when a person is young. In fact, at a young of FUE). The simple solution would then be to not operate on younger patients. age, it is not always possible to determine with However, no one likes losing his or her hair and it is particularly upsetting when certainty if any of one’s hair will be permanent or it occurs in the second or third decade of life. Visible thinning in teens and early what the ultimate quality of that hair will be.1 twenties often progresses to advanced alopecia by the end of their third decade. But what constitutes a ‘young’ patient? As a general This can cause great personal stress, especially due to the fact that the majority rule, when treating androgenetic alopecia, most of their peers maintain the appearance of a full head of hair. surgeons consider 25 to be the minimum age Arbitrarily not transplanting these patients, because of their age, could be for hair transplant surgery. Before this age the considered unfair. Every case is different and should be judged on its merits. evaluation of the alopecic patient, made usually by a Some doctors may argue that conservative surgery would be less harmful to thorough medical history, family history, and detailed these young hair loss sufferers than condemning them to many years of low physical examination, complemented by selective esteem.3 Their argument laboratory investigations and densitometry, used is based on the fact to measure hair miniaturisation, proves very hard that a large majority of to predict the pattern of female or male baldness men who will eventually and the degree of ultimate hair loss. Patterned hair develop type VI male loss, the most common type of hair loss affecting pattern baldness (MPB) men and women, is characterised by a process will still have long-term of progressive hair miniaturisation whereby donor-recipient area large, pigmented, terminal hairs are replaced by ratio that is adequate to fine colourless vellus hairs.2 Androgens play an transplant a cosmetically important role in this process of miniaturisation, acceptable density of hence the reason both male pattern hair loss (MPHL) hair. Interestingly, FPHL and female pattern hair loss (FPHL) are collectively is less difficult to predict referred to as androgenic or androgenetic alopecia. in younger patients. We In patterned hair loss there is a gradually shortening know from experience anagen phase resulting in affected hairs becoming that while frontal female shorter and finer. hairlines frequently The recession observed in androgenetic alopecia become more sparse follows a pattern and therefore the degree of hair with time, they are never loss is somehow predictable, allowing hair transplant entirely lost.4 Therefore surgeons to assess and plan treatments accordingly. it is safer to transplant Fig. 1 - The Hamilton/Norwood classification of degrees of severity In men, this condition preferentially affects hair on posterior to the hairline. of Male Pattern Baldness with Type I the least severe and Type VII the the superior and anterior temporal areas of the In addition, women tend most severe.

Aesthetics | September 2014 35 Clinical Practice Techniques @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

to maintain fairly good density in the occipital scalp, so their surrounding hair can easily cover whatever donor area scars may result from hair transplantation As with all surgery.5 Notwithstanding the above, it cannot be overly emphasised that the hair restoration surgeon should, ideally, take a conservative approach with women, and men in particular, in their early 20s, especially if they have Norwood patients, young Types III-vertex, IV, or V MPB (Fig. 1). It is wise to assume that a younger male patient will probably progress to at least a Norwood Type V balding pattern and patients must plan accordingly. Ominous signs in a young hair loss sufferer that point to the possibility of a very advanced stage of alopecia (i.e. Norwood Type VII), which is an absolute contraindication to surgery are the following:6 have realistic • A father or maternal grandfather with a Norwood Type VII pattern or worse expectations as • The presence of whisker hair, around the ears • The absence of dense fringe hair • The presence of diffuse non-pattern (or un-patterned) alopecia presenting as to the ongoing rapidly progressive, generalised thinning at a young age • Repeatedly higher than average miniaturised hairs in potential donor areas • MPB beginning in teenage years nature of their Case Study hair loss Patient JB is a 30-year old male complaining of progressive hair loss and a visible donor scar. He had two hair transplant procedures at ages 21 and 22. or no medical basis.3 As with all patients, young At the time, he was told he was a good candidate for surgery. Following his patients must have realistic expectations as to the procedures he was started on finasteride and minoxidil. In spite of a hair transplant ongoing nature of their hair loss, the limited amount and medical therapy, the patient’s hair continued to thin. Within a few years, his of donor hair available, and how this will impact donor scar became obvious, presenting a cosmetic problem far greater than his the future cosmetic appearance and extent of their hair loss. On physical examination, JB had a persistent frontal hairline, generalised transplanted areas. Although no rigid age limit thinning, and a readily visibly donor scar. Densitometry revealed a donor density of should exist with regards to hair restoration surgery, 1.2 follicular units /mm2 and 90% in my opinion, no matter what the cause of the hair donor miniaturisation consistent loss problem may be, targeted pharmacotherapy, with a diagnosis of diffuse un- following a pertinent diagnosis, is the best initial patterned alopecia (DUPA) which is choice for all patients under the age of 25. For a contraindication to hair restoration instance, the combination of finasteride and minoxidil surgery (Fig. 2). Current surgical can slow down, and to some extent, prevent the options for this patient remain progression of androgenetic alopecia into an extremely limited, as there is no advanced stage. Thus it gives patients time to think permanent zone to harvest hair. Scar about their options and to adjust to the fact that, revision surgery may improve but regardless of surgical or medical treatment, they will will not eliminate his existing scar. never have a full head of hair or the low hairline that Scalp micro-pigmentation can be they once had.1 discussed, but will give only partial Fig. 2 - Visible donor scar in a patient with DUPA cosmetic improvement. Dr Sotirios Foutsizoglou is the founder and medical director of Discussion SFMedica. He specialises in minor cosmetic surgery and aesthetic The age at which to perform a hair transplant procedure on a young man or medicine. He is a member of woman has been a controversial topic for decades. the International Society of Hair The decision making process, as to whether surgical hair restoration is Restoration Surgery (ISHRS) and appropriate for the presenting young patient, should include being on the performs hair transplant surgery on Harley Street, London. He is also the senior instructor in facial lookout for certain red flags that could influence the physician’s evaluation. anatomy and lead trainer in advanced non-surgical A thorough understanding of the pathophysiology of hair loss, the limitations procedures with KT Medical Aesthetics Training Group. of hair restoration surgery, its risks and benefits, as well as short- and long- term consequences can help establish whether or not a young patient is an REFERENCES appropriate candidate for a hair transplant procedure. 1. Bernstein RM, ‘Age and the donor zone in FU hair transplants’, Hair Transplant Forum, 23 (2013), Number 3. Establishing a proper diagnosis is indispensable in determining prognosis 2. Paus R, Cotsarelis G, ‘The biology of hair follicles’, N Engl J Med, 341 (1999), and making treatment decisions. The case study young man could have been pp. 491-7 3. Reich J, ‘The surgery of appearance: psychological and related aspects’, spared a failed hair transplant procedure and an unsightly donor scar if DUPA Med J Aug, 7 (1989), pp. 5-13. was diagnosed in the first place. Transplantation provides consistently natural 4. Shapiro J, ‘Clinical Practice. Hair loss in women’, N Engl J Med, 357 (16) (2007), pp. 1260-30 results and if a patient understands the long-term cosmetic limitations of hair 5. Avram MR, Rogers NE, Later and Older. Hair Transplantation, 5th Edition. transplantation, all patients are potential candidates for surgery. Transplanting or Informa Healthcare (2011) 6. Unger W. Planning and Organisation. Hair Transplantation. 5th Edition. not transplanting based on arbitrary age limits is unfair to patients, and has little Informa Healthcare 6A (2011), pp. 106-150.

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NUA Aesthetics are proud to be the UK distributors for Clinipro, Europe’s most advanced manufacturer in Fat Menopause Cryolysis. A new process in born, NUA Aesthetics presents a revolutionary machine Lipocontrast. CRYOTHERMAL Fleur-Louise Newsom explores the various lipolysis is the evolution in FAT FREEZING using physical and emotional symptoms associated with heat,cold,heat which produce the following benefits the menopause, and how these can be managed Menopause naturally occurs in women ‘the change’. Some noticeable differences aged between 45 and 55, although it include the hair becoming thinner and more can also start slightly earlier or later brittle, often breaking more easily. The skin in a woman’s life. The beginning of becomes drier, often becoming itchy and menopausal symptoms is often known as uncomfortable and there is a period of the perimenopause. The symptoms can accelerated skin ageing as collagen and vary, and not all women experience each of elastin levels begin to decline. Some women joints as a lubricant) to decrease as you age6. the symptoms. Regardless, the menopause can experience further skin irritation and These three naturally occurring substances is a life-changing event for all women, and sensitivity due to the skin becoming thinner. help to keep your skin plump and moist. one that requires special care and attention For example, rosacea can occur, which We always recommend that our customers from an aesthetic medical professional. sometimes appears as permanent redness sample new skin care products before they One of the first signs of the menopause is a and spots and can cause the person to feel are applied to ensure that the products are change in a woman’s monthly cycle. It can that their skin is burning. The cause of rosacea suitable for their hormonally changing skin. become heavier or lighter, and become is unknown, but it is reported2 that menopause We encourage people to read more about more irregular as time goes on. Amongst is one of the possible triggers. The physical what they are putting on their skin, taking care the symptoms of menopause are a few that symptoms that occur as a result of menopause to note down any ingredients that they may can cause much discomfort. These can are often the most distressing, and the find problematic. The best products to keep include hot flushes, headaches, urinary tract lack of oestrogen can initiate further health the skin moisturised and to retain elasticity are infecions, osteoporosis, vaginal dryness, problems, such as higher risk of osteoporosis3 those that stimulate natural synthesis of the pain and itching, cardiac issues, weight gain and heart-related illnesses2. This is caused body’s own supply of collagen and elastin, and skin ageing (amongst others). because oestrogen usually regulates the as actual collagen molecules are too large to These symptoms often last for a period body’s ability to maintain healthy levels of penetrate the skin7 and so topical collagen of two to five years, during which time bone mass, and also helps to maintain blood will not have any effect. Though this is not the Results Technology Repeat treatments Types of fat Fat the body is accepting the fact that it will pressure and cholesterol. Studies have shown case for HA which will penetrate the skin and on same areas reduction no longer be ovulating. This is caused that whilst hormone replacement therapy provide intense moisture where needed8. by a natural change in the body’s sex (HRT) can be used to prevent osteoporosis in Education here is key to helping women Lipocontrast Instant results & Cryothermal 30 Days Targets Soft Fat 30% + hormones, as levels of oestrogen start women that experience early menopause3, understand the fundamental changes to their 80% of results visible Technology using & Hard Fat to decrease. This prevents ovulation and it is not recommended for women with an bodies and how to increase awareness of within 2 weeks heat,cold,heat marks the start of the symptoms stated increased risk of cardiovascular issues (also ways to reduce worsening symptoms. Some above. There are, however, several relating to many other external factors such as of the most common physical symptoms are Normal 2-3 months to see Freezing 2-3 months Soft Fat 20% + coping strategies for dealing with the family history, for example)4. hot flushes and night sweats, which can lead Cryolysis visible results indicators of menopause. These are often to further skin problems, such as itching5 due dependent on the patient’s individual Physical changes to raised stress levels, and can generally be preferences; patients can opt to treat Skin care can become more of an issue at an uncomfortable experience and often quite Lipocontrast process menopause medically with HRT (Hormone this stage of life. It seems to me that ageing inhibiting for the sufferer. Another common Replacement Therapy)1 or more holistically is something that we accept as time goes symptom of menopause is drying of the 1. Before Session 2. Initial heating 3. Cooling 4. Final heating 5. After session with alternative therapies such as herbal on and most of us understand that wrinkles vaginal membrane, also known as vaginal supplements, choosing a healthy diet and are just an unfortunate part of dealing atrophy (VA)9. This occurs because of lack of also with health care products designed with ‘getting old’. However, as well as this, oestrogen and can be very uncomfortable, for menopause issues such as Promensil, menopause can also initiate changes in sometimes even painful for the patient. VA Menopace, Stratum C Menopause Skin the skin that are less ordinary and often causes issues when it comes to sex and Care, A.Vogel products, Balance Activ, and uncomfortable such as itching, redness can be treated with a lubricant or vaginal Wild Yam Cream. and dryness5. This change is caused by the moisturiser that will help to restore levels body’s lack of oestrogen, which in turn causes of moisture to the area, relieve the dryness Changes in appearance your body’s natural supply of collagen (the and bring normality back to a woman’s During menopause, the reduction in structural protein of connective tissues in the everyday life. The lack of libido during this oestrogen can cause the body to make body), elastin (protein found in the body’s time can often cause further psychological Web: www.nuaaesthetics.co.uk permanent changes in its appearance and connective tissues such as skin and organs) difficulties such as a lack of confidence and Email: [email protected] function, hence this time is often known as and Hyaluronic acid (found in the eyes and depression, which can be treated with the

Telephone: 0333 014 2500 Aesthetics | September 2014 39

38923PB full Aestetics page.indd medcine 1 ad.indd 1 02/07/20142/7/14 11:09:52 10:29 Clinical Practice Clinical Focus @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

advice of a medical professional. Amongst can be managed successfully with a balanced taken care of, particularly during this period. the symptoms listed above, fatigue and diet of fruit, vegetables and healthy fats and Menopause is a time for change, but it does mood swings are said to be associated with proteins found in foods such as avocado, not have to be a change for the worse. By a decrease in hormones, though there is nuts, legumes, fish and many other food advising your patients as to the right way varying scientific evidence to support this10. types12. to care for their bodies, and realising the Emotional support can be sought/provided to Another important factor to help prevent importance of managing symptoms properly, accommodate the needs of women on whom ageing is to drink enough water. This of women can navigate their way through the menopause may have had an emotional course applies to all patients, and not just to menopause whilst paving the way to an effect, such as counselling, and also to help menopausal women, as drinking water can overall healthier lifestyle. them to adjust to the changes and manage not only help improve your digestive health, the symptoms that menopause can bring. but can better the appearance of skin13 Fleur-Louise Newsom studied Treatments for menopause vary depending and make the patient feel revitalised and ITEC and City & Guilds in Beauty Therapy and quickly realised her on the severity of symptoms suffered by an refreshed. I have mentioned that skin ageing passion was in skincare. With 20 individual, and is dependent on their existing is a great concern for many women and it is years experience in the industry health. Many women opt for HRT if they have important for patients to know that there are and with her vast knowledge of experienced an early menopause, though many ways in which this can be controlled. skincare and wellbeing, she works closely with the product development team at 11 some sources , would recommend that this Eating and drinking well is a prominent factor Stratum C and answers queries relating to does not need to be taken by all women as skin excretes the toxins we put into our menopause skincare. and that cessation of HRT treatment should bodies, and the physical signs of this can be REFERENCE 14 occur at the age of 50, as taking HRT for blemishes, oiliness and wrinkles . 1. British Menopause Society, Managing the menopause. longer than necessary (average between two Skin can also be cared for using the correct British Menopause Society Council consensus statement on hormone replacement therapy. (London: Journal of to five years) can cause unnecessary side skincare products and cosmeceuticals, British Menopause Society, 2003) Vol.9, No.3: (p129-131) effects, including an increased risk of breast ensuring that they contain no harmful 2. NHS Choices, Symptoms of the menopause. (London: NHS Choices, 2014) < http://www.nhs.uk/Conditions/Menopause/ 2 cancer . HRT is usually prescribed to help ingredients and that they suit the patient’s Pages/Symptoms.aspx> [accessed 25 June 2014] prevent osteoporosis, though it can also help skin type, which changes during this stage 3. Currie, Dr Heather, Osteoporosis. (Scotland, Menopause Matters, 2011) [accessed to prevent or at least ease hot flushes and of life . Products that contain alcohol based 25 June 2014] (p.1) vaginal dryness. ingredients are often too harsh for sensitive, 4. The John Hopkins University, Menopause and the Cardiovascular System. (Maryland, USA: The John thin or dry skin and can cause allergic Hopkins Univeristy, 2014) [accessed on 26 June 2014] 5. Durward, Eileen, Why is the menopause giving me itchy diet. Many women have found that they are skin and also help to prevent the accelerated skin? (Irvine, Scotland: A. Vogel, 2013) [accessed 25 June 2014] (p.1) eating certain types of food and avoiding Many women choose more invasive 6. J.B Schmidt. The influence of hormone replacement therapy others. These might include dairy in high procedures, however this can often be on skin ageing in Maturitas: The European Menopause Journal. (Ireland: Elsevier Inc, 2001) Vol 39, pp 43-55. quantities, alcohol, sugar, caffeine, spicy food, problematic due to the high sensitivity and 7. C. W Lynde. Moisturisers: What they are and How They processed foods/saturated fat and hot food thinning of the dermis during menopause. Work (Toronto: University of Toronto, 2001) < http:// www.skintherapyletter.com/2001/6.13/2.html> [accessed on and drink when suffering severe flushes. In the optimum quantities, and according to 15.08.2014] This is to help relieve and prevent symptoms the latest scientific research, Matrixyl helps 8. Journal of Drugs in Dermatology. Efficacy of cream-based novel formulations of hyaluronic acid of different molecular that can often be exacerbated by eating these to increase collagen levels by up to 70%.16 weights in anti-wrinkle treatment. 2011 Sep;10(9):990:1000. particular foodstuffs. Women should generally Matrixyl 3000 (a combination of the peptides: 9. North American Menopause Society, Sexual Health & Menopause Online. (Ohio: NAMS, 2014) [accessed 25 June 2014] (p.1) 10. Hicks, Dr Rob, The menopause, an emotional rollercoaster. physical wellbeing and also help to prevent ageing’ products, but is often not used in the (Nottingham: Boots UK and Web MD, 2012) [accessed 25 June 2014] (p.1) during this stage of life. ageing. The correct quantities used should 11. Dr Louise Newson, Menopause – Alternatives to HRT, (Tyne There are many foods that are said to help be between a 3-8% concentration, as per the and Wear: Patient.co.uk, 2013) [accessed on 25 during menopause, but the research on research published in the Journal of Molecular June 2014] (p.1) these is inconclusive and arguably lacking in Pharmaceutics16. Products tailored to treat 12. Lewin, Jo. Eat to ease the menopause (London: BBC, 2013) [accessed on 27 June 2014] numbers of females who have incorporated contain high levels of quality ingredients that 13. Kathleen M Zelman, 6 Reasons to drink water, (WebMD, 2013) [accessed on 27 June 2014] that they made a significant difference in products targeted at menopausal women also 14. Katharine Waldman, Is your diet sabotaging your skin? (Prevention.com, Dec 2013) [accessed symptoms, including black cohosh, red clover, naturally occurring substance that helps keep on 27 June 2014] 15. Paula Begoun, Alcohol in skin care: The Facts 8 wild yam, evening primrose oil and angelica your skin hydrated and improve elasticity . It is (Paulaschoice.com, 2014) [accessed on 27 June 2014] women should stock up on supplements. products to prevent it from becoming dry, 16. Hamley, Prof Ian. Collagen effect of peptide amphiphile Numerous people worry about their calcium itchy and above all, wrinkly. The skin is, after C16-KTTKS on human fibroplasts. Journal of Molecular Pharmaceutics. (Washington DC: ACS Publications, 2013) and vitamin D levels, but it is clear that these all, the largest organ in the body, and must be Mar 4;10(3):1063-9.

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2659 3D Lipo Skintech.indd 1 29/1/14 14:51:08 Clinical Practice Treatment Focus @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

pigmentation. When treating Tips for best practice dark skin, it is vital to change the wavelengths and parameters to • Undertake regular conferences and allow for this sensitivity. For skins courses to update your knowledge that are tanned or measure four and ensure you are a qualified, to six on the Fitzpatrick Scale, experienced practitioner. I use ND-YAG 1064nm laser; • Become a licensed laser specialist. while for skins that measure one • Check the credibility of your laser and to four on the scale, a 755 nm manufacturer. Alexandrite laser can be used. • Always do a thorough consulation with extensive medical history and I also have a Q switch NDYAG offer pre and post-care advice. which is perfect for dark, fine, • Always carry out a patch test, and velous hair which would not when increasing fluence perform be affected by LHR, and this further patch tests. technique is particularly brilliant • Educate patients on the importance for bleaching or for post-LHR of SPF and avoidance of sun for the maintenance. I have worked duration of treatment. in the Middle East for the past • Update medical notes after each Laser hair 15 years, so when treating treatment. darker skin patients in this hot humid environment, it is possible to suffer post inflammatory pigmentation. By educating my patients in what they should do before and after the treatment, however, I am able to minimise this occurrence. I often advise patients that removal would be prone to these side effects to use topical solutions to minimise the melanocytes in the skin, stop all peeling creams two weeks prior to treatment Rebecca Treston shares her and very importantly, to have no sun exposure before the treatment and to technique and advice for best always wear a broad spectrum UV SPF. One major advance in LHR treatments as they have grown in popularity is their now relatively pain-free nature, which practice in removing hair with laser is due to cooling systems. I use the Zimmer cooling system which is effective While it seems that laser hair removal (LHR), one of the in counteracting the heat that is felt during the treatment. To ensure the most popular and therefore profit-yielding aesthetic patient feels no pain, I also apply a thick layer of topical anaesthesia one hour treatments, is readily available at an abundance of before a treatment, which acts to reduce the discomfort considerably. I find clinics, it is the expert touch and technique of individual that this combination is more than adequate to ensure that the patient will be practitioners that determines how great a reputation an relaxed throughout the treatment. Prior to offering any individual a treatment institution has for the treatment, and which in turn will at my clinic I will carry out a full and thorough consultation, and in the case of influence the volume of LHR patients coming through the LHR this first step is no different. During this, we can learn about the patient’s door. In general, it is those practitioners that hold an in-depth medical history, and we might even carry out further blood tests if we suspect understanding of the science behind the procedure that are the patient has hormone-related problems such as polycystic ovaries. It is most proficient at carrying out the treatment, and boast the important to understand the effects of any medications that the client might be highest patient satisfaction rate. The primary principle behind taking. For example, a supplement such as St John’s Wort can make the skin laser hair removal is selective photothermolysis (SPTL), or photosensitive to laser and result in burning or post-inflammatory pigmentation. heating up a target chromophore. In the case of LHR, the A consultation also allows us to assess the patient on an individual basis – to chromophore is melanin: the chemical that gives skin and hair discover the reasons why they have chosen the treatment, to ensure their its colour. Because of the selective absorption of photons suitability, to outline any possible side effects they may experience and to of laser light, only black or brown hair can be removed. By explain to them the realistic results that they can expect. Once the patient fully matching a specific wavelength of light and pulse duration understands the different stages of hair cycles and protocols of the treatment, it is possible to safely and thermally destroy the melanin in a consent formed is signed, and this is followed by a patch test to ensure the the area that causes hair growth – the follicle – whilst not patient does not have an adverse reaction. In my experience, there are certain heating the surrounding tissue (skin) and therefore causing areas of the body that yield the best results due to the hair being thicker, no damage to the skin. Since its widespread introduction in denser and darker. These include the bikini line, the underarm, the lower leg the 1990s, constant research has led to safer, more effective – and for male patients the neck. The number of treatments needed varies LHR treatments with dramatically less downtime, pain and between areas but in general, the face will require between four and eight exponentially improved results. For instance, although sessions, while the body will need four to six. Maintenance treatments may also white skin with coarse dark hair was the ideal subject for be required but these will be one or twice per year. the treatment, the latest generation of LHR treatments offer a variety of right wavelengths and varying parameters to Rebecca Treston is a licensed medical aesthetician and ensure treatments for all skin types. That said, on darker skin laser specialist, and a member of the American Academy of Anti-Ageing. In 1999, she relocated to Dubai and founded her types it is very important that the practitioner understands eponymous clinic. Today, Rebecca Treston @Euromed has a the treatment’s limitations and that these skin types are reputation as Dubai’s premier aesthetics clinic and offers the latest much more susceptible to burning and post inflammatory cutting edge anti-ageing body and skin perfecting treatments.

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www.syneron-candela.co.uk | [email protected] Tel. 0845 5210698 This is not intended for the U.S. market. ©2013. All rights reserved. Syneron and the Syneron logo are trademarks of Syneron Medical Ltd. and may be registered in certain jurisdictions. Candela is a registered trademark of the Candela Corporation. UltraSculpt and UltraShape are registered trademarks of UltraShape. PB82801EN Clinical Practice Spotlight On @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com The collagen supplement debate Little in the field of medical aesthetics divides opinion more than collagen supplements. The arguments from both sides are equally convincing when considered on their own, but when measured against the counter claims and held up to scrutiny, the waters become slightly more muddied. Allie Anderson asks the question: are supplements really the silver bullet to youthful-looking skin?

The best things come in small However, Rick Miller, a sports nutritionist dietary protein intake and forms no part of packages? and spokesperson for the British Dietetic my clinical practice.” However, there are One of the most commonly used methods Association, disagrees. “The synthesis of a handful of studies that have convinced of increasing collagen levels is hydrolysed collagen is unique in that there are about five many that hydrolysed collagen works. For collagen supplements. According to different forms of collagen in the body and example, scientists in Germany conducted a the protagonists, what makes this form they’re all composed from the same base – trial among 69 women aged 35 to 55. Those preferable is its reduced molecular size. amino acids,” he explains. “All proteins start who were given animal-sourced hydrolysed “The average molecular size of collagen from that base, and lysine and proline [from collagen over an eight-week period showed itself is about 300 kilodaltons (kD), and the which hydroxyproline is derived] are the improved skin elasticity compared with that average collagen supplement is somewhere two essential amino acids that are needed of participants who were given a placebo.2 between 30 and 90kD, which is still quite for the production of collagen. There are 7g Hydrolysed collagen was also shown to large for your body to process,” explains of lysine in a 3oz portion of beef, and 7g of produce significantly reduced eye wrinkle nutritional therapist and supplement proline in a 3oz portion of turkey. I don’t think volume of between 20 and almost 50%, supporter Eva Escofet. “In clinic, I have that’s outwith a normal diet.” in a group of women aged 45 to 65 who always used a particular type that’s only The message from the sceptics is that the took the supplement once a day for eight 3kD, so it’s extremely tiny and it’s truly pre- human body is mechanised to process weeks as part of another study conducted in digested.” With such a small, lightweight protein in the food we eat, contradicting Germany.3 molecule, Escofet adds, the collagen can the idea that dietary protein is insufficient. Miller argues that such studies are be passed straight through the gut without “We have hydrochloric acid and pepsin in methodologically flawed. “They haven’t having to be broken down by the stomach, our stomachs; we have the enzymes we taken into account the dietary component meaning it is more readily absorbed into need to break down those foods and digest [of protein], which is a huge confounding the body. Medical doctor and nutritionist amino acids, to convert them into proteins factor in skin viability and the progression Dr Vidhi Patel also promotes the use of that benefit the skin,” says nutritionist Kim of collagen synthesis,” he comments. The hydrolysed collagen in liquid form, citing Pearson. “Protein from food can be quite inherent problem in using objective markers its high absorbability as crucial. “Any active difficult for the digestive system to process, – such as wrinkle size – in assessing how ingredient will only be absorbed if it’s but that’s ultimately what it’s designed to do.” successful the supplements are in these digestible,” she comments. “The size of the trials, is that it’s impossible to rule out the molecule is imperative – if it’s too large you The science behind the claims effect of other variables. “Participants could won’t digest it. In hydrolysed collagen, the Concerns regarding the efficacy of collagen have gone away and eaten better in that molecules are tiny but multiple in number, so supplements are often centred on the eight weeks period,” Miller adds, “and you can easily digest and absorb them.” lack of reliable data. Dr Andy Pickett, a Practitioners have suggested that the microbiologist and expert in botulinum toxin, Skinade: Effect on acne after 60 days of use amount of collagen that appears to asks: “What evidence is there that they help produce optimum skin improvement in people in any way? And is there any basis their experience is around 10g when in fact that an oral collagen supplement ingested as a solid, but Dr Kathryn Taylor- ends up effectively depositing collagen Barnes suggests that due to the increased in the places it’s needed?” Cosmetic absorbability rate in a drinkable formulation, dermatologist Dr Raj Acquilla is concise in this reduces the amount to around 6g.1 response. “There is no credible evidence to According to Escofet, a protein-rich diet suggest that oral collagen is prioritised to the contains an insufficient concentration dermis in preference to another part of the of hydroxyproline, the specific amino body,” he says. “A collagen drink is no more acid needed for collagen synthesis. effective at skin rejuvenation than adequate

44 Aesthetics | September 2014 Clinical Practice @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com Spotlight On

“The skin is the last organ to be prioritised for any nutrient because it’s at the extremity”

citrus fruits, kiwi fruits, berries, and even the difference, but anecdotal evidence vegetables.” is good and clients see a positive result,” Dr Godfrey suggests that a hydrolysed she says. And clients in search of an elixir marine collagen supplement that’s packed to improved skin are often happy with a with additional ingredients produces trial-and-error approach – as long as don’t optimum results in the skin. “Hyaluronic believe that they are spending over the Skinade: effect on eczema acid is particularly beneficial to the skin odds. “There isn’t a great deal of published after 30 days of use because it slows down water evaporation science behind it, but at around the £1 a that’s quite a long time to make some good and provides something of a barrier to day price bracket, many people are willing nutritional changes to your diet.” water loss,” he comments. “There are to at least give it a try to see if it works,” Dr Other practitioners, including Dr Patel, other additional elements such as borage Philips adds. “There are some supplements suggest that trials conducted in rats can be oil and other vitamins, which individually at around triple that price, and that’s a lot of used to demonstrate that marine collagen have a variety of effects and seem to work money if a client finds three months down peptides, administered orally, improve the well together to support the action of the track that it doesn’t work.” deposition of collagen fibres.4 But there is the collagen.” However Dr Taylor-Barnes The anti-supplements camp stands firm, difficulty in extrapolating those findings to points to a study demonstrating that HA though, claiming that money is better spent humans, says Miller, as rats are known to shows poor absorption when taken orally elsewhere. “The skin is the last organ to be have very different enzymatic activity and and suggests that it is not expressed in prioritised for any nutrient because it’s at typically, much faster metabolisms than the skin.5 Vitamins C, A, E and B1, zinc and the extremity, so yes, people will see results humans. “Often, you see results a lot quicker, copper are important in a supplement, by boosting protein from the inside,” says but if you try to transpose that data to a says Dr Patel, who also suggests that Pearson. “In the UK we don’t eat enough human model you aren’t going to see the lysine and threonine – amino acids that protein so whether you give someone a same effects.” are not produced by the body – alongside form of protein supplement or feed them BioPerine, a patented black pepper extract, chicken, then you’ll see an improvement Active ingredients should be included as well. in their skin. I would suggest the latter.” Among the supplement enthusiasts, opinion Focusing on diet means more than simply on the best source of collagen differs. increasing protein foods, according to Some practitioners, Escofet included, prefer Miller. Equally important is avoiding activity bovine collagen. “The big difference is that that inhibits protein synthesis – notably animal-sourced proteins resemble human chronic dieting and stress, which stimulate collagen in molecular structure, so the the production of cortisol and disrupt the body recognises it and the bioavailability hormonal milieu of the body. is better,” she says. “In addition, fish is Are collagen supplements the panacea a prevalent allergen, whereas bovine for smoother, wrinkle-free skin? Perhaps collagen is hypoallergenic.” Dr Martin greater investment in scientific research Godfrey, a GP and medical writer and Skinade: Effect on crow’s that rules out the interplay of dietary protein feet lines after 30 days broadcaster, argues that marine collagen and other variables will convince even the is better. “Made from skin and scales, it Not just skin deep most sceptical in the future. But for now, it seems to contain good antioxidant activity Supplementary collagen has been seems the jury is still out. and improves the water-absorbing and shown to be absorbed in the intestine REFERENCES water-holding capacity of the skin,” he and accumulate in cartilage, producing 1. Schrauzer GN, ‘An Evaluation of Liquid Vitamin-Mineral Supplement Technology’, Journal of Medicinal Food, 1 (3), (1998) says. “There is also less potential risk from beneficial effects in people with 2. Proksch E, Segger D, Degwert J, Schunck M, Zague V, pathogens such as BSE.” osteoarthritis.6 Escofet points out that this Oesser S, ‘Oral supplementation of specific collagen peptides has beneficial effects on human skin Supporters and opponents seem to agree hydrolysed collagen is also used to treat physiology: a double-blind, placebo-controlled study’, Skin that in order to boost collagen in the body, gut permeability, or leaky gut, which is the Pharmacol Physiol. 27(1) (2014), pp. 47-55 3. Proksch E, Schunck M, Zague V, Segger D, Degwert J, Oesser additional nutrients are necessary. Miller root cause of many allergies and digestive S, ‘Oral intake of specific bioactive collagen peptides says these nutrients are abundant in a complaints. reduces skin wrinkles and increases dermal matrix synthesis’, Skin Pharmacol Physiol, 27(3) (2014), pp. 113-9 balanced diet. “Amino acids are the bricks For medical aesthetic practitioner Dr 4. Zhang, Z., Wang, J., Ding, Y., Dai, X. and Li, Y., ‘Oral to build your health – so how do you start Toni Philips, this is evidence enough that administration of marine collagen peptides from Chum Salmon skin enhances cutaneous wound healing and angiogenesis in building it?” he asks. “You need vitamin such supplements could also increase rats’, J. Sci. Food Agric., 91 (2011), pp. 2173–2179 C and iron. If you eat red meat you’re dermal collagen, but admits that the 5. Laznicek M, Laznickova A, Cozikova D and Velebny V, ‘Preclinical pharmacokinetics of radiolabelled going to get a very good bioavailable, added ingredients could be playing a hyaluronan’, Pharmacological Reports, 64, (2012), pp. 428-437 highly absorbable source of iron. Vitamin role. “You could argue that the vitamins 6. Bello AE, Oesser S, ‘Collagen hydrolysate for the treatment of osteoarthritis and other joint disorders: a review of C is plentiful in a high intake of fruit – in and hyaluronic acid are what’s making the literature’, Curr Med Res Opi, 22(11) (2006), pp. 2221-32

Aesthetics | September 2014 45 Clinical Practice Abstracts @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

A summary of the latest clinical studies

Title: The relationship between alopecia areata and alexithymia, Authors: D Thaysen-Petersen, M Barbet-Pfeilsticker, F anxiety and depression: a case-control study. Beerwerth, JF Nash, PA Philipsen, P Staubach, M Haedersdal. Authors: R Sellami, J Masmoudi, et al Published: British Journal of Dermatology, July 2014 Published: Indian Journal of Dermatology, July 2014 Keywords: At-home laser, IPL, low-fluence TM Keywords: Alexithymia, alopecia areata, anxiety, depression Abstract: At-home laser and intense pulsed light hair removal Abstract: Alopecia areata’s (AA) aesthetic repercussions can continues to grow in popularity and availability. A relatively limited Aneva Derma lead to profound changes in patient’s psychological status and body of evidence is available so our objective was to assess growing relationships. The goal was to investigate a possible relationship hair counts, thickness and colour quantitatively during and after Advanced Nutritional SKIN Beverage between AA and alexithymia as well as anxiety and depression. cessation of low-fluence laser treatment. Thirty-six females with Fifty patients were seen in the Department of Dermatology of skin phototypes I-IV and light to dark-brown axillary hairs were Hedi Chaker University Hospital, were included in this study. included. Entire axillary regions were randomized to 0 or 8 self- Anti-Ageing from Within Patient’s mean age was 32.92 years. 52% of patients were females. administered weekly treatments with an 810 nm home-use laser Depression and anxiety were detected respectively in 38% and at 5.0-6.4 J/cm2. Thirty-two females completed the study protocol. 62% of patients. There was statistically significant difference During sustained usage, there was a reduction in growing hair that between patients and control group in terms of depression (P = reached a plateau of up to 59% while remaining hairs became up 0.047) and anxiety (P = 0.005). 42% of patients scored positive for to 38% thinner and 5% lighter (P<0.0001). The majority of subjects alexithymia. No significant difference was found between patient (77%) reported ‘moderately’ to ‘much less hair’ in treated than and control groups (P = 0.683) in terms of alexithymia. Anxiety untreated axilla and assessed remaining hairs as thinner and lighter was responsible for 14.7% of variation in alexithymia (P = 0.047). (≥60%). After treatment cessation, hair growth gradually returned Our study shows a high prevalence of anxiety and depressive to baseline levels and 3 months after the final treatment, count and symptoms in AA patients. Dermatologists should be aware of the thickness of actively growing hair exceeded pretreatment values by psychological impact of AA, especially as current treatments have 29% and 7%, respectively (P≤0.04). Sustained usage of low-fluence limited effectiveness. laser induced a stable reduction of growing hair counts, thickness and colour. The reduction was reversible and hairs regrew beyond Title: Tarsodermal suture fixation preceding redundant skin baseline values after cessation of usage. Computer-aided image excision: a modified non-incisional upper blepharoplasty method analysis was qualified for quantification of hair counts, thickness for elderly patients. and colour after laser epilation. Authors: H Yoon, B Park, K Oh Published: Archives of Plastic Surgery, July 2014 Title: A double-blind, randomized, multicenter, controlled Keywords: Blepharoplasty, Blepharoptosis, Eyelids trial of suspended polymethylmethacrylate microspheres for the Abstract: In aging patients, non-incisional blepharoplasty correction of atrophic facial acne scars is not effective due to more severe blepharochalasis. Incisional Authors: Dr Jwala Karnik, Dr Leslie Baumann et al blepharoplasty is a common surgical method used for older Published: Journal of the American Academy of Dermatology, patients, but blepharoplasty in elderly patients typically results in April 2014 prolonged recovery times, and final blepharoplasty lines may be Keywords: Acne, Scarring, PMMA-collagen located in unintended or asymmetrical positions. Ten patients were Abstract: Polymethylmethacrylate (PMMA) microspheres in treated using a new combination method. We performed non- collagen (ArteFill, Suneva Medical Inc, Santa Barbara, CA) have incisional blepharoplasty using tarsodermal fixation. Incisional shown long-term benefit for nasolabial fold treatment. A pilot study blepharoplasty with additional elliptical excision of the upper has shown benefit for PMMA-collagen in atrophic acne scarring. eyelid skin was performed. We removed pretarsal tissue, fat, the We sought to demonstrate the safety and effectiveness of PMMA- orbicularis oculi muscle, and orbital fat. Telephone surveys were collagen for acne scarring in a controlled, blinded trial. Subjects administered to all patients for follow-up, to which 90% responded. with at least 4 moderate to severe rolling, atrophic scars randomly www.aneva.co.uk All cases of moderate to severe blepharochalasia were corrected received PMMA-collagen or saline injections. Subjects underwent up and there were no major complications. Patients who underwent to 2 injection sessions and were followed up for 6 months. Efficacy blepharoplasty had higher satisfaction scores. All patients were was assessed using a validated rating scale for each scar. 147 subjects satisfied with the postoperative shapes of their eyelids. The underwent injections. Success was achieved by 64% of those treated advantages include: ease of obtaining a natural-looking fold with with PMMA-collagen compared with 33% of control subjects (P = symmetry at the desired point; reproducible methods that require .0005). The treatment showed excellent safety with generally mild, short operation times; fast postoperative recovery that results in a reversible adverse events. No significant differences in efficacy or natural-appearing double-eyelid line; and high patient satisfaction. safety were noted between genders, for darker skin types, or in older age groups. PMMA-collagen demonstrates substantial effectiveness Title: Quantitative assessment of growing hair counts, thickness in the treatment of atrophic acne scars of the face while maintaining and colour during and after treatments with a low-fluence, home- an excellent safety profile. Further follow-up should be undertaken device laser: a randomized controlled trial. to demonstrate longer-term benefit and safety. Meeting the needs of your business, delivering high satisfaction to your patients Call us on 01234 313130 [email protected] www.aestheticsource.com 46 Aesthetics | September 2014 AnevaTM Derma Advanced Nutritional SKIN Beverage Anti-Ageing from Within

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GREATER WORKING COMFORT • Lightweight, ergonomic syringe for more comfortable handling

• Lower extrusion force for reduced fatigue

OPTIMISED CHOICE • Emervel Volume available in 1ml or 2ml - Your choice of comfort and flexibility depending on your patients’ needs.

You can sign up to receive email & text message alerts through Galderma (UK) Ltd Galderma (UK) Ltd’s A&C Meridien House, 69-71 Clarendon Road, subscription service for Healthcare Watford, Hertfordshire WD17 1DS Professionals and Non-Medical Tel: 01923 208950 Email: [email protected] Aesthetic Clinic Staff. Scan here, For more information visit www.galderma-alliance.co.uk or visit www.galderma-mail.co.uk

EME/030/0714 Date of prep: July 2014 Aesthetics Awards @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com Special Focus EMERVEL – MORE CHOICE AND CONFIDENCE IN The MID-FACE FILLER SOLUTIONS Volume is key to maintain facial balance and restore the faces natural contours. Emervel has gel textures finalists are especially designed for lifting capacity and volume restoration, optimised especially for the mid-face regions.

EMERVEL DEEP FOR SHAPE EMERVEL VOLUME FOR VOLUME REDEFINITION RESTORATION announced Emervel Deep for patients who require mid-face Emervel Volume for patients who require mid- shape redefinition due to flat zygomatic bones or face volume restoration due to volume loss Following months of anticipation, the finalists for The Voting is now open on The mild-to-moderate facial asymmetry. caused by ageing. Aesthetics Awards 2014 can now be revealed. Given Aesthetics Awards website both the exceptional quality and sheer volume of entries www.aestheticsawards.com received this year, reaching the finalist stage is a fantastic As a reader of Aesthetics journal you will be able to vote in The Aesthetics achievement and a wonderful demonstration of the Awards. Login to the Awards website commitment of so many to raising standards within the using your Aesthetics login, or by creating a new account, to cast your medical aesthetics profession. vote. Select categories will be decided by reader votes, while others will Winners will be decided either by Aesthetics reader votes or by our Awards judging be decided by the judging panel. panel. The voting and judging process is open from the 1st September until the 31st Please see each category below for October, with the winners announced at The Aesthetics Awards ceremony. clarification. Voting and judging will To be held at the four star Park Plaza Westminster Bridge Hotel, London, the close on 31st October 2014. Voting is IP address monitored and each awards will honour the winners and, where appropriate, highly commended individual can only vote once. Multiple INTRODUCING EMERVEL VOLUME 1ML – AVAILABLE SEPTEMBER 2014 and commended finalists in twenty categories. The night will also feature the votes under the same name or from presentation of the special Lifetime Achievement Award, a guest presenter, the same email address may also comedian and music. be discounted from the final total. SMOOTHER FLOW Multiple voting from within finalists’ • Optimized gel texture: Homogenous gel Tickets can be booked on the Aesthetics Awards website, or by contacting organisations will be monitored. particle calibration enables smooth and regular extrusion our Customer Service team by phone 0203 096 1228 or by email [email protected]. • 27 G Ultra-thin-wall needles improve flow rate and reduce extrusion force The judging panel… GREATER WORKING COMFORT A panel of 18 judges have been selected to consider those categories that will be decided by judges scores. For each of these categories, a • Lightweight, ergonomic syringe for more comfortable handling group of six judges have been assigned. These groups have been chosen specifically for their knowledge and expertise in that particular area, as well as to ensure the avoidance of any conflicts of interest in the judging process. • Lower extrusion force for reduced fatigue

OPTIMISED CHOICE • Emervel Volume available in 1ml or 2ml - Your choice of comfort and flexibility depending on your patients’ needs.

Amanda Cameron Mr Dalvi Humzah Dr Raj Acquilla Dr Tapan Patel Dr Johanna Ward Dr Tracy Mountford Dr Mike Comins Dr Patrick Bowler Dr Sarah Tonks Sharon Bennett

You can sign up to receive email & text message alerts through Galderma (UK) Ltd Galderma (UK) Ltd’s A&C Meridien House, 69-71 Clarendon Road, subscription service for Healthcare Watford, Hertfordshire WD17 1DS Professionals and Non-Medical Tel: 01923 208950 Email: [email protected] Aesthetic Clinic Staff. Scan here, For more information visit www.galderma-alliance.co.uk or visit www.galderma-mail.co.uk Dr Stefanie Williams Wendy Lewis Dr Christopher Mr Adrian Richards Marie Duckett Dr John Curran Mr Chris Inglefield Dr Beatriz Molina Dr Paula Rowland Payne Charlesworth

EME/030/0714 Date of prep: July 2014 Aesthetics | September 2014 49 Aesthetics Awards Special Focus @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

The finalists…

COSMECEUTICAL RANGE/ PRODUCT OF THE YEAR Winner decided by: votes Medik8 Range Heliocare; Advanced, Color & 360 (AesthetiCare) Epionce (Episciences Europe LLP) Obagi Systems (Healthxchange Pharmacy) NeoStrata Skin Active Cosmeceutical Range (Aesthetic Source Ltd) Dermamelan by mesoestetic (Mesoestetic UK) SkinCeuticals Range Retriderm - Retinol Protein-Rich Serums (AesthetiCare)

TREATMENT OF THE YEAR Winner decided by: votes Aqualyx (Healthxchange Pharmacy) INTRAcel (Healthxchange Pharmacy) Dermalux LED (Aesthetic Technology Ltd) 3D-lipomed (3D-lipo Ltd) NeoGen Plasma Skin Regeneration (Energist Medical Group) VelaShape III (Syneron Candela) Sculptra (Sinclair Pharma) Ultherapy (CoachHouse Medical)

DISTRIBUTOR OF THE YEAR Winner decided by: votes Medical Aesthetics Supplies Harpar Grace International AesthetiCare Healthxchange Pharmacy Church Pharmacy Medfx

INJECTABLE PRODUCT OF THE YEAR Winner decided by: votes Belotero (Merz Aesthetics) Juvéderm VOLIFT with Lidocaine (Allergan) Aqualyx (Healthxchange Pharmacy) Emervel Deep (Galderma UK Ltd) Sculptra (Sinclair Pharma) Stylage (Rosmetics)

50 Aesthetics | September 2014 Aesthetics Awards @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com Special Focus

The finalists…

EQUIPMENT SUPPLIER OF THE YEAR THE 3D-LIPOMED AWARD FOR BEST Winner decided by: votes NEW CLINIC, UK AND IRELAND Lumenis (UK) Ltd ABC LASERS Solta Medical 3D-lipo Ltd BTL Aesthetics Syneron Candela Winner decided by: judging panel Radiance MediSpa Elite Aesthetic Treatment Clinic Cosmex Clinic BEST CUSTOMER SERVICE BY A Rosmetics Skin Clinic MANUFACTURER OR SUPPLIER Specialist Skin Clinic Dr Leah Cosmetic Skin Clinic Winner decided by: votes Changes Clinic Limited AZTEC Services PHI Clinic Merz Aesthetics Galderma Lynton Lasers Ltd Boston Medical Group Ltd. Aesthetic Source Ltd BTL Aesthetic THE ROSMETICS AWARD FOR Medisico Aesthetics Ltd BEST CLINIC NORTH ENGLAND

THE JANEÉ PARSONS AWARD FOR SALES REPRESENTATIVE OF THE YEAR, SUPPORTED BY HEALTHXCHANGE PHARMACY Winner decided by: judging panel Air Aesthetics Clinic Botastic Aesthetics Ltd Cosmedic Skin Clinic Diane Nivern Clinic Ltd Winner decided by: votes Soul Care Aesthetics Emma Barlow (Healthxchange Pharmacy) Good Skin Days Belinda Aloisio (Loreal - SkinCeuticals) Smileworks Iveta Vinklerova (Boston Medical Group Ltd.) Myskindesign Ltd John Campbell (Allergan) Daniela Mighall (Merz) Linda Wormald (Healthxchange Pharmacy) Louise Taylor (Aesthetic Technology Ltd) Paula Dene (Merz Aesthetics) THE NEOCOSMEDIX AWARD FOR ASSOCIATION/INDUSTRY BODY OF THE YEAR

Winner decided by: votes BACN (British Association of Cosmetic Nurses) SOMUK (Society of Mesotherapy of the United Kingdom) PIAPA (Private Independent Aesthetic Practitioners Association)

Aesthetics | September 2014 51 Aesthetics Awards Special Focus @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

THE SYNERON CANDELA AWARD THE SINCLAIR IS PHARMA AWARD FOR FOR BEST CLINIC SCOTLAND BEST CLINIC WALES

Winner decided by: judging panel Winner decided by: judging panel Dermal Clinic Peaches skin Clinic Innocent Aesthetics Transform Cardiff Age Refined Medical Cosmetic Centre Specialist Skin Clinic Clinetix Temple Medical Spire Edinburgh Hospital BEST CLINIC IRELAND Face and Body Cosmetic Clinic La Belle Forme Winner decided by: judging panel River Medical Dundrum laser & skincare clinic Medi-Cosmetic ClearSkin

THE DERMALUX AWARD FOR BEST CLINIC SOUTH ENGLAND THE CHURCH PHARMACY AWARD FOR CLINIC RECEPTION TEAM OF THE YEAR

Winner decided by: judging panel Persona Cosmetic Medicine Lumley Aesthetics LLP Winner decided by: judging panel Health + Aesthetics Gemma Knight, Georgina Parker and Juliet Goodsell Medikas (Persona Cosmetic Medicine) Jill Zander Skin Rejuvenation Clinic Radiance MediSpa Reception Team Spire Southampton Hospital Hana Te Reo, Lucia Krivonakova, Ema Slavikova and Camelia The Skin Clinic Sevenoaks Rahoui (Harley Street Treatments Ltd) Firvale Clinic Temple Medical Reception Team Rebecca Raynor, Charlotte Crilly and Rose Garth (Jill Zander Skin Rejuvenation Clinic) Laura Zito (The Skin Clinic) Carol Smith and Christine Hockney (Firvale Clinic) Lynda Thompson, Jack Gibson, Emma Clarke, Jessica Girvan, THE OXYGENETIX AWARD FOR BEST Libby Warlow (PHI Clinic) CLINIC LONDON

TRAINING INITIATIVE OF THE YEAR

Winner decided by: judging panel CanuSCULPT (Dr Linda Eve) Winner decided by: judging panel European Medical Aesthetics Ltd (Dr Kate Goldie) Harley Street Treatments Ltd. The Galderma Facial Anatomy Course London Bridge Plastic Surgery Cosmetic Courses EF MEDISPA Obagi Medical System Training harpal clinic (Sharron Lister for Healthxchange Pharmacy) Aesthetic Skin Centre RA Academy (Dr Raj Acquilla) Dr Leah Cosmetic Skin Clinic Mr Dalvi Humzah Facial Anatomy Teaching The Rejuvenation Clinic and Medispa The Facial Aesthetics Masterclass

Sponsorship PHI ClinicPartner (Dr Tapan Patel and Dr Raj Acquilla)

52 Aesthetics | September 2014 Aesthetics Awards @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com Special Focus

THE MERZ AESTHETICS THE INSTITUTE HYALUAL AWARD FOR AESTHETIC MEDICAL AWARD FOR AESTHETIC NURSE PRACTITIONER OF THE YEAR PRACTITIONER OF THE YEAR

Winner decided by: judging panel Winner decided by: judging panel Sharon King Eve Bird Dr Terry Loong Mr Christopher Inglefield Helen Hannigan Dr Linda Eve Dr Raj Acquilla Frances Turner Traill Dr Kate Goldie Dr Johanna Ward Malti O’Mahony Dr Martyn King Dr Tracey Bell Louise Sommereux Dr Beatriz Molina Dr Tapan Patel Trudy Friedman Dr Simon Ravichandran Dr Askari Townshend Ros Bown

THE PINNELL AWARD FOR PRODUCT THE AESTHETIC SOURCE AWARD FOR INNOVATION LIFETIME ACHIEVEMENT

Winner decided by: judging panel ResurFX module of M22 (Lumenis UK Ltd) 3Dose BoNT Syringe (TSK Laboratory Europe B.V) Restylane Skinbooster SmartClick System (Galderma UK Ltd) Aneva Derma (Aesthetic Source Ltd) This award recognises the outstanding achievements and significant 3D-lipomed (3D-lipo Ltd) contribution to the profession and industry by an individual with a long Regenlite Transform (Chromogenex) career in medical aesthetics. The winner of this category will be selected VANQUISH (BTL Aesthetics) by the Aesthetics judges from within the profession. Individual entries miraDry (Aesthetic Business Partners LLP) have not been accepted for this category.

Book Now! Don’t miss your chance to attend the most prestigious event in medical aesthetics. Individual ticket: £200 plus VAT Table of 10: £1,900 plus VAT To book your tickets visit www.aestheticsawards.com, call 0203 096 1228 or email [email protected]

Aesthetics | September 2014 53 In Practice Marketing @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

Three simple ways to boost your local marketing

Jill Woods explains how to make the most of business in your local area

Marketing any business that is geographically anchored to one Instead I’m talking about strategic networking, with individuals town or local area generally makes the whole process easier. or organisations that can put you in front of groups of your ideal Providing there are enough of your ideal patients within 10 miles of patients, and not just one or two of them. This obviously requires your practice, marketing should, in theory, be straightforward. you to know exactly who your ideal patients are. If you don’t know Your ultimate goal is to become well known, and doing that in a this, you need to go back to basics and work out who your best relatively small geographical area is much easier than achieving the patients are. They will most probably be repeat patients; those that same level of fame nationally. Even with the odds stacked in their are happy with your service and willing to spend money in your clinic favour, many practices struggle, or at least find it difficult, to attract on a regular basis. Your best patients are your ideal patients and you the numbers of patients they would ideally like to see coming to want to find more of them. Once you know who they are, you need their clinic. To get the phone ringing and increase the footfall in to figure out where they congregate en masse, and who has the your practice, there are three key elements of marketing that you power to put you in front of them. For example, it may be the editor need to execute successfully. Once you do, you will find that you of Yorkshire Life or the owner of a local health centre, or even the have a whole host of new patients making enquires and booking manager or captain of a local netball team. It really does depend on appointments. who your ideal patients are. These gatekeepers are the people you Many people misunderstand marketing as just advertising or need to network with. Get to know them, and help them get to know promoting their practice. In doing so, they miss out on a huge you and the services you offer. Once you have made a meaningful amount of important marketing activity. connection with these people in your community, you need to work Marketing actually covers six key areas known as the ‘6 P’s’ out how you can help them to help their audience. What real value Product - The service you offer can you add that, in turn, demonstrates what you can do, and how Pricing - What you charge you can solve any problem their audience may face. For example, People - Are your employees performing effectively in their roles? you could help them by giving advice on how to look fantastic for Place - The environment where you deliver your services the annual club charity ball using simple self-help techniques, or Processes - How you manage the practice and patient you could share a six-week countdown calendar to help them get communications ready for their summer holiday. In the eyes of potential patients Promotion - Raising awareness of you and your practice you immediately gain credibility by being associated with, and To successfully stand out from the crowd you need to deliver a great introduced by, a person that they already know and have respect combination of all of these elements. The following are three areas for. However, you still need to demonstrate how you can help these that you can develop within your practice to help you raise your potential patients. profile and gain prominence in your local area. Getting in front of these groups of people can take many forms: 1. SEEK FAME • A printed article This is not national celebrity fame, but fame at a local level. If people • A face-to-face presentation don’t know about you and the services that you offer in your local • A practical demonstration area, you are going to struggle to find the new patients needed to • A joint offer promoted by email turn your practice into the amazing success story it could be. Bear • A feature on their website in mind local fame is not going to come looking for you, you have • A guest post on their blog to make it happen. To get known locally you must go out, into the • A video embedded on their website community, and network with as many people as possible. Please note at this point you are helping them, not selling to them. By this I do not mean visiting networking clubs where thirty people You have to earn the right to sell to them by building trust and rush around pressing business cards into each other’s hands whilst confidence first. So start by demonstrating your expertise and asking, “How can we do business?” Nor am I talking about seeking provide them with information or a skill they can get real benefit individual patients who may be a parent at your daughter’s school. from – for free. If you can show that you are the best at what you do

54 Aesthetics | September 2014 In Practice @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com Marketing

in your area, you will be demonstrating to potential customers why about “I” and “me”, or “us” and “we”, than one talking in the third they should choose you for their treatments rather than a competitor. person.Even if you have a relatively large practice, try to be personal That is the kind of networking that boosts your local fame quickly and and help people decide whether they like you and can trust you. delivers real results in the form of new enquiries and new patients. Again here you can incorporate a local spin on the content you write. Talk about local groups you are involved with, events you have 2. GET ONLINE attended as a practice, or regional awards you have won. Nowadays almost everyone turns to their favourite search engine to e) Use pictures of you and real people in your practice. Everyone has help locate a service that they want to access, even if it is just in their seen the stock photos hundreds of times before and they do nothing local area. So it goes without saying that you need a web presence to help build trust. From a local perspective this also increases in order to show up on these search results. There are two ways I awareness of who you are in the community. This will all help to build would recommend you do this. your local fame. As a general rule, think about the overall message your website images portray. For example, a picture of your empty Have a website waiting room will not give the impression of a popular clinic. Websites are a fantastic way to showcase your expertise, help people get to know you and give them an easy way to make contact. Claim all of your online business directory listings Here are a few points you should consider when putting one Hundreds of different online directories collate basic business together; information from telephone book listings and include them on their a) Host it yourself – don’t use a third party hosted site. You often website as free business listings. Depending on what search terms don’t get a bespoke domain name, are not in complete control of the are used, and the location of the people searching the internet, content and structure, and often don’t own the content on the site. these listings often appear high in the search results if there are b) Focus the content on your home page around your ideal patients, no other good quality websites that relate to the search terms. If and not around you as a practitioner. This is not the place to talk someone in your area searches for any of the keywords relating to about your qualifications or extensive CPD record. Here is where you your practice, even if they don’t type the town or location name, the should talk about problems that prospective patients can relate to search engines know geographically where they are. The search and how (in brief terms) you can help. Also talk about the town/area results provided, including these business directory listings, will be you are based in so visitors see the local connection and know you tailored to their location. As you will then be found via one or more are there to help local people. of these listings you need to invest time in reguarly updating your c) Build in a mechanism for capturing people’s email addresses. website’s content. This way, potential patients find you they see Offer something of great value in exchange for their contact details. This means you can start to communicate with them on a regular basis, and build a relationship that is far more likely to convert into paying patients, rather than potential patients visiting your site and The revolutionary methodical leaving without making a connection with you. Consider a cheat sheet or check list, a “Five things you should know” or “How to that is changing the medical prevent…” type document that they can access in exchange for aesthetic and surgical approach. leaving their email address. d) Don’t try to be corporate. Healthcare is all about building trust, The Ultimate Wireless and people will relate far more to a site that looks personal and talks Platform for all skin tones Plexr main features: • Plasma generator Through the • Wireless and ergonomically designed • No current leakage to the patient • Reliable long-lasting battery, control system impersonal features battery level LED Applications for Plexr: medium of the • Blepharoplasty • Face & body lifting • Treatment of skin dyschromia internet you have • Treatment of stretch marks FREE • Removal of fibromas, nevi, keloids, warts, Training of xanthelasma to enable potential Soft Surgery • Treatment of dyskeratosis Methodical • Treatment of active acne, acne scars Contact us & skin damage patients to make for more details an emotional connection with you and your team . Tel: 0207 481 1656 | [email protected] | fusiongt.co.uk In Practice Marketing @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

Developing your service to to a brilliant clinical outcome and the subsequent follow-up call, the whole patient experience has to be the best it can be. If you please your ideal patients succeed in delivering this to your patients, your local fame will grow exponentially. Happy patients will tell anyone who will listen that means reviewing every they received excellent customer service, and direct word-of-mouth recommendation is the most effective business promotion activity ‘touch point’ - that is, every there is. By being brilliant at what you do, you will create a local buzz way that they have contact around you and your practice. with your business Ask – don’t guess To start this process you have to find out what is ‘exceptional’ in the good quality information and know you are the local “go to” clinic for eyes of your ideal patients. The simplest way to do this is to ask the treatment they want. them. Don’t guess and don’t set out to deliver a service that you would love to receive unless you fall exactly into the profile of your Here are some pointers to make the most of business directory ideal patient. Ask patients about every element of the service you listings: offer, leave no stone unturned. Developing your service to please a) Find as many of your existing business listings as you can your ideal patients means reviewing every ‘touch point’ - that is, Search the internet for your phone number, your name and your every way that they have contact with your business, both before practice name (one at a time) – this usually pulls out most of the and after they become a patient. You need to make sure the words, directory listings. images and environment you create are consistent and resonate b) Claim your listings well with them. These include your: On sites where you find existing listings, you need to claim • Website ownership of them. Look for buttons that talk about claiming your • Business card business, or say “Improve this listing” or “Own this business?” Once • Shop front you click the appropriate link they will usually lead you through the • Reception team process of populating your listing. • Leaflets c) No listing? • Voicemail message On sites where there is no existing listing for your business there will • Internal décor be an option to register your business or set up a profile. Find this • Clinical equipment option and begin to build a listing. If you have a LinkedIn profile you • Online directory listings can also create and add a company page to the listing. • Promotional videos d) Populate your listings • Products for sale It’s important to complete all of the listing options as extensively • Emails or letters as possible. Use logos, pictures, videos, social media profile links, • Written marketing material descriptive text and key words – whatever options are available. • Social media postings Most of these sites will offer you a paid upgrade to add further • Blog posts features. In my experience, this option often does not justify the • Stories in the local paper outlay. However if you don’t have a website this may prove worth the • Public speaking events investment. • Conversations e) Keep a record & remember to update It’s vital to keep a record of all of the sites you register on and all of If all of these elements resonate with your ideal patient then you will, your login details for each site. This means that in the future, if you in their eyes, have created an excellent experience and they will change your phone number or want to add more details, you can come back for more. quickly update all of your listings. Crucially, they will become your local promotional marketing tool, To aid with this process I have created a spread sheet to help you to recommending you to their family and friends. This above anything easily keep track of your listings. Access it online at www.jillwoods. else will sky rocket your local reputation. People trust people they com/wp-content/uploads/2014/07/Business-Directory-Tracker.xlsx know, so if a friend or family member gives them a recommendation If you follow these simple steps you will improve the chances of for a solution to a problem they have, they are much more likely to potential local patients finding you online and picking up the phone, consider that as a good option. Hopefully, this information has helped emailing you or calling into your clinic. you see how you can boost your local marketing – how easily you can ensure more people learn about you, find you, benefit from what 3. DELIVER QUALITY you do, and tell other people about you. These three elements in The next element of your marketing that you need to crack is to combination, and if executed well, will make sure more and more of deliver an exceptional patient experience. Of all of the things you do your ideal patients reach out and pick up the phone. within your marketing mix, delivering an amazing patient experience is the one that has the power to really grow your practice in your Jill Woods trained and worked as a podiatrist for 11 local area. It’s also the one that requires time, honesty and money to years before changing to follow the nomadic career of her husband. Following a few years of running online get absolutely right. businesses, Jill now combines this experience with her But that investment will repay you many times over. From the love for marketing to provide specialist marketing support moment the phone is answered to a prospective patient, through for healthcare professionals.

56 Aesthetics | September 2014 2862 Med-fx Ad September 2014_Med-fx Sales Ad 05/08/2014 15:53 Page 1

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From complaint to litigation: top tips for keeping a cool nerve

Liz Bardolph looks into the possibilities for damage limitation with regard to unhappy patients. This article is based on a presentation at the 2014 FACE conference

Introduction It may even prevent litigation by helping resolution at a local level. There has been a rapid increase in the variety of cosmetic “An apology, an offer of treatment or other redress, shall not of itself treatments available, with the majority of growth occurring in amount to an admission of negligence or breach of statutory duty.”3 the non-surgical sector. In addition, more media exposure and However, take advice from your insurance company before framing increased accessibility have resulted in a rise in the number of your apology, as you do not want to admit liability. After seeing the treatments undertaken. This in turn has increased the potential patient, record the key facts immediately. for iatrogenic harm and poor treatment outcomes. Just because The acronym SOAP may help to marshal your thoughts.4 a known complication has occurred it does not necessarily rule out the possibility of a clinical negligence claim. It is easy to be Subjective concerns are those articulated by the patient wise after the event, and as Lord Denning remarked, “To condemn as negligence that which was only a misadventure.”1 This article Objective refers to what you as the clinician can see will suggest general principles for complaint handling, along with Assessment means the possible diagnosis on the presenting facts ways to avoid, or at least minimise, the possibility of complaints happening in the first place. Should the complaint involve lawyers Plan would be how you intend to proceed with the possibility of litigation, the duties of an expert witness will be explained, along with what is accepted as good practice. Looking after the patient in this way can help to resolve the majority of complaints. If there is a threat of legal action, after investigating General principles for complaint handling the complaint, you would be advised to write a witness statement Most patients want an acceptance of fault, an explanation, and an where all the issues are stated as fact using clear language. apology. The House of Commons Constitutional Affairs Committee (2006) felt that the ‘compensation culture’ was a myth. Recently Keeping out of trouble lawyers have seen an increase in claims arising from sub-optimal Although it is trite to say that no one sets out to harm a patient, cosmetic treatments, with most patients wanting corrective steps can be taken to ensure that patients have minimal grounds treatment.2 All clinics will have their own protocols for dealing for complaint. Needless to say, the clinic must be fit for purpose with a complaint by telephone, letter, email or face to face. The with adherence to health and safety and cleanliness guidelines. important thing is to deal with it immediately, as any delay could From a clinical perspective, record keeping not only enables others make the situation more difficult to resolve. Depending on the to see what has happened, how the patient has responded, and complaint, it is a matter of judgement as to when to inform your a future plan of action, but it can also demonstrate adherence insurance company and product manufacturer. The amount of time to clinic protocols. In the event of a claim, the case notes will be spent on looking into the complaint should be proportional to its a key component of the evidence, so they must be clear and seriousness. Communication is key, so actively listen to what the contemporaneous. When seeing a patient for the first time, it is complainant is saying, through tone of voice and body language, important to document the results of your assessment leading to a and ensure you have full understanding of the concerns. Resist diagnosis. One of the best ways of doing this is to use a diagram the temptation to be defensive and offer excuses. Instead, offer so that, for instance, skin tone, loss of volume and asymmetry can an apology along with an explanation of what you are doing to be noted. Reasons for treatment need to be recorded, as this put things right. Even if the complaint is groundless, the patient could affect the timing or feasibility of treatment. There needs should be thanked for giving you the opportunity to look into the to be dialogue during the consent process so that the material matter. As a matter of course we all apologise in our daily lives, information — i.e.that which is relevant to the patient – can be taken often without thinking. Not only does it show intent to do better, into account when giving information. In some US hospitals the but it can reduce hostility and form an important part of reparation. acronym PARQ is written in the notes to denote that the Procedure

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Cosmetic Ad August 2014.indd 1 11/08/2014 11:48:54 In Practice Law @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

and Alternatives –including doing nothing – have been discussed, the Risks have been explained and the patient has had the Patients seeking redress opportunity to ask Questions.5 A signature on the consent form indicates that a discussion has taken place and that the patient do not necessarily has agreed to treatment. However, this is not evidence of valid consent. want financial

Duties of an Expert Witness compensation, but an Very few cases reach the courts or the professional regulators, as most are settled through negotiation. This is partly because acceptance of fault and the onus is on the patient to prove negligence, which can be a considerable legal hurdle, and partly because of cost. corrective action. The patient has to prove on the balance of probabilities (51%) that the defendant owed a duty of care, the defendant breached that being incurred. If new facts come to light and you change your duty causing damage to the claimant, and that the damage was mind, inform the instructing solicitor immediately. As part of not too remote i.e. there was a linear connection. negotiating a settlement you may be asked to attend a joint If legal action becomes a reality an expert witness is usually meeting of experts; as part of good practice, careful preparation instructed by a solicitor. A person can be an expert witness if, “The is required. Finally, in order to fulfil your obligations to the court witness has acquired by study or experience sufficient knowledge you must understand and comply with the rules set out in the Civil of the subject to render his opinion of value in resolving the issue Procedure Rules Part 35. before the court.”6 There are courses available whereby you can qualify to be an accredited expert witness, and be admitted to a Conclusion voluntary register. The expert’s duty is to advise the court, and The range, number and accessibility of cosmetic treatments has this carries a huge responsibility. Apart from their statutory duty to risen over the years resulting in an increase in the number of sub- the court, the expert must be impartial to avoid bias and must not optimal treatments and complaints. act as advocate. The duties of an expert can be found in the Civil Patients seeking redress do not necessarily want financial Procedure Rules.7 The expert witness will be required to look at all compensation, but an acceptance of fault and corrective action. the evidence from both sides and submit a written report. Many of these complaints can be contained by the practitioners They need to research the subject, gather and analyse the facts of themselves if they bear in mind some basic principles. Responding the case and present their findings as evidence and opinion. She/ to the complaint immediately will help to take the angst out of he must state all the material facts and if they do not have enough it. Communicating with the patient to ensure you understand information they must say so with any assumptions being noted. and acknowledge the concerns are important starting points. The expert witness will need access to good quality peer- An apology, without admitting liability, can also go a long way to reviewed publications. From this it is important they keep up to reparation by demonstrating that you care and are prepared to do date in his/her field of practice. In the event of the expert changing something about the complaint. Thorough and contemporaneous their mind, this must be made known to the instructing solicitor. record keeping, paying particular attention to assessment, Failure to comply with the Civil Procedure Rules may result in little diagnosis, and the consent process, provides evidence that you weight being attached to the evidence or it may be inadmissible. have carried out your duty of care. The case notes, as well as Either way his or her career as an expert may be curtailed. being a patient record, may be used if there is a claim against you. Until 2011 experts were immune from being sued, but this was If lawyers become involved, the instructing solicitor will ask an overturned by the Supreme Court in Jones v Kaney8, a personal expert witness to provide an opinion. His/her role is to advise the injury claim where due to the expert’s incompetence, the claimant court, having weighed up the evidence on both sides and reached suffered considerable financial loss and proceeded to bring a a conclusion. However, it is important that they are totally unbiased claim against the expert. and must not be an advocate. Receiving a complaint is unsettling, but a prompt and diplomatic response will go a long way to Good practice for experts resolving it. To carry out duties as an expert witness, working within your Liz Bardolph has been involved in medical professional area of expertise and being objective and unbiased aesthetics for over sixteen years and is past president are key requirements. There must be no conflict of interest. It is of the British Association of Cosmetic Nurses. advisable to use up-to-date references on current legislation, Following her consultancy work in litigation as research and updated techniques pertaining to practice, which will an accredited Civil Expert Witness, Liz hopes to complete the Masters Postgraduate Degree in be included in your final report. This can only be achieved if you Medical Law and Ethics at the end of 2014. are a practising clinician and have kept abreast of developments REFERENCES through, for instance, attendance at conferences and by reading 1. Roe v Minister of Health (1954) 2All ER 131 and networking. Instructions from the solicitor must be followed 2. Luckman M., ‘Avoiding litigation: what aesthetic nurses need to know about handling complaints’, Journal of Aesthetic Nursing 3(6) (2014), p. 296. carefully, as time and money can be wasted in giving unnecessary 3. Compensation Act (2006), section 2. information, which may be inadmissible. At the outset the 4. Transcription411, The SOAP note (www.transcription411.com) 5. Sokol DK, ‘Let’s stop consenting patients’, British Medical Journal, 348 instructing solicitor will request a time limit for report submission. (2014), p. 2192 As they will have a deadline it is important that the agreed 6. R V Bonython [1984] SASR 45 per King CJ 7. Civil Procedure Rules (2013) Part 35, Practice Directions. timetable is adhered to, with any slippage resulting in penalties 8. Jones v Kaney [2011] UKSC 13

60 Aesthetics | September 2014

In Practice Business Process @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

Vital statistics

Gilly Dickons explores the benefits of collecting figures to boost your business

Statistics. Does the word fill you with dread or enthusiasm? Personally, I love statistics. These figures can prove extremely interesting, useful and informative the earlier you for assessing your everyday practice. Every practice owner benefits from having a clear understanding of the data that underpins their business. As the saying goes: knowledge is power. For a practitioner setting up a new start to use a practice, consider starting the way you mean to go on by harvesting valuable data that you can review periodically. This way you can set yourself goals system to store and targets, as well as bench mark performance. For those practitioners that already have a good client base with regular clinic days, it is essential that you are continually building a database to help manage the business as it grows. valuable data, If you haven’t already got a system in place to store information, you can start with something as simple as a spreadsheet alongside an online diary (such as the simpler it those provided by Google or Apple) – you don’t have to adopt a costly web- based solution. However, for those of you who would like everything stored in the same place, there are some great web-based systems out there that are will be as this cost effective to subscribe to, and simple to learn how to use. In the life of your business, the earlier you start to use a system to store valuable data, the simpler system will grow it will be as this system will grow with you. A good CRM (Customer Relationship Management) solution or Diary Management system can support many areas of your business including your with you. marketing, consultation notes, stock control, invoicing, and scheduling and Once in place the system will help you to produce appointment reminders. and study the figures that underpin your business, Before embarking upon installing or subscribing to a system I would advise you supporting your planning and development. If to spend some time thinking about what your day-to-day needs will be. Many this analysis is not a process that you do at least online systems will offer you a demonstration, with initial support once you quarterly, it may seem quite intimidating to carry begin to use it. out. To make the process of collecting statistics less daunting, I propose that you focus on the There are some basic things to look out for in your search for the ideal system, following key performance indicators, starting with for example: your new enquiries: • Can you access the diary easily, and clearly, from your phone or tablet? • Can you upload consultation notes and patient photographs? Number of new enquiries • Is there a diverse but simple reporting system? Carefully log every new enquiry. This information • Can you have multiple user logins without it costing a fortune? needs to include name, phone number, email • Can you run multiple venues, staff or treatment rooms and still navigate the address, postcode and marketing source. Ask system easily? yourself at this stage whether you are capturing • Is it quick to open and to input data? every new enquiry. If not, you need to take action. • Are costs transparent? Ensure there are no hidden extras – you shouldn’t have to spend a fortune to access a good system. Number of new enquiries who book • Is the diary clear with adaptable time slots? Do you handle your calls personally or do you have • Is there initial training? designated staff who take care of this? If you have a • Can the system send out automated text reminders and possible emails? team carrying out this work then ensure that there is

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www.mesoestetic.co.uk tel: 01625 529 540 [email protected] In Practice Business Process @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

an appropriate system available for staff to log information. You need to identify Advertising Spend / New Enquiries = Cost Per the number of clients that are booking an appointment during the initial enquiry. Lead. For example: You had 10 new enquiry calls The industry gold standard for conversion is 60%, and the average is recognised (leads) over the last month. You spent £100 on to be 45%. However, 70-85% is totally achievable and should be the target for advertising. Dividing £100 by 10 we get a cost of £10 your business. Is there potential to increase your conversions by ensuring that per lead. If we assume that you are operating at an you are looking after every new enquiry? What impact would it have on your industry standard conversion rate of 45%, you have revenue if you could convert new enquiries to appointments then treatment? converted 5 of these leads. If you want to increase Let’s look at a hypothetical example using 10 botulinum toxin enquiries from your monthly sales you need to increase your potential clients who will spend £900 over three visits a year: advertising budget accordingly. In the meantime, it 45% conversion rate gives a potential £4,050 is up to you to establish what is a ‘reasonable’ cost 60% conversion rate gives a potential £5,400 per lead for your practice – there are some forms 80% conversion rate gives a potential £7,200 of advertising that can be very expensive. This Every 1% improvement in your conversion rate will increase your revenue by £90! analysis will ensure that you can pursue the most cost effective solution, as it will highlight your most Number of new enquirers who attend consultation successful source of new clients. You now need to assess the attendance rate of these new clients. If 90% of patients are turning up to their appointments, then the quality of your appointment- Cost of lost leads/enquiries making process and follow up is good – be this due to correct phone manner Another way to look at cost per lead and the value and protocol and/or subsequent reminders. Are you getting many no-shows? If of conversions is the cost per ‘lost’ lead/enquiry: so, you could consider charging a deposit or holding credit card details for your A conversion of only 45% (remember this is the appointments. You should also consider why these customers might be making average for this sector) instead of a possible 80% appointments yet failing to attend. If you aren’t sending reminders, could they be could cost your business £3,150 over those 3.5 lost forgetting that they booked at all? To boost the number of enquirers who attend clients for a 12 month treatment programme. consultation, send appointment reminders 24-48 hours before the appointment; a good diary management system will do this on your behalf. Although some Average spend per treatment customers will inevitably change their mind about the appointment that they have Looking at this information will help you to plan made, if time is set aside in your clinic diary to see a patient and they don’t turn up, and forecast business, giving you a deeper this is time that could have been spent with another patient. Therefore it is in your understanding of your business and clients. You can interest to make every effort to ensure that they attend, and keeping track of the use this information to target marketing campaigns. numbers of no-shows will help you to monitor this. Galderma’s IMPACT study highlighted that when someone buys more than one product or service Number of clients who go on to treatment from your clinic they are 10 times more likely to It’s time now to consider your conversion of appointment to actual treatment. come back to you – does this reflect in your data? This figure should really be running at 80% plus. The 20% margin here allows for clients who are not suitable, or ready, for treatment. Most people who are asked Average frequency of treatment often say that, off the top of their head, their conversion rate is 90%. However be Have you considered how frequently your clients certain of the facts – you may need to revisit your consultation technique in order undergo treatment over a 12-month period? Again, to secure such a high number. Whilst you have done the hard work in preparing this will enable you to forecast and plan ahead. the patient for treatment, these prospective clients may then go into a different You will be able to determine when clients may be practice ready for treatment. Secure the business at the end of your consultation. dropping off your books, when they need reminders, Don’t just assume your conversion is high and that you don’t need to look at the and what their value is to you over the year. exact figures; you may be surprised to learn your exact conversion rate. I have briefly covered the most obvious and central Number of returning clients – your retention rate figures to planning and growing a successful This statistic really has a huge impact on your business. It is really important to business. If you can make the time to explore these, operate a solid recall system, reviewing client treatments at the correct interval. either by checking your records or using a great Always try to book the next appointment before the client leaves the clinic. CRM/Diary Management system, you will be able to Review appointments can be a great way to build relationships with new clients extract valuable information to support the growth of so, even if they do not require post-procedural monitoring, it is a good idea to your practice. This will, without doubt, be time well invite patients back in after their initial treatment to check that they are happy spent and will ensure that your practice goes from with the results. The time spent on review appointments and forward scheduling strength to strength. will be an investment – the recent Galderma IMPACT study1 shows that it is 32 Gilly Dickons is the founder of times easier to sell to an existing customer and five times more expensive to Aesthetic Response, a unique, expert recruit a new one. Schedule in time to really assess your client retention as this enquiry management service to the UK’s makes a huge contribution to your success. aesthetic and cosmetic sector. AR’s team of patient advisors manage calls and diaries on behalf of a variety of practices, Your cost per lead/enquiry using exceptional customer service skills to convert Your business will benefit from understanding your cost to generate each valuable enquiries into consultations. new lead as this will help you to plan a marketing budget, ensuring that you REFERENCE do not waste valuable resources. This is a simple but effective calculation: 1. Galderma IMPACT study (2014)

64 Aesthetics | September 2014 Medisico Advert_Embed_v2.pdf 1 20/08/2014 12:12

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K In Practice In Profile @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com “Being at the cutting edge of new technology is wonderful” Since leaving Sydney, Australia 25 years ago, Dr Rita Rakus has become a well- established cosmetic doctor and aesthetic trainer in the UK

In a 1994 review, a journalist so impressed can improve problems, such as sun damage, the forefront of the industry. She says, “Go to with Dr Rita Rakus’ subtle approach to and get patients looking younger.” conferences, spend time with experts and lip volumising entitled her the ‘London Dr Rakus has won both the Ulthera Ultra find out what’s going on in other countries Lip Queen’, and it has stuck with her ever Premiere Treatment Provider Award and – broaden your horizons.” She adds, “But since. “It’s a great compliment,” says Dr the Premier Pellevé Partner Award. She has always make sure you enjoy it. If you find Rakus. “In those days, lips were very artificial. treated over 3,000 patients to date, making that aesthetics isn’t for you then change your I specialise in a very subtle lip and try to her the world’s biggest user of Pellevé- specialty.” Reflecting on her career, Dr Rakus make patients look slightly more youthful – GlideSafe. But the cosmetic doctor says her comments that the one thing she would have no one would even know that they’ve had biggest achievement is being able to make done differently is to have worried less. “You any treatment done.” After qualifying as a people happy. “My ethos is to try to make at try to help your patients as much as possible medical practitioner in Sydney, Dr Rakus least one person happy every day,” she says. but there will always be the odd patient who had decided to move to the UK in 1989 to As a practitioner, Dr Rakus believes that has a complication. The most important thing learn more about non-invasive aesthetic the most important thing to be aware of to do is to inform your patients of all the procedures. “The aesthetics field was quite is the patient’s individual circumstances. complications that could occur – all you can advanced here,” she explains. “There were “Whether they’re a working mum or a model, do is be well prepared. A good network of more opportunities in the UK to further my everyone’s got different needs, budgets and colleagues to help you out is also useful.” training and development as a practitioner.” situations in life,” she explains. Not everyone In 2000, Dr Rakus met Dr Patrick Bowler and wants the plastic look, she claims; some Q&A together they formed the British Association patients just want to feel more confident What treatment do you enjoy giving of Cosmetic Doctors (BACD - now known during their day-to-day life. “People react the most? as the BCAM) and, alongside other industry differently to you, if you feel better about I enjoy all aspects of my aesthetic portfolio, yourself,” says Dr Rakus. “It could just be a experts, developed an official training but especially love to treat lips. programme for aesthetic practitioners. Dr little frown line that’s annoying a patient – we What technological tool best Rakus is still actively involved in training and can soften that line and cheer them up.” compliments you as a practitioner? lecturing, travelling frequently in order to stay As a trustee of Hand in Hand, a charity that My radiofrequency, ultrasound and laser up-to-date with emerging technology and supports impoverished Indian villages, Dr machines because they give such good techniques. “In the clinic we tend to stay at Rakus is actively involved in raising money results. the cutting edge of technology and really to fund schooling, ecology, literacy and What’s the best piece of career advice specialise in providing excellent treatment citizenship. “My patients come from every you’ve ever been given? and training,” says Dr Rakus. Based next to field so I always talk to them about the To learn how to assess your patients Harrods, in Knightsbridge, and with satellite different things they do,” she says. “This properly – this will enable you to treat clinics throughout the UK, Dr Rakus sees gives me the opportunity to get involved in a them safely. patients from all over the world. wide range of charity work.” Do you have an industry pet-hate? “Aesthetic medicine is now so broad, and Dr Rakus does note that aesthetics can I think it’s important to share knowledge accepted. Around 25% of our patients are sometimes be a difficult industry to work and help each other. Usually that happens, male and we see people from all walks in. She says, “It takes special skills, but but it’s such a shame when it doesn’t. of life,” she says. As many more people if you’re an artistic person and enjoy What aspects of the industry do you continue to work until later in life, Dr Rakus correcting problems for people then it’s a enjoy the most? believes that a 60-year-old is no longer great pleasure and can be an extremely I enjoy meeting new doctors and patients when I’m travelling. I also love to seen as ‘old’. “These patients are working satisfying. If you prefer looking through a see the technological advances – being for longer and want to keep looking fresh microscope then aesthetics is not for you.” at the cutting edge of new technology is and on the ball,” she explains. “They still feel For newly qualified practitioners, Dr Rakus wonderful. young inside – until they look in the mirror. I advises that travel is the best way to stay at

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the public, the review’s recommendations called on existing frameworks – the RCS and Health Education England (HEE) – to develop adequate and appropriate qualifications for the aesthetic sector. This will be a difficult process, involving a multitude of stakeholders working in several differing arenas of medical aesthetic practice. It is high time that aesthetic practice is recognised not as an industry or sector, but as a truly professional specialty. The difficulty in producing a syllabus or qualification is that there is currently no national body that can truly represent the different groups within the aesthetic sector. Many clinical specialties have their own colleges (Royal College of Surgeons, Royal College of Physicians,) or faculties (Faculty of Travel Medicine, Faculty of Podiatry) that have a central role in setting educational and training standards. The last word Yet for a specialty that has a large public role, attracting increased interest from Mr Dalvi Humzah argues for clarity and unity the Department of Health, there is no move to set up a specific royal college for in aesthetics aesthetics, or at least a multidisciplinary faculty of aesthetics/cosmetic surgery & We work in interesting times. Words are The GMC is involved in the revalidation medicine. used interchangeably and with imprecise and professional standards of doctors and The setting up of such a body should, in my meanings to communicate, and in some medical students. In particular, the GMC opinion, feature on the priority list of those cases misdirect, our potential patients. The maintains a Specialist Register for which currently regulating the industry due to the terms ‘Aesthetic’ and ‘Cosmetic’ are used; entry is obtained through specific faculties major role that aesthetic medicine has in the former has been defined as, “Relating and Royal Colleges. Surgeons were initially the current industry — estimated to be in to perception by the senses – concerned separated into nine specialties, however the region of 2.3 billion pounds. The setting with beauty or the appreciation of beauty”, this has recently been expanded to 10, to up of such a college or faculty would be the latter may be considered as relating to, include Vascular Surgery. Within these 10 of benefit to physicians, surgeons, dentists “Treatment intended to restore or improve specialties is the separate specialty of Plastic and nurses. With such a faculty as this, a person’s appearance derived from the & Reconstructive Surgery. Within this specialty there could be a central organisation art of adorning (beautifying) the body.” The is the sub-specialty, ‘Aesthetic Surgery’, often that has input regarding the standards, simultaneous use of the two terms has called ‘Cosmetic Surgery’, defined by the educational and academic requirements created a sector that in many people’s view is Royal College of Surgeons (RCS) as “The of the professionals in this specialty. With unregulated and lacks cohesion. changing of appearance by choice and not all the recent interest from the regulatory Those who offer cosmetic/aesthetic for the treatment of disease.”1 And yet even bodies, both nationally and internationally, treatments – cosmetic doctors, physicians, these current specialties have a tendency as well as interest from the public, the nurses, surgeons – refer to themselves as to be unclear; for example, the sub-specialty time is now ripe for the ‘aesthetic sector’ ‘practitioners’. This unclear titling is further ‘Plastic’ is appended to other specialties, to move away from being an ‘industry’ to confused by the different titles that are causing further confusion for patients. The becoming a fully-recognised specialty in its used to denote medical specialities. This is GMC and the surgical colleges do not own right, with its own faculty or college. particularly prevalent on the surgical side, currently recognise aesthetic surgery as a Mr Dalvi Humzah, is a with terms appended to different titles, e.g. distinct specialty. consultant plastic, reconstructive facial aesthetic surgeon, occulo-plastic It is evident that work needs to be done to and aesthetic surgeon. He is surgeon, facial plastic surgeon etc. This promote clarity for the public. The recent fully registered with the General inconsistent use of titling confuses the public investigations by leading figures such as Sir Medical Council and holds a license to practice medicine; his – those who are our patients. Bruce Keogh have likened regulation within name appears on their Specialist Register for But what is the view of the regulatory bodies? the cosmetic sector to be similar in effect to plastic surgery. This article does not reflect The Nursing and Midwifery Council (NMC) purchasing a ballpoint pen or a toothbrush. any views of any professional bodies that Mr set professional standards and the Royal Interestingly, in his review, the phrase used Humzah is involved with. College of Nursing (RCN) represents nurses was ‘Cosmetic Sector’, moving away from the REFERENCES 1. The Royal Collage of Surgeons, The Surgical Specialities: and nursing practice. The General Medical commonly-used phrase, ‘Cosmetic Industry’. 6 – Plastic and Reconstructive (www.rcseng.ac.uk) < http:// Council (GMC) and the General Dental Whilst calling for high quality care and revised www.rcseng.ac.uk/media/media-background-brief ings-and-statistics/the-surgical-specialties-6-2013-plas Council (GDC) also act as regulatory bodies. methods of informing and empowering tic-and-reconstructive>

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Galderma Aesthetic & Corrective Med-fx Boston Medical Group Ltd Division Contact: Faye Price Contact: Iveta Vinklerova +44 01923 208950 +44 01376 532800 +44 0207 727 1110 [email protected] [email protected] [email protected] Sinclair Pharmaceuticals www.galderma-alliance.co.uk www.medfx.co.uk www.boston-medical-group.co.uk [email protected] 0207 467 6920 Bocouture® 50 Abbreviated Prescribing Information Please refer to the Summary of Product rash, have been reported after treating vertical lines between the eyebrows (glabellar frown lines) www.sinclairispharma.com Characteristics (SmPC). Presentation 50 LD units of Botulinum toxin type A (150 kD), free from and other indications. Overdose May result in pronounced neuromuscular paralysis distant from h 50 c complexing proteins as a powder for solution for injection. Indications Temporary improvement the injection site. Symptoms are not immediately apparent post-injection Bocouture® may only z in the appearance of moderate to severe vertical lines between the eyebrows seen at frown (gla- be used by physicians with suitable qualifications and proven experience in the application of Candela UK Ltd Healthxchange Pharmacy bellar frown lines) in adults under 65 years of age when the severity of these lines has an important Botulinum toxin Legal Category: POM. List Price 50 U/vial £72.00 Product Licence Number: Contact: Michaela Barker Contact: Steve Joyce Medical Aesthetic Group Zanco Models psychological impact for the patient. Dosage and administration Unit doses recommended for PL 29978/0002 Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer +44 0845 521 0698 +44 01481 736837 / 01481 736677 Contact: David Gower Contact: Ricky Zanco Bocouture are not interchangeable with those for other preparations of Botulinum toxin. Recon- Landstraße 100, 60318 Frankfurt/Main, Germany. Date of revision of text: November 2013. stitute with 0.9% sodium chloride. Intramuscular injection (50 units/1.25 ml). Standard dosing is Full prescribing information and further information is available from Merz Pharma UK Ltd., 260 [email protected] [email protected] +44 02380 676733 +44 08453076191 20 units; 0.1 ml (4 units): 2 injections in each corrugator muscle and 1x procerus muscle. May Centennial Park, Elstree Hill South, Elstree, Hertfordshire WD6 3SR.Tel: +44 (0) 333 200 4143 www.syneron-candela.co.uk www.healthxchange.com [email protected] [email protected] be increased to up to 30 units. Not recommended for use in patients over 65 years or under 18 Services: Adviser (LPA) Services www.obagi.uk.com www.magroup.co.uk www.zancomodels.co.uk years. Injections near the levator palpebrae superioris and into the cranial portion of the orbicu- Adverse events should be reported. Reporting forms and information can be found at laris oculi should be avoided. Contraindications Hypersensitivity to Botulinum neurotoxin type www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Merz Pharma UK Ltd A or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, at the address above or by email to [email protected] or on +44 (0) 333 200 4143. Lambert-Eaton syndrome). Presence of infection or inflammation at the proposed injection site. Special warnings and precautions. Should not be injected into a blood vessel. Not recommend- 1. Bocouture 50U Summary of Product Characteristics. Bocouture SPC 2012 September Available ed for patients with a history of dysphagia and aspiration. Adrenaline and other medical aids for from: URL: http://www.medicines.org.uk/emc/medicine/23251. 2. Prager, W et al. Onset, longevi- treating anaphylaxis should be available. Caution in patients receiving anticoagulant therapy or ty, and patient satisfaction with incobotulinumtoxinA for the treatment of glabellar frown lines: a taking other substances in anticoagulant doses. Caution in patients suffering from amyotrophic single-arm prospective clinical study. Clin. Interventions in Aging 2013; 8: 449-456. 3. Sattler, G et lateral sclerosis or other diseases which result in peripheral neuromuscular dysfunction. Too fre- al. Noninferiority of IncobotulinumtoxinA, free from complexing proteins, compared with another quent or too high dosing of Botulinum toxin type A may increase the risk of antibodies forming. botulinum toxin type A in the treatment of glabelllar frown lines. Dermatol Surg 2010; 36: 2146-2154. Should not be used during pregnancy unless clearly necessary. Interactions Concomitant use 4. Prager W, et al. Botulinum toxin type A treatment to the upper face: retrospective analysis of daily with aminoglycosides or spectinomycin requires special care. Peripheral muscle relaxants should practice. Clin. Cosmetic Invest Dermatol 2012; 4: 53-58. 5. Data on File: BOC-DOF-11-001_01 be used with caution. 4-aminoquinolines may reduce the effect. Undesirable effects Usually ob- served within the first week after treatment. Localised muscle weakness, blepharoptosis, localised Bocouture® is a registered trademark of Merz Pharma GmbH & Co, KGaA. pain, tenderness, itching, swelling and/or haematoma can occur in conjunction with the injection. 1139/BOC/NOV/2013/LD Date of preparation: March 2014 Temporary vasovagal reactions associated with pre-injection anxiety, such as syncope, circulatory problems, nausea or tinnitus, may occur. Frequency defined as follows: very common ≥( 1/10); common (≥ 1/100, < 1/10); uncommon (≥ 1/1000, < 1/100); rare (≥ 1/10,000, < 1/1000); very rare (< 1/10,000). Infections and infestations; Uncommon: bronchitis, nasopharyngitis, influenza infection. Psychiatric disorders; Uncommon: depression, insomnia Nervous system disorders; Common: headache. Uncommon: facial paresis (brow ptosis), vasovagal syncope, paraesthesia, dizziness. Eye disorders; Uncommon: eyelid oedema, eyelid ptosis, blurred vision, eye disor- der, blepharitis, eye pain. Ear and Labyrinth disorders; Uncommon: tinnitus. Gastrointestinal disorders; Uncommon: nausea, dry mouth. Skin and subcutaneous tissue disorders; Uncommon: pruritus, skin nodule, photosensitivity, dry skin. Musculoskeletal and connective tissue disorders; Common: muscle disorders (elevation of eyebrow), sensation of heaviness; Uncommon: muscle twitching, muscle cramps. General disorders and administration site conditions Uncommon: in- jection site reactions (bruising, pruritis), tenderness, Influenza like illness, fatigue (tiredness).Gen - eral; In rare cases, localised allergic reactions; such as swelling, oedema, erythema, pruritus or ELEGANT • FULFILLED • MY TIME

Silhouette Soft Tel. 020 7467 6920 Contact: Emma Rothery www.silhouette-soft.com [email protected]

Bocouture® 50 Abbreviated Prescribing Information Please refer to the Summary of Product rash, have been reported after treating vertical lines between the eyebrows (glabellar frown lines)

Characteristics (SmPC). Presentation 50 LD50 units of Botulinum toxin type A (150 kD), free from and other indications. Overdose May result in pronounced neuromuscular paralysis distant from complexing proteins as a powder for solution for injection. Indications Temporary improvement the injection site. Symptoms are not immediately apparent post-injection Bocouture® may only in the appearance of moderate to severe vertical lines between the eyebrows seen at frown (gla- be used by physicians with suitable qualifications and proven experience in the application of bellar frown lines) in adults under 65 years of age when the severity of these lines has an important Botulinum toxin Legal Category: POM. List Price 50 U/vial £72.00 Product Licence Number: psychological impact for the patient. Dosage and administration Unit doses recommended for PL 29978/0002 Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer Bocouture are not interchangeable with those for other preparations of Botulinum toxin. Recon- Landstraße 100, 60318 Frankfurt/Main, Germany. Date of revision of text: November 2013. stitute with 0.9% sodium chloride. Intramuscular injection (50 units/1.25 ml). Standard dosing is Full prescribing information and further information is available from Merz Pharma UK Ltd., 260 20 units; 0.1 ml (4 units): 2 injections in each corrugator muscle and 1x procerus muscle. May Centennial Park, Elstree Hill South, Elstree, Hertfordshire WD6 3SR.Tel: +44 (0) 333 200 4143 be increased to up to 30 units. Not recommended for use in patients over 65 years or under 18 years. Injections near the levator palpebrae superioris and into the cranial portion of the orbicu- Adverse events should be reported. Reporting forms and information can be found at laris oculi should be avoided. Contraindications Hypersensitivity to Botulinum neurotoxin type www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Merz Pharma UK Ltd A or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, at the address above or by email to [email protected] or on +44 (0) 333 200 4143. Lambert-Eaton syndrome). Presence of infection or inflammation at the proposed injection site. Special warnings and precautions. Should not be injected into a blood vessel. Not recommend- 1. Bocouture 50U Summary of Product Characteristics. Bocouture SPC 2012 September Available ed for patients with a history of dysphagia and aspiration. Adrenaline and other medical aids for from: URL: http://www.medicines.org.uk/emc/medicine/23251. 2. Prager, W et al. Onset, longevi- treating anaphylaxis should be available. Caution in patients receiving anticoagulant therapy or ty, and patient satisfaction with incobotulinumtoxinA for the treatment of glabellar frown lines: a taking other substances in anticoagulant doses. Caution in patients suffering from amyotrophic single-arm prospective clinical study. Clin. Interventions in Aging 2013; 8: 449-456. 3. Sattler, G et lateral sclerosis or other diseases which result in peripheral neuromuscular dysfunction. Too fre- al. Noninferiority of IncobotulinumtoxinA, free from complexing proteins, compared with another quent or too high dosing of Botulinum toxin type A may increase the risk of antibodies forming. botulinum toxin type A in the treatment of glabelllar frown lines. Dermatol Surg 2010; 36: 2146-2154. Should not be used during pregnancy unless clearly necessary. Interactions Concomitant use 4. Prager W, et al. Botulinum toxin type A treatment to the upper face: retrospective analysis of daily with aminoglycosides or spectinomycin requires special care. Peripheral muscle relaxants should practice. Clin. Cosmetic Invest Dermatol 2012; 4: 53-58. 5. Data on File: BOC-DOF-11-001_01 be used with caution. 4-aminoquinolines may reduce the effect. Undesirable effects Usually ob- served within the first week after treatment. Localised muscle weakness, blepharoptosis, localised Bocouture® is a registered trademark of Merz Pharma GmbH & Co, KGaA. pain, tenderness, itching, swelling and/or haematoma can occur in conjunction with the injection. 1139/BOC/NOV/2013/LD Date of preparation: March 2014 Temporary vasovagal reactions associated with pre-injection anxiety, such as syncope, circulatory problems, nausea or tinnitus, may occur. Frequency defined as follows: very common ≥( 1/10); common (≥ 1/100, < 1/10); uncommon (≥ 1/1000, < 1/100); rare (≥ 1/10,000, < 1/1000); very rare (< 1/10,000). Infections and infestations; Uncommon: bronchitis, nasopharyngitis, influenza infection. Psychiatric disorders; Uncommon: depression, insomnia Nervous system disorders; Common: headache. Uncommon: facial paresis (brow ptosis), vasovagal syncope, paraesthesia, dizziness. Eye disorders; Uncommon: eyelid oedema, eyelid ptosis, blurred vision, eye disor- der, blepharitis, eye pain. Ear and Labyrinth disorders; Uncommon: tinnitus. Gastrointestinal disorders; Uncommon: nausea, dry mouth. Skin and subcutaneous tissue disorders; Uncommon: pruritus, skin nodule, photosensitivity, dry skin. Musculoskeletal and connective tissue disorders; Common: muscle disorders (elevation of eyebrow), sensation of heaviness; Uncommon: muscle twitching, muscle cramps. General disorders and administration site conditions Uncommon: in- jection site reactions (bruising, pruritis), tenderness, Influenza like illness, fatigue (tiredness).Gen - eral; In rare cases, localised allergic reactions; such as swelling, oedema, erythema, pruritus or Experience all the benefits of VYCROSS™ technology. Treat various areas of the face using only 3 products. It’s that versatile.

Instructions and directions for use are available on request.

Allergan, Marlow International, 1st Floor, The Parkway Marlow, Buckinghamshire SL7 1YL, UK Date of Preparation: August 2014 UK/0880/2014

15049 UK VYCROSS Advert Aug 2014.indd 1 18/08/2014 10:16