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Aesthetics front cover v2.indd 1 Female Hair Treating Lips Creating12/10/2015 Press 11:51 Laser-assisted Loss Dr Sanjay Gheyi Releases Salvar Björnsson shares his approach Julia Kendrick Drug Delivery CPD discusses causes and to lip rejuvenation explains how to Dr Firas Al-Niaimi details how lasers can aid the treatments for hair loss using hyaluronic acid create effective press delivery of drugs to treat aesthetic concerns in women fillers and lasers material for your clinic Med-fx Clinic Facial Aesthetics A4 Ad_DD Facial Aesthetics A4 Ad 14/10/2015 18:50 Page 1
Excellence in Facial Aesthetics
As you will know, the UK Facial Aesthetic A complete range of the latest market is now worth £3.6 billion, with over specialist products: 7.5 million injectable procedures being carried out in the UK each year, and this is • Botulinum Toxins growing by 20% year on year. • Dermal Fillers • Cosmeceuticals Med-Fx is the market leading provider of Facial Aesthetic products and support Innovative services and services. Whether it’s the provision of the customer support: very latest products or support and training in new techniques, Med-fx can help to • Access to accredited training ensu re your business is capitalising on this • e-Script on-line prescription service continuing market growth. • Dedicated sales & support team • Order up to 6pm So if you already provide Facial Aesthetic for next day delivery and Skin Rejuvenation treatments, or are looking to begin offering these in your clinic, Med-fx can help provide you with the excellence you need in all aspects of your aesthetics business.
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Excellence in Facial Aesthetics Med-fx Clinic Facial Aesthetics A4 Ad_DD Facial Aesthetics A4 Ad 14/10/2015 18:50 Page 1
Contents • November 2015
06 News The latest product and industry news 15 On the Scene Out and about in the industry this month 16 Conference Reports Reports from the annual BCAM and BACN conferences 18 News Special: Too Much Too Young? Aesthetics investigates the impact of young people seeking treatment Special Feature 21 Aesthetics Conference and Exhibition 2016 Facial Resurfacing The latest additions to the ACE 2016 agenda are revealed Page 23 CLINICAL PRACTICE
23 Special Feature: Facial Resurfacing Practitioners discuss the use of chemical peels and lasers for facial resurfacing in aesthetic clinics 29 CPD: Laser-assisted Drug Delivery Dr Firas Al-Niaimi examines how lasers can penetrate the stratum corneum to aid treatment of aesthetic concerns 35 Adverse Reactions to Hyaluronic Acid Injections Dr Maryam Zamani shares advice on how to successfully manage In Practice Excellence in Facial Aesthetics HA filler complications The Changing Consultation 40 Vitamins in Skincare Page 62 Dr Ahsan Ullah explains how essential vitamins can enhance your As you will know, the UK Facial Aesthetic A complete range of the latest patient’s skincare regime market is now worth £3.6 billion, with over specialist products: 43 Treating Lips Clinical Contributors 7.5 million injectable procedures being Dr Sanjay Gheyi details his approach to rejuvenating lips with lasers • Botulinum Toxins Dr Firas Al-Niaimi is a consultant dermatologist carried out in the UK each year, and this is and HA fillers and laser surgeon, based at St Thomas’ Hospital in growing by 20% year on year. • Dermal Fillers London and is a group medical director of sk:n clinics. 49 Identification and Management of Female Hair Loss He has authored more than 95 publications and 120 • Cosmeceuticals Salvar Björnsson discusses the various causes and treatment options scientific presentations. Med-Fx is the market leading provider of for hair loss in women Dr Maryam Zamani is a board-certified Facial Aesthetic products and support Innovative services and ophthalmologist with experience in ocuplastic surgery services. Whether it’s the provision of the customer support: 53 Abstracts and dermatology. She obtained her medical doctorate very latest products or support and training A round-up and summary of useful clinical papers from the George Washington University School of Medicine in the US. in new techniques, Med-fx can help to • Access to accredited training ensu re your business is capitalising on this • e-Script on-line prescription service IN PRACTICE Dr Ahsan Ullah is an aesthetic and private general practitioner. With vast experience working for the NHS continuing market growth. • Dedicated sales & support team and privately, he is now the medical director of My Skin 55 Effective Press Releases Clinic in Harley Street and provides dermatology and • Order up to 6pm Julia Kendrick shares advice on creating your own PR material So if you already provide Facial Aesthetic aesthetic services with a holistic approach. for next day delivery to meet business and marketing needs and Skin Rejuvenation treatments, or are Dr Sanjay Gheyi is the medical director and laser Patient Communication surgeon at the Coltishall Cosmetic Clinic in Norfolk, looking to begin offering these in your 59 which has been established for nine years. clinic, Med-fx can help provide you with the Victoria Smith describes how effective communication with patients He offers a range of laser, skin and vein care services excellence you need in all aspects of your can boost your clinic’s reputation to his patients. aesthetics business. 62 The Changing Consultation Salvar Björnsson is a certified surgical assistant in hair transplants from the International Society of Hair Dr Renée Hoenderkamp explains how the patient consultation has Restoration Surgery. He is also the CEO of Vinci Hair evolved and why this is improving aesthetic practice Clinics, which offers solutions for men and women in the UK and trains other practitioners entering the field. 67 In Profile: Dr Maria Gonzalez Dr Maria Gonzalez reflects on her career in medical aesthetics and highlights the importance of continued learning Call or visit our website today: 69 The Last Word Dr Farid Kazem argues the need for more education on the difference Last chance to book for 0800 783 06 05 between genuine and counterfeit products www.medfx.co.uk the Aesthetics Awards 2015 NEXT MONTH www.aestheticsawards.com • IN FOCUS: Evolution of Aesthetics • CPD: Treating scars in Asian skin • Birthmarks • Using Instagram
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Conferences, conferences and more can attract such a fantastic team of professionals so quickly. ACE conferences – if I am counting correctly, promises to be the biggest and best so far, with an unsurpassed there have been five in as many weeks! quality of education and practical training and, of course, some The highlights include the British College of surprises! Turn to p.21 to find out more. Aesthetic Medicine and the British Association This month is our laser edition and, judging by the countless Amanda Cameron of Cosmetic Nurses’ events, of which you can exhibition stands I have passed recently, many laser companies Editor read the reports on p.16. While conferences are vying for your business. It must be a complete minefield for can sometimes be exhausting, they serve those who are looking to purchase a new piece of equipment – a valuable purpose within our industry; providing us with more where do you start? Hopefully our journal can help de-mystify the opportunities for education that allow us to progress and grow. process; we have three fantastic articles on lasers in this issue, Reflecting on the last few weeks, I have been excited by which each detail the science and practicalities of treating many the dynamic group of young doctors and nurses joining our indications with various types of devices. Turn to p.23 to read industry who are not only charismatic, but also keen to learn, up on facial skin resurfacing with lasers and peels, p.29 for our knowledgeable and able to present well. The next generation excellent CPD article on laser-assisted drug delivery, and p.43 is looking good and I have faith that our new practitioners can to learn about combining laser treatments with hyaluronic acid support us in our endeavour to ensure UK regulation is made law to treat patients’ lips. With so many articles to educate and inform, at last. On a side note, I am still looking for those comfortable, we are confident that you will thoroughly enjoy this issue. Please fashionable conference shoes… we’ll publish an exclusive report do let us know by tweeting us @aestheticsgroup or emailing once I’ve found them! [email protected] The next big UK conference will be the Aesthetics Conference and On a final note, this month is your last chance to book tickets to our Exhibition (ACE) 2016 and I am delighted to announce that we have prestigious awards ceremony – visit www.aestheticsawards.com Your Complete all the speakers in place already – it is so gratifying to know that we or call our support team on 0203 096 1228.
TM Skin Fitness Editorial advisory board We are honoured that a number of leading figures from the medical aesthetic community have joined Aesthetics journal’s editorial advisory board to help steer the direction of our educational, clinical and business content
Business Partner Mr Dalvi Humzah is a consultant plastic, reconstructive and Dr Raj Acquilla is a cosmetic dermatologist with over 11 years aesthetic surgeon and medical director at the Plastic and Derma- experience in facial aesthetic medicine. UK ambassador, global tological Surgery. He previously practised as a consultant plastic KOL and masterclass trainer in the cosmetic use of botulinum toxin surgeon in the NHS for 15 years, and is currently a member of the and dermal fillers, in 2012 he was named Speaker of the Year at British Association of Plastic, Reconstructive and Aesthetic Surgeons the UK Aesthetic Awards. He is actively involved in scientific audit, (BAPRAS). Mr Humzah lectures nationally and internationally. research and development of pioneering products and techniques. Award winning distributors Sharon Bennett is chair of the British Association of Dr Tapan Patel is the founder and medical director of VIVA Cosmetic Nurses (BACN) and also the UK lead on the BSI and PHI Clinic. He has over 14 years of clinical experience and AestheticSource supply the science of committee for aesthetic non-surgical medical standard. Sharon has been performing aesthetic treatments for ten years. has been developing her practice in aesthetics for 25 years and Dr Patel is passionate about standards in aesthetic medicine great skin direct to your clinic, providing has recently taken up a board position with the UK Academy of and still participates in active learning and gives presentations you with outstanding customer service Aesthetic Practitioners (UKAAP). at conferences worldwide. Dr Christopher Rowland Payne is a consultant Mr Adrian Richards is a plastic and cosmetic surgeon with and groundbreaking technologies, dermatologist and internationally recognised expert in cosmetic 12 years of specialism in plastic surgery at both NHS and private dermatology. As well as being a co-founder of the European clinics. He is a member of the British Association of Plastic and ingredients, products and treatments. Society for Cosmetic and Aesthetic Dermatology (ESCAD), he was Reconstructive Surgeons (BAPRAS) and the British Association of also the founding editor of the Journal of Cosmetic Dermatology Aesthetic Plastic Surgeons (BAAPS). He has won numerous awards and has authored numerous scientific papers and studies. and has written a best-selling textbook.
Dr Sarah Tonks is a cosmetic doctor, holding dual Dr Maria Gonzalez has worked in the field of dermatology qualifications in medicine and dentistry. Based in for the past 22 years, dividing her time between academic work Knightsbridge, London she practices a variety of aesthetic at Cardiff University and clinical work at the University Hospital treatments. Dr Sarah has appeared on several television of Wales. Dr. Gonzalez’s areas of special interest include acne, programmes and regularly speaks at industry conferences on dermatologic and laser surgery, pigmentary disorders and the the subject of aesthetic medicine and skin health. treatment of skin cancers.
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 Priti Dey • Customer Support Executive ABC accredited publication T: 0207 148 1292 | M: 07500 007 013 T: 0203 096 1228 | [email protected] [email protected] MARKETING ARTICLE PDFs AND REPRO Amanda Cameron • Editor Marta Cabiddu • Marketing Manager Material may not be reproduced in any form without the T: 0207 148 1292 | M: 07810 758 401 T: 0207 148 1292 | [email protected] publisher’s written permission. For PDF file support please [email protected] EVENTS contact Priti Dey; [email protected] Chloé Gronow • Assistant Editor Helen Batten • Head of Events The Science of Great Skin Reveal The Beauty Of Great Skin Powerful Nutrient-rich Eyelash Serum Advanced Nutritional Skin Beverage Advanced Skin Technologies T: 0207 148 1292 | M: 07788 712 615 T: 0203 096 1228 | [email protected] © Copyright 2015 Aesthetics. All rights reserved. Aesthetics [email protected] Kirsty Shanks • Events Manager Journal is published by Synaptiq Ltd, which is registered Kat Wales • Journalist T: 0203 096 1228 | [email protected] as a limited company in England; No 3766240 T: 0207 148 1292 | M: 07741 312 463 DESIGN [email protected] Peter Johnson • Senior Designer Jack Wynn • Journalist T: 0203 096 1228 | [email protected] T: 0207 148 1292 | M: 07584 428 630 Chiara Mariani • Designer Call us on 01234 313130 [email protected] www.aestheticsource.com DISCLAIMER: The editor and the publishers do not necessarily agree with the views [email protected] T: 0203 096 1228 | [email protected] expressed by contributors and advertisers nor do they accept responsibility for any errors in the transmission of the subject matter in this publication. In all matters the editor’s decision is final. Product images shown are not to scale
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Acquisition Talk #Aesthetics Allergan completes Kythera acquisition Follow us on Twitter @aestheticsgroup Global pharmaceutical company Allergan has announced that it #SkinCancer has completed the acquisition of Kythera Biopharmaceuticals in Dr Anjali Mahto @DrAnjaliMahto a transaction valued at approximately $2.1 billion. The acquisition Looking forward to having a GP colleague in my adds the treatment Kybella (deoxycholic acid), which became the first #skincancer clinic this morning – vital to improve links Food and Drug Administration (FDA) approved non-surgical injection with primary care for submental fullness in April of this year, to Allergan’s portfolio. Brent Saunders, CEO and president of Allergan said, “The completion of the #Conference Kythera acquisition is an important moment for Allergan, adding highly Dr Uliana Gout differentiated products and development programmes that enhance @UlianaGout our product offering to global customers and their patients.” Kybella will Great day and discussions @MerzMappConference join Allergan’s existing portfolio of medical aesthetic products, which #KateGoldie @pdsurgery includes Botox, Juvéderm XC, Juvéderm Voluma and Latisse. @DrStefanieW @MerzAesthetics Standards GMC releases public consultation update figures #BCAM Dr Nestor @DrNestorD Looking forward to @BCAM01 annual conference this The General Medical Council (GMC) has released response figures Saturday! Day of education and catching up with friends from its recent public consultation on the guidance available to and colleagues UK-based doctors offering cosmetic interventions. The consultation, which ran from June 8 to September 4, was #Training introduced by the GMC to gather public opinion on how doctors Medikas @Medikas1 can market their services properly and take particular care of Great training day organised by @Galderma team at the young people undergoing treatment, amongst other concerns. RSM @Medikas1, treated 2 models on the non-surgical In total, the GMC received a total of 142 responses, 40 from face lift organisations and 102 from individuals. In regards to responses by #PatientSatisfaction country, 80 respondents were from England and 26 from other parts Dr Ravi Jain @DrRaviJain of the UK. Scotland provided 11 responses, while four responses came It’s all about patient from Northern Ireland. No responses from Wales were recorded. satisfaction. #Harmony The final guidance, which is expected to be published in early 2016, @Riverbanks #Ultherapy will aim to set ethical standards that will be expected of both surgical and non-surgical doctors in the UK.
Breast implants UK regulator suspends #Training Clinetix @clinetix Silimed silicone implants It was a pleasure to have two enthusiastic nurse practitioners in the clinic today for some advanced The Medicines and Healthcare Products Regulatory Agency (MHRA) training on dermal fillers and toxins has suspended the sale of South American manufacturer’s Silimed silicone implants in the UK after contamination was found during an #Education inspection. The German Notified Body, which monitors the quality of Adrian Baker @Nurse_A_Baker products and medical devices, found the contamination during @RajAcquilla Thank you for a superb day of learning with you @WeAreMBNS. A practice changing educational event! a visit to the manufacturer’s facilities in Brazil. The MHRA, along with other European regulators, are currently testing and investigating the #Threadlift products to determine their safety. Silimed has stated that it is currently Dr David Eccleston @DavidEccleston preparing a technical note to show that all devices are compliant with Down at #royalsocietyofmedicine in order to add international standards. The company also said that the issue is only #threadlift #mash technique of Dr Irfan Mian to our limited to the European Union. According to the MHRA, urological menu @MediZenClinics implants and other surgical devices are among the suspended appliances and Silimed’s CE mark has been suspended.
Reproduced from Aesthetics | Volume 2/Issue 12 - November 2015 aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics
Awards Last chance to book for the Aesthetics Awards 2015 Countdown to ACE 2016 With the voting process for this year’s awards complete, tickets are selling fast with medical aesthetic professionals preparing for a spectacular evening of Latest programme updates celebration and entertainment. The ceremony, which will take place at the Park Plaza Westminster Bridge Hotel on December 5, will play host to more than 500 Mr Dalvi Humzah will lecture guests with entertainment from British stand-up comedian Simon Evans, and music on facial anatomy at Conference and dancing until the early hours. sessions on the mid-face, The awards will celebrate Commended and Highly Commended finalists and perioral and periorbital areas winners in 23 categories, as well as the winner of the Schuco International Award for Special Achievement. Dr Beatriz Molina, who is on the judging panel for this year’s awards said, Dr Raj Acquilla and Dr Tapan Patel are set “I am delighted to be selected as one of the judges – it’s a process and event to perform live treatment demonstrations at the Conference session dedicated to the forehead, to celebrate the best in aesthetic medicine and it forms part of a drive to raise temple and brow as well as at the Injectables standards in our sector.” She continued, “By sharing and celebrating all that is workshop on perioral, chin and jawline positive, we hope, over time, that the public will become better educated in treatments with Mr Dalvi Humzah making informed choices when selecting their aesthetic practitioners.” Bookings can be made via www.aestheticsawards.com Insight
Sexual rejuvenation Consultant plastic surgeon and ACE steering Cosmetic Insure and committee chair Mr Dalvi Humzah says: Dr Sherif Wakil partner for sexual “The Aesthetics Conference and Exhibition is growing every year and a rejuvenation treatment cover higher standard of advanced educational content delivery is always taken into account Aesthetic insurance broker Cosmetic Insure has partnered with P Shot and O during the planning of the ACE agenda. Shot trainer Dr Sherif Wakil with the aim of providing an easier route of insurance The steering committee always strives for for all practitioners who perform the sexual dysfunction treatments. Due to what excellence to provide delegates with practical the insurers describe as ‘an increase in patient demand’, the company, with the and cutting-edge tutorials delivered by world leading experts. Practitioners and medical assistance of Dr Wakil, were able to appoint an underwriter to fully examine the aesthetic professionals who attend ACE will safety of P Shot and O Shot treatments, as well as the training provided by Dr Wakil. go back to their clinics with enhanced skills “This will allow practitioners to be fully covered and able to practice these treatments and enriched knowledge, and will be able safely. I am very confident that Cosmetic Insure will deliver a safe policy to further to achieve better results to increase patient develop the popularity of these treatments,” said Dr Wakil. satisfaction. ACE 2016 cannot be missed!”
Pigmentation What delegates say Study suggests Picosecond “Excellent speakers and alexandrite laser successfully wide variety of topics covered” treats MIP Cosmetic Doctor, London “It’s great to meet up with A recent study on patients with minocycline-induced pigmentation (MIP) all of our colleagues in Ireland and indicated ‘superior clearance’ of the reaction when treated with a picosecond England, it’s very informative and alexandrite laser. The pigmentation condition is an adverse effect of minocycline very enjoyable” Cosmetic Doctor, Dublin therapy, an antibiotic used to treat infections such as acne and rosacea. Researchers “Nice location, good interaction, useful studied three patients with MIP in the facial area and treated them with a 755 mm lectures and demonstrations.” picosecond alexandrite laser. One patient, a 60-year-old white woman, saw complete Aesthetic Nurse, Devon clearance of the condition at a 12 week follow-up. The two other patients, a 75-year- old and a 59-year-old white man, saw superior clearance – which the researchers www.aestheticsconference.com described as being ‘near complete resolution’ – after the same treatment and follow- HEADLINE SPONSOR up appointment. The researchers concluded, “This proved to be a well-tolerated, safe, and efficacious treatment that developed rapid clearance of MIP.”
Reproduced from Aesthetics | Volume 2/Issue 12 - November 2015 @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com
Conference Registration for ACE 2016 now open
Registration for next year’s Aesthetics Conference and Exhibition (ACE) 2016 is now open. With more than 2,000 delegates expected to attend the event, which will take place on April 15 & 16 at the Business Design Centre in Islington, delegates can now register online to secure their places and experience the comprehensive and engaging agenda. ACE 2016 will welcome back the popular free Masterclass, Expert Clinic and Business Track sessions, along with the addition of the Treatments on Trial agenda, where four company representatives will give presentations on their products allowing direct comparison between treatment options. Delegates can register for free, or choose to add the premium content Conference programme to their booking by paying for either a one-day pass for the 15 or 16, or paying for a two-day pass to experience the full Conference agenda, which includes eight sessions focused around anatomical areas. To book your place at ACE 2016 and find out more visit www.aestheticsconference.com
Photoageing Acne StemCutis begins Study unveils success of photoageing trial candidate acne drug
Biotechnology company StemCutis LLC has Biotechnology company Novan Therapeutics has received encouraging results from enrolled the first three subjects of its phase 1/2 a phase 2b study analysing a nitric-oxide topical gel candidate drug. SB204, which clinical trial, which will determine the safety of is the company’s leading drug candidate for the treatment of acne vulgaris, was used a single injection of allogeneic mesenchymal in the trial and produced significant results on inflammatory and non-inflammatory bone marrow cells (aMBMC) for the treatment lesions at week 12 on a recorded 213 patients. All participants were randomly split into of cutaneous photoageing. The open-label, five groups: SB204 2% twice daily, SB204 4% once daily, SB204 4% twice daily and interventional study, which will be led by vehicle once or twice daily. According to the study, the 4% dose of SB204 proved to board certified dermatologist Dr Curt Littler, is demonstrate the most significant difference in inflammatory lesions, and the 1% and considered to be the first clinical trial in the US 4% groups were effective at decreasing non-inflammatory lesions. The study noted to use allogenic stem cells for the treatment of that patients treated with SB204 had 80% less sebum on the skin’s surface compared photo-aged skin. to those in the vehicle groups. Nathan Stasko, president of Novan Therapeutics, According to the company, the study will be split said, “These study results reproduce our phase 2a trial, which showed a similar into two portions, phase 1, which will analyse separation between the active drug and vehicle.” He continued, “Replicating a the ‘Intrinsic Ageing of the Skin’ and phase 20% differential between SB204 and vehicle in percent lesion reduction gives 2, the ‘Chronic Effect of Ultraviolet Radiation us great confidence in moving into the phase 3 programme.” Based on the trial on Normal Skin’. The study will assess the results, Novan announced plans to initiate two phase 3 trials with SB204 once daily in safety and tolerance of IV administration of the beginning of 2016, with 1,300 patients expected to be enrolled in each study. aMBMC during the twelve month study period, and will record the incidence and severity of Dermal fillers adverse events, any significant changes on clinical laboratory tests, vital signs of changes, FDA approves Juvéderm Ultra XC physical and cutaneous examinations, 12 lead electrocardiograms, spirometry and CT scans of for lip augmentation the chest. Dr Littler said, “The unique design of this clinical trial combines low-dose Fraxel laser The Food and Drugs Administration has approved pharmaceutical company Allergan’s treatment on the face with a single intravenous Juvéderm Ultra XC for lip augmentation in adults over the age of 21. infusion of stem cells in the subject’s arm.” He Juvéderm Ultra XC is a smooth gel formulation made up of a modified form continued, “The administration of low-dose Fraxel of HA. Philippe Schaison, executive vice president of Allergan Medical said, laser is expected to create minor inflammation “Understanding that the desire with lip augmentation is to achieve a natural- in the facial skin, which is intended to facilitate looking and lasting result, we continued our research of Juvéderm Ultra XC for homing of the stem cells to the face after a single the lips.” He continued. “With this approval, this filler is now the only filler that is intravenous infusion of Stemedica-manufactured approved to last up to one year in the lips while providing natural-looking results.” stem cells.” The study will use approximately 30 The gel formulation also contains a small amount of local anaesthetic (lidocaine), male and female subjects between the ages of which helps to improve the comfort of the injection. According to the company, 40-70 years old, for a 12-month period, with an common adverse effects for the treatment include redness, swelling, firmness, expected completion date of December 2017. bruising and discolouration.
Reproduced from Aesthetics | Volume 2/Issue 12 - November 2015 aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics
Skincare Vital Statistics iS Clinical releases multi- purpose moisturiser Around 1% of men over the age of Skincare brand Innovative Skincare (iS) Clinical has 25 will develop launched a new moisturiser that aims to hydrate the skin acne and target a multitude of skin concerns. The Reparative (NHS) Moisture Emulsion aims to prevent DNA damage by using extremophilic enzymes, which work to protect cells and repair fragile proteins, and superoxide dismutase (SOD), a proven antioxidant that is reported to safely absorb harmful free radicals and protect skin from photoageing. The Hair loss aff ects moisturiser also includes 5% hyaluronic acid, which aims approximately 1.2 billion to increase skin firmness and resistance to stress, as well people around the world as glycosaminoglycans to maintain the structure collagen. (LaserCap Company) Also included is bio-identical copper tripeptide growth factor, which aims to stimulate the synthesis of collagen in skin fibroblasts for a firmer complexion.
Laser 60% of patients source information Lutronic Lasers introduces on cosmetic surgery carbon peel treatment via search engines (American Academy of Facial Plastic and Reconstructive Surgery) Laser manufacturer Lutronic Lasers has launched a new treatment that aims to aid collagen stimulation and improve the appearance of pigmentation. The Spectra Carbon Peel, which is performed using the Lutronic Spectra XT device, claims to require little to no downtime and Eczema aff ectsfi v e works to improve the appearance of fine lines and wrinkles, reduce million people in the pore size and smooth uneven skin tone. The procedure begins with the UK every year application of a carbon-based lotion to the patient’s face, followed by laser (National Eczema Society) treatment that aims to lightly remove the carbon particles and erode the top layer of skin. The laser energy then heats the skin, causing it to contract to reduce pore size and stimulate healthy new collagen. Jim Westwood, managing director of Venn Aesthetics, the UK distributor of Lutronic Lasers said, “We are delighted to introduce this advanced and novel treatment to In a survey of 527 women, 15.37% the aesthetic market and we are happy to offer clinics a fast, comfortable said that social media aff ected their and highly effective patient treatment.” decision to get cosmetic surgery (RealSelf) Botulinum toxin Revance Therapeutics begins At least 100,000 new cases botulinum toxin topical gel of skin cancer are diagnosed trial for canthal lines in the UK every year (British Skin Foundation)
Biopharmaceutical company Revance Therapeutics has begun a phase 3 study to evaluate the safety and efficacy of a topical drug candidate for the treatment of lateral canthal lines. The trial of 450 adult patients will determine the effects of RT001, a topical gel that the company claims could In a study of 146,042 be marketed as the first non-injectable form of botulinum toxin type A. Dan psoriasis patients in the UK, Browne, CEO of Revance said, “Success in treating canthal lines would set 10,400 were diagnosed with the stage for potential future indications of RT001 topical gel across other depression areas of the face and body.” Assessment will be recorded after 28 days using (JAMA Dermatology) the Patient Severity Assessment and the company plans to release the trial results in the first half of 2016.
Reproduced from Aesthetics | Volume 2/Issue 12 - November 2015 @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com Events diary Survey 12th – 15th November 2015 Survey analyses popularity of 20th World Congress of Aesthetic Medicine, aesthetic procedures in UK Miami www.aaamed.org A survey commissioned by aesthetic manufacturer Intraline Medical Aesthetics 14th November 2015 has analysed the popularity of medical aesthetic procedures in the UK. The survey of 2,006 respondents over the age of 25, suggested that one in five women British Cosmetic Dermatology Group 10th Annual undergo dermal filler treatment for anti-ageing benefits, and 40% of those claimed Course, London that they would undergo treatment to satisfy their partners. Another finding from www.bcdg.info the survey indicated that 25% of male respondents regularly have dermal filler 3rd – 4th December 2015 treatments to ‘reward themselves’. Weddings were identified as a key milestone in decision-making, with one in 25 women undergoing treatment to look their best on B.A.D Research Techniques Course, London the big day and 10% having a procedure for a significant birthday. Blair French, vice www.bad.org.uk/events president of marketing for Intraline Medical Aesthetics said, “The market research 5th December 2015 we conducted showed that men and women are looking at aesthetic treatments as one way to enhance their appearance.” He continued, “Knowing this information, The Aesthetics Awards 2015, London our goal is to ensure these individuals are aware they are not alone in looking into www.aestheticsawards.com aesthetic treatments and we wanted to provide the necessary information for each 28th – 31st January 2016 individual so they can make an informed decision that they are confident about.” IMCAS World Congress 2016, Paris www.imcas.com/en/attend/imcas-world- Weight loss congress-2016 Non-surgical balloon device 15th – 16th April 2016 Aesthetics Conference & Exhibition 2016, London receives FDA approval www.aestheticsconference.com A device designed to help obese adult patients lose weight has been granted approval by the FDA. The ReShape Integrated Balloon System aims to help patients Skincare lose weight by taking up space in the stomach; an alternative to having surgery. The FDA said the balloon “may trigger feelings of fullness or work by other mechanisms Schuco International yet to be understood.” Dr William Maisel, acting director at the FDA’s Center for Devices and Radiological Health, said, “For those with obesity; significant weight launches loss and maintenance of that weight loss often require a combination of solutions, including efforts to improve diet and exercise habits.” He continued, “The new UNIVERSKIN balloon device provides doctors and patients with a new non-surgical option that can be quickly implanted, is non permanent, and can be easily removed.” According Aesthetic skincare distributor to the company, the procedure requires the patient to be mildly sedated while Schuco International has the balloon is delivered into the stomach through the mouth via an endoscopic announced it is the exclusive procedure. The balloon should then be used in combination with a diet and an UK & Ireland distributor of exercise plan, for optimum weight loss results. UNIVERSKIN, a brand which aims to offer personalised Industry skincare to patients. Developed by plastic surgeons, Globe AMT announced as UK dermatologists, biologists and pharmacists, UNIVERSKIN aims to treat a range of distributor of DEKA aesthetic concerns including; oxidative stress, wrinkles and sagging, inflammation, skin barrier disorders, Laser technology manufacturer DEKA has appointed aesthetics distributor keratinisation, hyperseborrhea and pigmentation. Globe AMT as its official UK distributor. DEKA will join other brands and According to Schuco, UNIVERSKIN allows practitioners products including the Quantificare 3D skin analysis cameras and the to add up to three active ingredients to the base Nevisense EIS diagnostic system in Globe AMT’s extensive portfolio. Neil serum, which is then mixed to create a unique formula, Roberts, managing director of Globe AMT said, “We’re proud and delighted to tailored to treat each patient’s individual skin concerns. be representing such a significant and prestigious brand. DEKA are one of the The company explains that the product’s highly active global powerhouses in laser technologies. The addition into the Globe AMT base serum can aid the treatment of damaged and portfolio represents another significant distribution agreement for our exciting inflamed skin, applying nanotechnology in a unique business.” DEKA produce laser technology for the international market that aim minimalist serum that contains omega 3, hyaluronic to treat aesthetic concerns including; age-related issues, tattoo removal, hair acid, vitamin E and biomimetic peptides. removal, pigmented lesions and psoriasis.
Reproduced from Aesthetics | Volume 2/Issue 12 - November 2015 aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics
Industry Allergan and Intas Pharmaceuticals in agreement 60 Jim Westwood, Managing Director after trademark debate of Venn Aesthetics
US pharmaceutical company Allergan has entered into a settlement with Indian What is your background? manufacturer Intas Pharmaceuticals on the use of the trademarks ‘Botox’ and My background is extensively within healthcare, having worked for ‘BTX-A’ for botulinum toxin. The court order, which was issued on September AstraZeneca and Eli Lilly within their 9 in the Delhi High Court, stated, “The defendant (Intas Pharmaceuticals) has healthcare development and market acknowledged the plaintiff’s (Allergan) exclusive rights in respect of the registered access team for more than 15 years. marks ‘Botox’ and ‘BTX-A’ and it has agreed not to use the said marks in isolation or collectively. The plaintiff has also acknowledged and accepted the defendant’s Venn Aesthetics is relatively new to the market– use of the mark ‘BTXA’ without a hyphen and segregating the letters forming part tell us about it. of the word ‘BTXA’.” According to a previous order from Delhi High Court, Allergan Venn Aesthetics is a distributor of aesthetic claimed that the trademark Botox has been used in India since 1992. equipment in the UK. Our company was developed to deliver innovative and efficacious best-in-class An application to register the BTX-A trademark was made by Intas Pharmaceuticals solutions to the aesthetic beauty market for in June 2002, which was not granted, but the company secured permission practitioners and patients alike. With the speed from the Drug Controller of India to sell a drug under the brand name BTXA, of developing technology, Venn always has an where the dispute between both companies originated. A spokesperson for eye on the supportive published clinical evidence Intas Pharmaceuticals said in a statement, “Allergan had challenged the order of of any technology. Devices and technology can the Delhi High Court before the Division Bench, and both parties have amicably often develop at a faster rate than that of the resolved the dispute on the terms that Intas can continue to use BTXA for its clinical research, and Venn Aesthetics ensures product but will not use the trademark Botox or BTX-A.” practitioners and patients benefit from the most up- to-date aesthetic technology available to them. We Training are a relatively new subsidiary of Venn Healthcare, which offers devices to the healthcare industry. BAAPS to launch fellowship What does the Venn Aesthetics portfolio offer? Venn Aesthetics is the UK distributor for Lipotripsy training programmes – Shock Wave Therapy for the treatment of cellulite and inch loss. We also offer the full The BAAPS (British Association of Aesthetic Plastic Surgeons) is launching Lutronic laser portfolio of devices that includes a series of fully-funded fellowships for trainees looking to develop a career Infini, Spectra XT, Clarity, Solari and Petit Lady II. Lutronic was established more than 15 years ago in aesthetic surgery. The three-month fellowships come as a study, which was and delivers intuitive and versatile devices that are presented at the Annual Scientific Meeting of BAAPS by trainee member Mr Reza underpinned by clinical research. Lastly, we have Nassab, claimed that funding for reconstructive surgery on the NHS has been just brought on board Classys, which includes reduced, and currently there are very few training opportunities for those seeking Clattu, the new controlled cooling treatment for fat a career in aesthetic surgery. With support from the British Association of Plastic, reduction that boasts the world’s first 360° cooling Reconstructive and Aesthetic Surgeons (BAPRAS), the fellowships will enable hands- panel. With our range of devices, I feel that Venn on practice, mentorship and understanding of how to deal with patient complications. Aesthetics offers a full spectrum of solutions to the Brendan Eley, CEO of the National Institute of Aesthetic Research (NIAR) who are ever-growing market place. collaborating with BAAPS on the programme, said, “Not only will trainees be able to What can we expect next from Venn Healthcare? access the expertise and guidance of top surgeons in busy private units, but fellows We are pleased to be announcing the launch of will be further rewarded for undertaking quality research and audits, which we will our own Remote Expert technology which will be under the auspices of the NIAR.” Mr Nigel Mercer, president of BAPRAS said, enable healthcare professionals to speak directly “Credentialing will soon be implemented, but this is simply the most basic level for a to their patients/clients via high definition video practitioner to be able to legally practice. We want to develop experienced surgeons either at work or at home. It is a platform that will operating at the gold standard, and this is what these fellowships are designed to have application from the high street through provide. The public deserves no less.” to an individual clinic or GP surgery. What is As part of the training programme, fellows are expected to be exposed to a certain unique about our Remote Expert technology is number of treatment cases, including 20 breast treatments, 10 truncal, 20 facial and that it can work from any good quality PC, and periorbital and 10 botulinum toxin cases, among others such as nasal, ear and dermal the video suite enables scheduled end-to-end consultations with the ability to add in another filler injections. Michael Cadier, president of BAAPS said, “As the only association consultant/healthcare professional to the call which is solely dedicated to the advancement of aesthetic plastic surgery, we are should a second opinion be needed. ready to take up the mantle of responsibility for training with a groundbreaking new programme alongside our colleagues in other plastic surgery societies and the This column is written National Institute of Aesthetic Research – for the development of the profession but, and supported by most important of all, for patient safety.”
Reproduced from Aesthetics | Volume 2/Issue 12 - November 2015 @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com
Acne News in Brief Study monitors adherence ZO Skin Health introduces Offects to clinical and topical acne Sulfur Masque Skincare manufacturer ZO Skin Health has treatments added a deep pre-medicated cleansing masque to its collection. The Offects Sulfur Masque aims to treat oily or acneic skin by A study published in BioMed Central (BMC) Dermatology has suggested that the absorbing surface oils, exfoliating dead skin outcome from clinical treatment with adjuvant therapies, such as facial cleansing, cells and removing pore-blocking dirt and topical treatments and moisturising, can greatly affect the improvement of debris. According to the company, the main mild-to-moderate acne vulgaris. The study, which evaluated 643 participants in an ingredient is sulphur, a naturally occurring observational, non-interventional prospective study, assessed the effects of both non-metal mineral commonly used to treat clinical and adjuvant methods with 566 patients completing three study visits over a acne and skin inflammation. three-month study period. An ECOB, a validated questionnaire used by researchers, was used to assess clinical adherence, as well as a 0-5 point scale to monitor AAFPRS appoints new 2015-2016 treatment adherence and acne severity post treatment. Overall, clinical improvement president was observed throughout follow-up visits with an increased amount of patients The American Academy of Facial Plastic reporting reductions of more than 50% on the total number of lesions (two months: and Reconstructive Surgery (AAFPRS) 25.2%; three months: 57.6%) and reductions of severity scores (2.5, 2.0 and 1.3 at one, has appointed reconstructive surgeon Dr Edwin Williams as president of the two and three months after treatment). Adherence to treatment was associated with organisation. Dr Williams, who is a Fellow a significant reduction on severity grading, a lower number of lesions and a higher of the American College of Surgeons, proportion of patients with more than a 50% improvement. will serve a term as president between 2015-2016 and will work closely on Vitamin C developments in cosmetic surgery, as well as the improvement of AAFPRS education DMK launches new programmes for members.
vitamin C product Dr Kannan Athreya announced as Swisscode ambassador Skincare manufacturer Danné Montague-King (DMK) has Aesthetic practitioner Dr Kannan Athreya launched a new vitamin C-based product designed to aid is the new brand ambassador for the production of collagen, improve skin texture and aid the cosmeceutical skincare manufacturer prevention of acne scarring. Swisscode. The company, which developed FibroMax C, which is produced in a liquid vial form, is made of 20% the Pure and Bionic skincare ranges, aims to pure vitamin C (ethyl ascorbic acid) and silicia silylate to protect offer products that improve the appearance the skin’s barrier from external stresses, such as UVB damage and of skin texture, provide protection from UV pollution. The manufacturer claims that patients can also apply this rays and smooth fine lines and wrinkles. product as a topical treatment at home on skin concerns such as pigmentation and fine lines. FibroMax C is available now. Vida Aesthetics launches new website Complications Distributor and training company Vida Aesthetics has launched a new website Blindness from dermal fillers to enhance user experience. The website aims to provide a simplified look with an improved search functionality. Users will indicated to be rare now be able to search for new products and ingredients, along with informative According to a recent literature review, reported cases of blindness after dermal filler videos and articles on treatments. treatment have been indicated as a rare adverse event. The review, which was led by Vancouver-based dermatologist Dr Kate Beleznay, used the National Library of Medicine, Cosmedics Skin Clinics expands its Cochrane Library and Ovid Medline to analyse research published up until January of team this year. Studies reported that there were 98 cases of vision changes identified. The The Cosmedics Skin Clinic in Bristol has highest areas of complications were the glabella (38.8%), nasal region (25.5%) nasolabial expanded its team with the addition of fold (13.3%) and forehead (12.2%). In regards to the filler type causing this complication, aesthetic practitioner Dr Sarah Thio. Specialising in minor cosmetic surgery autologous fat was suggested as causing the most instances with 47.9% of cases, followed procedures, including removing common by hyaluronic acid (23.5%) and collagen (8.2%). skin blemishes and lesions such as moles, Dr Beleznay said, “With the increased use of soft tissue augmentation for revolumisation, cysts, skin tags, warts and lipoma, Dr Thio it is imperative to be aware of potential devastating ocular complications.” She continued, also trains GP registrars in skin surgery “Although the risk is very low, we believe that prevention begins with education and the methods. ability to recognise potentially grave adverse events.”
Reproduced from Aesthetics | Volume 2/Issue 12 - November 2015 Dermal filler Intraline releases two filler products in UK
Aesthetic manufacturer Intraline Medical Aesthetics has released two new HA-based dermal filler products to the UK market. Intraline One and Intraline Two aim to integrate themselves naturally into injected tissue. They contain a natural medical grade HA concentration and a lesser amount of butanediol diglycidyl ether (BDDE), which aims to maintain product purity. Reece Tomlinson, CEO of Intraline Medical Aesthetics said, “I am delighted that Intraline products are now available in the UK, where the aesthetics industry continues to go from strength to strength.” He continued, “At Intraline, we pride ourselves on bringing a fresh perspective and continual innovation to aesthetic treatments and are committed to providing safe and quality products with fantastic results.” Dr Zack Ally, founder of aesthetic training company Derma Medical and a user of Intraline One and Two, said, “Intraline dermal fillers are pure in composition and have some of the highest molecular densities of any product on the market today. It is exciting to use a new and effective product, produced by a company who truly value the importance of safety and comprehensive training in aesthetic treatments.”
Hair loss Kythera submits IND for alopecia treatment
Kythera Biopharmaceuticals has submitted an Investigational New Drug Application (IND) to the FDA for further study of a new treatment for androgenetic alopecia (AGA). The company plans to evaluate the safety of KYTH-105, also known as setipiprant, in a human proof-of-concept study on male subjects with AGA, which is an inherited genetic disorder that can result in hair thinning and partial or complete baldness. Kythera’s chief medical officer, Dr Frederick Beddingfield, said, “This submission is a significant milestone in the development of KYTH-105 for male pattern hair loss. KYTH-105 represents a unique scientific approach to the treatment of hair loss that has the potential to help millions of men achieve a positive self-image.” According to company data recorded in March of this year, men with AGA were found to have higher levels of prostaglandin D2 (PGD2) in the balding scalp area, which is a possible key variable in hair loss. Setipiprant is a selective oral antagonist of the PGD2 receptor and the KYTH-105 treatment was found to promote hair growth in preclinical and in vitro human hair follicle models.
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S-THETICS industry discussion with UltraPulse Mr Nigel Mercer, Beaconsfield Masterclass and
The S-THETICS clinic in Beaconsfield, Buckinghamshire, User Meeting, welcomed practitioners and patients to a discussion session with plastic surgeon Mr Nigel Mercer on the London synergy between surgical and non-surgical procedures on September 22. Miss Sherina Balaratnam, founder and medical director of S-THETICS, co-presented with Mr Mercer on topics such as emerging aesthetic trends, the wide array of treatment options available and how practitioners can achieve natural-looking results. Also on the agenda was a discussion of regulatory issues and patient safety; highlighting the importance of patients conducting thorough research before undergoing treatment. To illustrate, before and after images were presented to demonstrate natural-looking results with dermal fillers, blepharoplasty and facial lifting procedures. Miss Balaratnam said, “I am keen to help patients understand the need to carefully consider both the treatments they are considering and the Aesthetic practitioners attended a practitioner that may undertake this. It was an honour to have someone of Mr Mercer’s calibre UltraPulse CO2 laser masterclass and user visit my clinic and share his valuable experience and insights with patients.” The evening meeting at the Royal Society of Medicine in concluded with a question and answer session and an open forum discussing a range of London on September 28. The day began treatment options from a patient perspective. with a welcome from Lumenis regional sales manager, Edward Campbell-Adams, followed by a programme of presentations Frances Turner Traill Skin Clinic from plastic surgeon Mr Max Murison and dermatologist Dr Gerd Gauglitz. Mr Murison opening, Lanarkshire began proceedings with an introduction to CO2 technology, before co-presenting with More than 150 patients and aesthetic practitioners Dr Gauglitz on particular approaches using attended the opening of aesthetic nurse the laser, which aims to provide versatility prescriber Frances Turner Traill’s new clinic in and precision for an array of resurfacing Hamilton in Lanarkshire on September 24. The needs. Settings for the UltraPulse include; evening began with a welcome drinks reception, DeepFX, for treatment of wrinkles, ActiveFX followed by a series of talks and demonstrations for mild treatment of hyperpigmentation and from the new clinic team showcasing treatments TotalFX which aims to target the full range of that are available, which include; wrinkle smoothing injections, radiofrequency skin tightening, treatment concerns. Computer Aided Collagen Induction (CACI) non-surgical facelifts and laser treatments for Live demonstrations consisting of burn scar hair removal, acne and pigmentation concerns. New and existing patients were also given treatment and full-facial resurfacing then the opportunity to be involved in a question and answer session with Turner Traill to find out led to a question and answer session with more about all of the clinic treatments. Turner Traill said, “This opening represents a major delegates, and round table discussions on investment in aesthetic services in central Scotland and I look forward to helping a host of topics including treating acne scarring and new patients achieve their aesthetic aims.” combination approach. Mr Murison said of the masterclass, “It was great and the joint input from dermatology and plastic surgery made EF Medispa Clinic Opening, London it an informative event for all the delegates. The amount of effort put in provided one of Medical spa chain EF Medispa invited aesthetic professionals the most comprehensive days of instruction I and patients to the opening of their fourth London clinic in have ever been involved in.” Justin Richards, Canary Wharf on October 8. Attendees were welcomed with manager of aesthetics marketing at Lumenis a drinks and canapé reception, followed by the opportunity to said, “The day was very well received and experience the clinics new ‘Drip and Chill’ IV infusion treatment attended by UK and European based plastic within the medispa’s ‘Drip and Chill’ lounge. surgeons, dermatologists and aesthetic Esther Fieldgrass, founder of EF Medispa said, “We decided practitioners.” He continued, “The meeting to open in the city due to the popularity of the ‘Drip and Chill’ was the perfect opportunity for us to treatments in our other locations. When we were looking through reconnect with our loyal clients and educate our patient base, we noticed that the majority worked in high- non-users on why UltraPulse is so unique pressured positions, such as banking and finance, and we felt and versatile for everyday procedures, such that we could provide this treatment at a nearer location to those as resurfacing or treating the thickest, more working within stressful environments.” complex burn scars with SCAARFX.”
Reproduced from Aesthetics | Volume 2/Issue 12 - November 2015 @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com
BACN Conference, Birmingham
Members of the British Association of Cosmetic Nurses (BACN) met Her presentation at the ICC in Birmingham for their annual conference on October 3. highlighted The day featured presentations on a wide range of subjects, which the need for included treating lips, tear troughs, pigmentation and acne; as well practitioners to as discussions of the latest BACN activities, working within consent have a thorough law, and updates on the Nursing and Midwifery Council’s revalidation understanding pilot. Sharon Bennett, chairperson of the BACN, said, “The day went of facial anatomy phenomenally well; the speakers were brilliant, lots of topics were and selecting covered and the audience seemed to get a lot of information out of appropriate each presentation.” To begin the conference, aesthetic nurse Rachael patients for treatment. Having this knowledge, she argued, will Brown spoke on treating lips. While performing a live demonstration, greatly reduce the numbers of complications we see. Following her she emphasised the need to treat the lower face as a whole in order session Baker said, “It was great to be at the BACN conference and to achieve natural results, and shared her best practice techniques for I was really pleased to be invited. There have been some fantastic successful lip volumisation. Oculoplastic surgeon Mrs Sabrina Shah- speakers, really high-calibre presentations, and the event was very Desai then took to the stage to discuss her techniques for treating the well organised – it’s been a pleasure to take part this year.” The tear troughs. As well as presenting the different classifications of tear afternoon saw presentations from Dr John Quinn, who discussed the troughs, Mrs Shah-Desai spoke on the importance of being aware importance of product rheology and depth placement when using of patients with body dysmorphia and recognising when to refuse hyaluronic acid dermal fillers; Dr Sherif Wakil, who provided delegates treatment. Nurse prescriber Karen Urquhart discussed the practicalities with an overview of using threads; and Dr Martyn King, who spoke on and challenges of running a nurse-led acne clinic, explaining that prevention and management protocols for complications in aesthetic building relationships with local GP surgeries can lead to valuable clinics. Paul Burgess, CEO of the BACN, concluded, “The 2015 BACN patient referrals. Urquhart also spoke on treating complications, conference has been the biggest and best ever. We sold out a week explaining that, although challenging, effective communication and ahead, and with more than 200 delegates and 30 exhibitors we’ve quick management should ensure that your relationship with the had to turn people away, which we’ve never had to do before. We are patient concerned is not impaired. Nurse prescriber Anna Baker absolutely delighted with how the day went and the reaction we’ve then shared her knowledge of using toxins to treat the lower face. had has been superb.” BCAM Conference, London
The British College of Aesthetic Medicine impact of undergoing VASER treatment. Dr therapy being classified as a medicine in (BCAM) held its annual conference at Jain advised delegates to always take patient the US and most European countries, in the the Church House Conference Centre in concerns seriously and, if they are unable to UK the Medicines and Healthcare products Westminster on September 26. offer appropriate treatment, they should refer Regulatory Agency (MHRA) has, after much The day comprised both a clinical and patients on to colleagues who are able to deliberation, now confirmed that IV nutrition business agenda, which each featured an help. The morning clinical sessions continued therapy is not regarded as a medicine in the array of engaging presentations and live with presentations on liposuction and fat UK, and is therefore not subject to MHRA demonstrations. Conference director Dr grating, lipolysis, and hair transplantation, regulation. The day concluded with a live Beatriz Molina said, “Attendance was strong while the business agenda featured talks on demonstration of PDO vs. Silhouette Soft with 250 delegates eager to hear from a revalidation and appraisal, as well as stress thread lift techniques, in which Dr Otto and range of high-quality speakers, both from management techniques for practitioners Dr Kuldeep Minocha treated one side of within the aesthetic practitioners sector and and patients. Journalist and media consultant a patient’s mid-face in order to compare the wider business community, offering Fiona Scott shared advice on speaking to the results that can be achieved. Aesthetic advice and insight on how to run a successful the press, arguing that achieving editorial practitioner and BCAM delegate Dr Nestor and ethical business.” Following a warm coverage in the media can sometimes be Demosthenous made the trip from his welcome from Dr Molina, Dr Ravi Jain took more valuable than advertising in the media. clinic in Glasgow and said, “It’s been an to the podium to discuss the psychological Dr Samantha Gammell and Dr Jacques Otto absolutely fantastic day. It’s great to come then presented down to London and meet with friends and on intravenous (IV) colleagues; there are lots of great companies nutritional therapy, here and the speakers have been second- highlighting the to-none.” marketing challenges Dr Molina concluded, “I truly believe we have they have faced raised – and will continue to – raise the bar when launching at the annual BCAM conference. I am already their new brand. Dr working on next year’s conference at the Gammell noted that Church House Conference Centre, which will despite IV nutritional take place on Saturday September 24, 2016.”
Reproduced from Aesthetics | Volume 2/Issue 12 - November 2015
@aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com
A regulatory issue Regulation – or lack thereof – has long been an issue in the medical aesthetics industry. While Health Education England (HEE) has submitted standards for expected qualifications and education to practise aesthetics, they are still awaiting ministerial approval. Sally Taber, director of Treatments You Can Trust who took part in the HEE With the consumer press increasingly reporting a trend in consultation, explains, “HEE demands that delivery of injectable cosmetics will young girls seeking aesthetic treatment, Ruth Donnelly be allowed only upon suitable training to investigates the effect this has on the industry Qualification Curriculum Level 7 and we believe this will rule out most beauty therapists currently performing injectable treatments.” In Too much too young? addition to HEE’s work, the General Medical Council began consultation on guidance for Ever since 17-year-old American socialite number of patients below the age of 18 all doctors who offer cosmetic interventions Kylie Jenner admitted to having had lip filler undergoing non-surgical procedures in in June 2015, including points regarding injections in May this year, reports have 2014,3 but a 0.7% decrease in the 20 to 29 the specific care of children and young flooded consumer media that claim more age group,4 certainly not the surge that the people.6 The final guidance document is and more young girls are seeking to emulate mainstream media would have us believe. due for release early next year, however as the heiress. Many of these stories have The ASPS figures do show a more significant beauty therapists are not qualified medical concentrated on the 20-30 age group, but at increase in the number of teenagers seeking professionals, the guidelines will not apply to the end of September both The Times1 and treatment, with a 3% rise overall, and a them, so this may well have limited impact. the Mail Online2 reported that girls as young 7% and 6% increase respectively in teens While there is no solid evidence that as 14 were not only requesting, but receiving undergoing botulinum toxin injections and beauty therapists are injecting teenagers, cosmetic injectable treatments, influenced HA fillers.5 But can the American statistics be it is clear that there is a significant lack of by celebrities like Jenner and the new ‘selfie’ applied in the UK? The lack of data available UK-based data available that can tell us culture. Many feel that this media uproar makes it impossible to attribute any figures to how widespread the concern is. HEE’s reflects badly on the aesthetics industry, but the concern. standards of education could of course help do the statistics support the stories? reduce the risk of beauty therapists offering Going underground injectable treatments, however they will not The inside track The general feeling amongst the help us discover how many young people While the press may be awash with practitioners interviewed on this matter is are seeking and undergoing treatment stories about teenagers having lip filler, that if teenagers are receiving cosmetic here in the UK; whether this be from beauty many industry professionals tell a different treatment, then it is not being performed by therapists or medically-qualified practitioners. story. Sharon Bennett, chair of the British medically-qualified practitioners. Consultant Perhaps, then, a database that collates the Association of Cosmetic Nurses (BACN), plastic surgeon Mr Stephen Hamilton says, age of each person undergoing treatment is explains that she posed a question to BACN “This is a potential concern, particularly the way forward. Hopefully the media furore members about the number of young girls with the portrayal of cosmetic surgery as over Kylie Jenner and her followers might requesting treatment. She says, “The answer an easy choice in some parts of the media, work in the industry's favour and spur the came back that very few under 16s asked and probably to a great extent in those parts government into taking action. for treatment.” Dr Paul Cronin, of the Eternal aimed at young women.” Youth Clinic in Cheshire, has not seen a Mr Hamilton adds, “There are certainly a REFERENCES 1. Danielle Sheridan, ‘Girls risk their lives with cheap lip injections’, noticeable increase either, although he lot of column inches devoted to [cosmetic The Times, 26 September 2015
Reproduced from Aesthetics | Volume 2/Issue 12 - November 2015
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and professionals can develop their aesthetic practice. Featuring advice from experienced Aesthetics Conference consultants in marketing, regulation, sales, finance, and law, these sessions will focus on crucial guidance for practitioners and clinic managers in & Exhibition 2016 order to create a successful practice and stand out from competitors. The wide-range of discussions will enable delegates to further develop their knowledge With registration now open and aesthetic professionals looking forward to and understanding of how to make a practice cost- experiencing the Aesthetics Conference and Exhibition (ACE), we can now efficient, increase retention and improve patient reveal what you can expect from the exciting new agenda taking place on April satisfaction. These sessions, which will run across LTH 15 and 16. Following the success of last year’s event and overwhelmingly positive both days, will focus on development across all skinmed feedback from both delegates and exhibitors, ACE has cemented its reputation areas, from front-of-house staff to clinic managers as the leading educational medical aesthetics event. The comprehensive agenda and business owners. For each session attended, A three dimensional alternative to surgery of free practical content within the Masterclass, Expert Clinic and Business Track delegates will be able to apply for CPD accreditation, programmes, alongside the Conference sessions focused around anatomical with Conference sessions awarded 1–1.5 points, areas, will once again attract thousands of practitioners and aesthetic professionals Masterclasses given 1.5 each, Expert Clinic sessions from across the industry. worth 0.5–1 point, Business Track sessions worth 1 . L For 2016, the ACE steering committee, led by consultant plastic surgeon 0.5 points and Treatments on Trial attendees I FT Mr Dalvi Humzah, and comprising Dr Raj Acquilla, Dr Tapan Patel, chair of the awarded 2 points. Alongside the comprehensive British Association of Cosmetic Nurses Sharon Bennett and Aesthetics journal educational programme, the 2,500m² exhibition editor Amanda Cameron, are dedicated to providing delegates with a packed floor will feature more than 100 top medical aesthetic agenda of CPD-accredited education in more than 58 sessions. Popular speakers suppliers, with representation from Healthxchange, 2 . from last year’s educational agenda who have already announced their return for AestheticSource, Lynton Lasers and BTL Aesthetics T IG ACE 2016 include Mr Taimur Shoaib, Dr Simon Ravichandran, Dr Daron Seukeran among many others who will showcase cutting-edge HT EN and Dr Maria Gonzalez. They will be joined by new additions to the ACE team of products, advances in services, and innovations to industry leaders, including Dr Uliana Gout, Dr Kieren Bong and Dr Kate Goldie. target an array of medical aesthetic concerns. 3 . H Y DR A novel addition to this year’s agenda is the new Treatments on Trial programme, Delegates can register for free online to gain access ATE where delegates will be offered an exclusive opportunity to directly compare to the Masterclass, Expert Clinic, Treatments on Trial products with similar indications in an active debate with company representatives. and Business Track agendas, as well as the Exhibition Comes Highly Recommended During each session, which will take place on Saturday 16, four different company floor. The paid-for premium Conference programme “I believe that high intensity focused ultrasound representatives will give demonstrations of their product, describing the main will include eight sessions from a team of more (HIFU) technology represents an exciting benefits and presenting patient results. Delegates will then be able to get involved than 20 world-leading speakers, focusing on key advance in non-surgical facial rejuvenation” in an engaging question and answer debate, discussing product usage, techniques anatomical areas of the body, including the stomach, and potential contraindications. forehead, perioral, periorbital, mid-face, neck and Mr Paul Banwell. Consultant Plastic ACE 2016 will again include the extremely popular live demonstration Expert décolletage, temple, thighs and buttocks and vaginal & Cosmetic Surgeon Clinic agenda, with sponsors including Syneron Candela, SkinCeuticals, Fusion rejuvenation. Delegates will have the choice to book Images courtesy of The Banwell Clinic GT and AesthetiCare already confirmed. These sessions represent a fantastic either a one-day pass for the Friday or Saturday, or a opportunity for leading cosmetic injectors and skincare professionals to showcase two-day pass to experience the whole agenda. Here’s why 3D-skinmed is a must investment for 2015 the best techniques and lend practical advice to delegates. The agenda will also include non-sponsored discussions on managing filler complications, facial To book your place at ACE 2016 and to find out Advanced multi-technology platform offering 1 3D-HIFU anatomy, lasers and chemicals peels from expert practitioners. more visit www.aestheticsconference.com the latest clinical treatments for facial lifting, High Intensity Focused Ultrasound is the latest clinically Leading aesthetic companies will be welcomed to ACE to host Masterclasses, skin tightening, acne scarring, scarring and proven technology for face lifting and the improvement in HEADLINE SPONSOR cosmeceutical product infusion. 1.5mm providing an exclusive opportunity for delegates to learn more about products, 3.0mm the appearance of lines and wrinkles in one single session. 4.5mm best practice techniques and patient outcomes in 90 minute in-depth workshops. Synonymous with the 3D-Brand this affordable The Business Track agenda will deliver invaluable insights on how practitioners 3D-RF / 3D- Dermaroller RF cutting edge technology and consumables 2 Focus Fractional Radio Frequency is the 3rd generation make this advanced treatment accessible to a of RF technology. It utilises three or more pole/electrodes wider consumer base. to deliver the RF energy under the skin providing more superficial skin tightening to compliment the deeper results A highly profitable addition to any clinic’s menu. achieved by HIFU. As expected of the 3D-Brand, backed by one of 3 the largest National PR awareness campaigns 3D-Impact 3D-Impact creates an intensive delivery of cosmetic that the industry will have witnessed! ingredients to help fight the visible signs of aging and maximising the skins hydration.
For further information or www.3d-skinmed.co.uk Reproduced from Aesthetics | Volume 2/Issue 12 - November 2015 a demonstration call: 01788 550 440 @3Dskinmed The most advanced “multi-platform technology for non-surgical facelift
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Delving beneath the surface of peels and lasers Skin resurfacing using chemical peels and lasers of different modalities are popular and effective methods of rejuvenating skin, as well as treating some skin complaints. Allie Anderson speaks to practitioners about how they should be used in aesthetic clinics
They say youth is wasted on the young, and this is paradoxically, resurfacing entails controlled injury to the skin in order to improve its perhaps particularly true in relation to the skin. Until appearance. This can be performed by peeling or the application of lasers: a third the age of around 30, most people are relatively option – dermabrasion – is not discussed herein. carefree when it comes to looking after their skin, since, to a great extent, the skin appears to look after PEELS itself. The process of skin cell renewal is reliable and In a peeling treatment, chemicals are applied to the skin so that the epidermis peels consistent, and crucially – it’s relatively rapid.1 With age away, revealing fresh skin beneath. As well as proving effective in combatting and and poor treatment of the skin, however – be it sun reversing visible signs of skin ageing – such as fine lines and wrinkles; dull, rough exposure, smoking, or lack of an adequate skincare skin; enlarged pores; uneven tone; and areas of pigmentation – peels can be used regime – successful skin cell renewal becomes more to treat acne and resulting scarring, rosacea and pigmentation disorders such as challenging.1 melasma and chloasma.3 Peel solutions are categorised in part by how deeply they penetrate into the skin, ranging from superficial (or micro/light), medium and deep SKIN REJUVENATION peels, with results typically improving as penetration depth increases.4 During skin cell renewal, firstly, the outermost layers of the epidermis (the stratum corneum) are shed naturally Superficial peels – these commonly contain either alpha-hydroxy acid (AHA), through a process called desquamation. such as glycolic acid; or beta-hydroxy acid (BHA), such as salycilic acid, at New cells are then formed beneath that gradually various concentrations.5 make their way towards the surface, in a process called keratinisation,1 meaning that damaged skin is renewed • Glycolic acid – the preferred treatment at James Willis Faces is a glycolic acid regularly. Second, fibroblasts in the dermis deposit well- solution, supported by a robust homecare regime both in preparation for and structured and plentiful collagen fibres, which keep the following the peel itself. “We have a mandatory two-week home preparation period skin plump and elastic.2 As a result, the face retains the that comprises a simple but effective five-step procedure, one of which involves characteristics of youthful skin, despite behaviours that a little bit of glycolic acid,” explains managing director and therapist Alison Procter. will, in time, degrade its health. As we age, however, “That routine is maintained for around six months after treatment as well. For the peel these youth-prolonging mechanisms become less itself, we provide a series of six glycolic peels of increasing strength, one a week for effective. The matrix that holds the stratum corneum six weeks, and the effects are very impressive.” The first peel is normally 40% glycolic together becomes denser, enabling the cells to build acid concentration, and based on a number of factors such as the patient’s age, skin up, and consequently making desquamation more type, the severity of the complaint and the desired result – as well as how the patient difficult and keratinisation slower.1 Moreover, collagen reacts to the mildest solution – subsequent peels will contain an added exfoliant synthesis begins to decline during our 20s and 30s, (proteolytic enzymes), a higher concentration (70%) of glycolic acid, or both. and the collagen that is produced is increasingly fragmented and degraded thereafter, causing the skin • Salycilic acid – this formulation is often favoured when treating patients with to weaken and lose elasticity.2 Although taking care of skin of colour. Dermatologist Dr Marina Landau says, “For a superficial peel I the skin from a young age will go some way to staving might use the BHA salycilic acid, which is less inflammatory and can therefore be off the tell-tale signs of facial ageing, they are inevitable. used relatively safely on darker phenotypes.” Published evidence suggests that But for those wishing to turn back the clock, an effective such superficial peels are the best and sometimes the only option for Fitzpatrick method of rejuvenation is skin resurfacing, the goal of skin types IV and above.6 This is because deeper peels carry an increased risk which is to bring new skin to the surface by mechanical of post-inflammatory hyperpigmentation, to which darker skin types are more or chemical removal of the topmost layer. Perhaps susceptible.7 Salycilic acid has been shown to elicit more marked long-term
Reproduced from Aesthetics | Volume 2/Issue 12 - November 2015 103764 G&T Peels Ad A4:Layout 1 29/09/2015 17:40 Page 1
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© Ferndale Pharmaceuticals Ltd® 2015 aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics improvements with fewer side effects, and is better tolerated, than therefore there is a significant risk of hypopigmentation, even in glycolic acid in patients with acne.3 lighter-skinned patients.11 The advantage, says Dr Bhojani-Lynch, is that you can get the more advanced results associated with deeper • Naturally derived acids – a holistic approach to skincare is penetration. Caution is crucial because of the toxicity profile of imperative to the Diane Nivern Advanced Skincare and Medical phenol, which is rapidly absorbed and can cause serious harm.12 Aesthetics clinic, and this is reflected in the resurfacing treatments on As it’s a much more painful procedure than shallower peels, sedation offer. “The peels I use mostly comprise acids that are naturally derived, or anaesthetic may be required.13 “Most phenol peels are only done as opposed to synthetic, laboratory-standardised chemicals. That on very small areas, like under the eyes and across the top lip – and fits more comfortably with our ethos, which entails a whole-person they tend to be performed in hospitals where there are resuscitation approach to skin health and skin rejuvenation,” Nivern explains. facilities,” adds Dr Bhojani-Lynch. In fact, UK guidelines recommend “These peels will normally contain naturally occurring citric, malic or phenol peels are carried out by an experienced surgeon or lactic acid, combined with ingredients that help to feed, peel and dermatologist on Care Quality Commission-registered premises.13 restore the skin at the same time.” These include centella asiatica, which has numerous applications in cosmetology and is known for its APPLICATION OF PEELS wound healing properties; it promotes the proliferation of fibroblasts The procedure tends to be more or less standard, regardless of the and increases collagen synthesis, inhibiting inflammation and thereby type of peel. First, the face is fully cleansed, often with an acetone- ensuring newly formed skin is stronger.8 Nivern reports that the or alcohol-based solution to degrease the skin. A barrier gel may system she uses produces good results in cohorts of patients with also be applied to the more delicate areas, such as the nasolabial wide-ranging complaints, including: ageing skin; younger people with folds. The practitioner applies the peel and, with many types of congested skin; men with ingrowing hairs; people with adult-onset peels, determines how long it is left on by observing the patient’s acne or acne pitting and scarring; and irregular pigmentation in black, response and monitoring changes in the skin’s appearance. “We’re Asian and Chinese patients. looking for flushing, redness, and frosting of the skin, where it goes very pale,” explains Nivern, “at which point we would immediately Medium-depth peels – whereas superficial peels, as their name neutralise and wash off the peel.” However, not all peel treatments suggests, penetrate superficially, medium-depth peeling inflicts have a visible endpoint that indicates that it has reached optimum controlled injury down to the papillary dermis.9 “Most peels are success. Procter’s glycolic system involves the peel being left on the epidermal in nature,” says Dr Tahera Bhojani-Lynch from The Laser treatment area for a set time of 10 minutes (assuming it is tolerated), and Light Cosmetic Medical Clinic. “If you get a little bit through to before neutralising the acid with warm water sponges. After this, the dermis, you produce more collagen; the new skin is a bit tighter and depending on the specific protocol, a combination of serums, and it gives you some additional effects.” An often-used ingredient moisturisers and – most notably – a high-SPF (30 to 50+) sun cream is trichloroacetic acid (TCA) at strengths of between 15% and 40% is applied. Practitioners interviewed concurred that strict, continued concentration. Because the peeling agent penetrates more deeply use of sun protection and lifelong UV avoidance is the most (according to its concentration), these effects are typically achieved important factor in the success of any resurfacing treatment, and in with one treatment, where a series of treatments is needed with a preventing and minimising complications.14 more superficial peel. A comparative study found that single TCA (35%) peels generate significantly greater improvement in cheek CONSIDERATIONS wrinkles and are associated with higher patient satisfaction than a Occasional side effects and complications are possible, as outlined series of 30% glycolic peels, although the former is associated with below: much greater discomfort.10 According to Dr Bhojani-Lynch, a moderate TCA peel is her go-to treatment to reverse signs of ageing in patients who have more severe sun damage, and is safe and effective for PEEL DEPTH Potential side effects/complications3 darker skin types at a low concentration.6 “You could use a mild TCA peel and repeat it over two or three weeks to get the effect of a Transient burning moderate peel, but you would need to exercise caution,” she adds. Irritation Erythema Before deep peel Two months after deep peel Scarring (rare) SUPERFICIAL Post-inflammatory Hyperpigmentation (PIH) (rare) Infection (rare)
Pigmentary changes Infection Allergic reactions Compromised skin healing Images courtesy of Dr Marina Landau MEDIUM AND Hypersensitivity Deep peels – more aggressive peels containing phenol are now DEEP PEELS Lines of demarcation between treated rarely used in the UK, because of the increased risk of complications and untreated areas and adverse effects, when compared with superficial and medium- Scarring depth peels.11 These occur because phenol is a stronger solution Persistent redness and penetrates several layers causing a second-degree burn;
Reproduced from Aesthetics | Volume 2/Issue 12 - November 2015 @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com
The practitioner’s expertise is an important factor in preventing Before After complications: they should identify patients who may be more at risk (those with PIH and keloid scars and people who are deemed potentially uncooperative), and select a peel depth that balances desired results with possible adverse events for each patient.3 Contraindications include isotretinoin, used to treat severe acne; guidelines suggest waiting six months after discontinuing the medication before undergoing chemical peeling.15 Notwithstanding, anecdotal evidence shows overwhelmingly that superficial and medium-depth peels are, for the most part, safe and relatively free of complications, hence their popularity. “Chemical peels are an important part of my treatment armamentarium, and I feel comfortable with this procedure because it has a long history,” comments Dr Landau. Research supports this view, suggesting that dermatological uses date back as far as the 1870s.16 Dr Landau Results following treatment with the Lumenis Ultrapulse CO2 laser. Images adds, “Patients understand the idea of renewing the skin by courtesy of Joseph Niamtu II DMD peeling off the old layers and the clinical results are impressive.” RF energy to the deep, middle and upper level dermis and the LASERS epidermal layer. This creates controlled thermal damage that The core component of laser resurfacing is heat, and most often uses generates a tightening effect, and triggers a healing response in light waves for its creation. When a wavelength of light is applied the dermis to boost collagen production.” to the skin, it targets substances in the skin’s molecules called chromophores, which absorb the light and turn it into heat energy. APPLICATION OF LASERS Different light wavelengths penetrate at different depths and target Machines typically either have a rolling motion, whereby the head is particular chromophores – haemoglobin for vascular lesions,17 melanin rolled over the skin in a number of passes; a stamping motion, where for pigmented lesions,18 and water for lines and wrinkles. 19 Generally the hand-piece is moved up and down between adjacent areas of speaking, two types of lasers are used in skin resurfacing: ablative and skin to be treated; or a scanning-type mode. The skin is numbed with non-ablative. a topical solution for around 45 minutes: for full resurfacing, which is more painful and requires greater downtime, local anaesthetic is Ablative lasers – Ablative lasers cause wounding to the skin and, injected. Next, the skin is thoroughly cleansed and when goggles are consequently, removal of its outermost layers, thereby stimulating in place to protect the patient’s eyes, the treatment is applied. The skin renewal of collagen-rich skin beneath. is lasered one area at a time based on the laser’s spot size, although, Non-ablative lasers – Non-ablative lasers also work by boosting according to Dr Al-Niaimi, best results are achieved by treating the collagen production, but they bypass the top skin layers and conduct entire face to avoid visible demarcation. “The face is divided into heat deeper in the dermis. Targeting water chromophores, a cellular so-called ‘sub-units’. At a minimum, you would treat an entire sub-unit reaction is triggered that stimulates the production of collagen and – the whole nose or the whole mouth unit – or, for optimum results, elastin, thus firming and plumping the skin.20 you treat the entire face, but you use a ‘blending’ technique,” he Fractional lasers – A more recent development, the fractional laser explains. This involves applying a milder form of laser to the rest of the is commonly used as an intermediate treatment between the former face, feathering the borders with low-pulse energy and density.22 As two, working at both the epidermal and dermal layers. The laser with peels, post-laser aftercare centres on sun protection. In addition, beam is divided into thousands of minuscule columns, each intensely regular cleansing and moisturising is essential – using occlusive targeting a tiny fraction of the skin at a time while leaving surrounding ointments following ablative procedures and lighter moisturisers tissue unharmed. This promotes faster healing than the traditional for non-ablative. “A good antiseptic is the key component of good laser procedures, in which the whole area is exposed.21 Consultant aftercare to prevent infection,” explains Dr Al-Niaimi. “Patients are able dermatologist and medical director of sk:n clinics, Dr Firas Al-Niaimi, to return to work the day after a RF resurfacing treatment,” adds Xu. offers a combination of full-area, fractional, ablative and non-ablative treatments, using erbium-doped yttrium aluminium garnet (Er:YAG) COMPLICATIONS and carbon dioxide (CO2) as their media. “Depending on the severity Types of complications include: of the condition treated, the patient’s age and skin type, and the downtime request, we can choose the most appropriate laser,” he • Erythema comments. “The fractional non-ablative laser has a shorter downtime, • PIH but it will require a number of treatments because the effects are not • Infection as dramatic as ablative. But if someone has a severe form of wrinkling • Scarring or acne scarring, and does not mind downtime, then obviously the • Swelling ablative resurfacing will be quicker and give better results.” • Severe itching Radiofrequency lasers – These (non-ablative) lasers use • Acne radiofrequency (RF) energy, rather than light energy, to generate the heat required to affect the resurfacing process. Lucy Xu, The severity of each complication can be classified as minor, treatment director at Premier Laser and Skin, explains, “The system intermediate or major and will vary depending on the type of patient we use utilises gold-plated isolated microneedles to deliver and concern treated, as well as the strength of the laser used.22,23
Reproduced from Aesthetics | Volume 2/Issue 12 - November 2015 103764 NeoRetin Half Page Ad:Layout 1 29/09/2015 17:17 Page 1
Notwithstanding, most devices and types of laser are deemed safe and effective, balanced against the pain and downtime of the procedure itself. Most complications have been shown to be caused not by device malfunction, but by errors on the part of the practitioner.24 In the hands of experienced and reputable aestheticians, one can expect these complications to be minimal.
CONCLUSION Skin resurfacing by application of chemical peels or lasers is a popular choice for patients. Like any aesthetic procedure, especially those that cross over into the realm of medical treatment, Effective it is essential that clinicians fully understand the complexities and Pigmentation potential pitfalls of these options. In capable hands, however, skin resurfacing can be a safe and effective treatment and therefore, Resolution a valuable addition to the practitioner’s toolbox. That’s kind on skin FURTHER READING Dr Firas Al-Niaimi, ‘Laser complications in aesthetic procedures’, Aesthetics, Volume 1/Issue 11, October 2014.
REFERENCES 1. Howard, D., Skin Exfoliation 101, (Los Angeles: International Dermal Institute)
© Ferndale Pharmaceuticals Ltd® 2015. 1Truchuelo M et al, Journal of Cosmetic Dermatology, 2014. 2Cameli N et al, Dermatological Experiences, 2012.
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Laser-assisted Drug Delivery: a novel use of lasers in dermatology Dr Firas Al-Niaimi examines how lasers can penetrate the stratum corneum to aid treatment of aesthetic concerns
Abstract the passage of molecules to the cutaneous compartments is Topical medicaments are the mainstay of the dermatologists’ comparatively unimpeded.5 Laser technologies deploy a particular therapeutic arsenal. The stratum corneum in the upper layer of wavelength of light to selectively destroy the chromophore the epidermis is rather impermeable to water-soluble and large of interest. Ablative lasers in common use include the carbon molecules. Traversing this layer is key to optimal drug delivery. dioxide (CO2; wavelength peak 10,600 nm) and erbium-doped Studies thus far suggest that laser pre-treatment improves yttrium aluminium garnet (Er:YAG; wavelength peak 2940 nm) transepidermal absorption of topical agents and allows for a devices, both of which have wavelengths targeting water.6 The much deeper penetration of drugs than is possible with topical water molecules are found both intra- and extra-cellularly. Laser medicaments alone. Laser-assisted drug delivery enhances the devices have traditionally been used in continuous mode, in which ability of topically-applied medicaments to penetrate the skin, the entirety of the water-containing epidermis being treated is which may allow for more efficacious action of current treatments; ablated.6 More recently, ablative fractional laser technologies such that conventional duration of treatment can be shortened or (AFXL) have been developed. AFXL exploits fractional lower concentrations of active agents be used, potentially obviating photothermolysis, in which multiple vertical columns of tissue are side effects of treatment. In order to discuss how we eventually thermally destroyed to create unimpeded channels communicating got to this stage, it is important to look at the animal model studies with the outermost layer of the stratum corneum.1-3 Each channel that have supported the concept of laser-assisted drug delivery. is surrounded by a cuff of dense thermally-coagulated tissue, There has been a tremendous interest in the application of this collectively referred to as microscopic treatment zones (MTZs).7 modality across a range of dermatologic and aesthetic procedures. Only a fraction of the skin surface is treated, in which MTZs This article will, however, only focus on the aesthetic component; facilitate penetration of topical molecules from the surface to although this modality has been used in dermatologic conditions the layer of interest, whilst leaving most of the skin surface area such as actinic keratosis, Bowen’s Disease, basal cell carcinoma, untreated and intact.7 The untreated skin serves as a reservoir of vaccination, local anaesthesia, haemangioma, and burn scars. For stem cells, growth factors and inflammatory cells that are able to further information on these applications the reader is advised to rapidly migrate to the traumatised skin and facilitate faster healing look up the recent published studies in this field. with less scarring.8 The depth of these ablated channels can be determined by the fluence used. Introduction Increased penetration of drugs or molecules via MTZs can be Topical therapies play an important role in dermatology, whether understood using Fick’s first law in physics Figure( 1), which in its used for inflammatory dermatoses, (pre)malignant skin disease or simplest form states that the degree of flux of molecule (J) across aesthetic indications. For optimal therapeutic effect, delivery of a barrier is a product of the partition coefficient (Km, a reflection the drug to the relevant compartment within the skin is required. of the number of molecules available for diffusion across a In recent years, ablative laser devices have been employed to aid membrane), the diffusion constant (Dm, a reflection of the inherent delivery of biological molecules throughout the various cutaneous diffusibility of a molecule across the membrane) and concentration compartments.1-3 Whilst other physical mechanisms to enhance difference of that molecule on either side of that barrier (ΔC), transdermal drug delivery have been investigated, including divided by the path length (L):9 tape stripping, iontophoresis, radiofrequency, ultrasound and microneedling,1 the focus of this article is to review the rationale J = Km x Dm x ΔC underlying laser-assisted delivery of drugs and explore the future L considerations of this modality. Non-laser methods of delivery will not be discussed here owing to the breadth of the subject. Figure 1: Fick’s first law in physics Increased permeability of the stratum corneum via MTZs increases Mechanisms of laser-assisted drug delivery Km, therefore increasing the overall flux of the molecule. As the The stratum corneum is the outermost layer of the skin and is molecular size of the drug increases, there is greater frictional largely impregnable to compounds with molecular weights greater resistance to movement of the molecule and Dm decreases, hence than 500 Daltons (Da).4 Once the stratum corneum is traversed, decreasing overall flux.9
Reproduced from Aesthetics | Volume 2/Issue 12 - November 2015 @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com
Pre-clinical studies: animal models Work on animal models has informed the clinical use of AFXL. Photodynamic therapy (PDT) comprises the photodynamic reaction Larger trials with greater between a photosensitiser, light of a select wavelength (or band) and oxygen to generate reactive oxygen species that target numbers within treatment microbes and malignant cells. PDT is most commonly used in dermatological practice to combat non-melanoma skin cancer and control arms are (NMSC) and acne vulgaris.10 Haedersdal undertook CO -AFXL prior to treatment with MAL-PDT 2 required for each of the on porcine skin creating single MTZs, each 300 micron in diameter and 1850 micron in depth, surrounded by a 70 micron cuff of proposed therapies to thermally coagulated tissue.11 In skin treated with AFXL and MAL- PDT (AFXL-PDT), increased porphyrin fluorescence was observed corroborate efficacies and in a uniform fashion up to 1.5 mm from the ablated channels. This suggested that for MAL, MTZs placed at 3 mm intervals, equating side effects of therapy to less than 1% surface area, could be used to treat the entirety of the lesion. This finding is substantiated by an additional study that used an Er:YAG laser to create multiple MTZs, and suggested that blinded randomised controlled trial (RCT) of 61 patients (adults there is no increase in lidocaine absorption if the number of pores and children) attending the emergency department who required is increased beyond a certain density.12 Moreover, there was no cannulation showed that pain upon cannulation was significantly increased absorption of lidocaine if progressively higher fluences lower when pre-treated with the Er:YAG laser prior to application were used to extend the MTZs beyond the stratum corneum into of 4% lidocaine.18 There appears to be no diminution in the degree the epidermis or dermis.12 of analgesia at lower energy laser settings (2.0J/cm2), compared 5-fluorouracil (5-FU) is a chemotherapeutic agent commonly to the high energy (3.5J/cm2) settings used in the aforementioned used in dermatology for treatment of NMSCs, including actinic studies, as inferred from an intra-individual study of 30 patients keratoses (AKs), Bowen’s disease and superficial basal cell comparing both settings, with one used on each antecubital fossa.19 carcinomas (BCCs).13 Imiquimod (5%) is a commercially available These proof of principle studies are supported by clinical immunomodulatory agent that is similarly used to treat various applications. In a randomised, split-face clinical study of 12 patients, NMSCs.14 Work in murine skin has suggested that 5-FU penetration Yun and colleagues looked at the effect of pre-treating one side of was enhanced 36-133 fold following pre-treatment with Ruby, the face with low fluence Er:YAG prior to application of 5% topical 15 20 CO2 or Er:YAG lasers. Similar work has demonstrated enhanced lidocaine and whole face resurfacing in two passes. Subjective transdermal delivery of imiquimod in porcine and murine models pain scores on the side of the face that had been pre-treated with following a low-fluence fractional Er:YAG laser,16 with enhanced ablative laser were significantly lower than the side not pre-treated imiquimod delivery up to 65 fold after one pass and 127 fold after with ablative laser. However, only 56% patients were able to tolerate four passes. The authors further demonstrated that reduction in the second pass of the resurfacing, forcing us to question its value dose of imiquimod to 0.4% delivered equivalent concentrations in future work. of imiquimod as topically applied 5% imiquimod (commercially available), which may allow for the future use of lower Vitiligo concentrations of drugs leading to similar clinical efficacy.16 Vitiligo is an auto-immune condition in which depigmented patches Together, these findings in porcine skin suggest that there is a occur on the skin. In a study involving 25 patients with stable, critical density of MTZs, beyond which additional MTZs confer no symmetrical vitiligo, recalcitrant to other therapies, a half-body benefit with respect to penetration of the drug. Photosensitisers comparative analysis, in which patches of vitiligo on one half of can penetrate superficial and deep levels of skin and conventional the body underwent CO2-AFXL, followed by topical application of settings for the LED illumination can be employed. Pre-treatment betametasone solution under occlusion followed by a course of with AFXL permits greater penetrance of drug, in particular larger narrowband-ultraviolet B (NB-UVB) phototherapy (treatment), whilst and more hydrophilic molecules, which may act in a shorter patches on the other side (control) received CO2-AFXL and NB-UVB timeframe.2,3 Furthermore, AFXL pre-treatment may improve alone was performed.21 Treatments with CO2-AFXL were given at efficacy of topically-applied medicaments and permit lower half monthly intervals, whilst NB-UVB was given two to three times concentrations of active agents to be used with reduced frequency weekly over six months. 44% of patients achieved more than 50% or duration of application. repigmentation on the treatment arm, which was significantly better than the control arm, owing to greater penetration of the topical Local anaesthetics corticosteroid. Whilst the results are of interest, the protracted course Many dermatological procedures are performed under local of treatment and associated expense may preclude this treatment anaesthesia. Topical agents have a long latency before effect in other healthcare systems, however the study provides further takes place and anaesthesia may be incomplete owing to poor support of the application of this concept. penetration of the skin, whilst injections are associated with pain. Pre-treatment with the conventional Er:YAG laser prior to application Hypertrophic and keloid scars of topical 4% lidocaine has been shown to reduce sensation to Improvement in the appearance of scars is often observed needle prick within five minutes compared to laser plus placebo following AFXL treatment and is likely attributable to removal of a (62% reduction) or lidocaine alone (61% reduction).17 Similarly, a section of the fibrotic scar and a relative normalisation of collagen
Reproduced from Aesthetics | Volume 2/Issue 12 - November 2015 aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics structure and composition.22 Waibel investigated 15 patients with hypertrophic scars resulting from trauma, injury or burns. Each patient received up to five treatments with CO2-AFXL (10-15% density using the UltraPulse Lumenis machine) followed by topical triamcinolone application (10mg/ml or 20mg/ml).23 Blinded observers noted improvements in texture, degree of hypertrophy and dyschromia at six months following the final treatment session. The authors suggest that AFXL as a method of drug delivery may have benefit over triamcinolone injections owing to uniformity of depth and distribution of triamcinolone, as well as avoiding the pain associated with intralesional injections. Another group reported the treatment of a total of 70 keloid scars in 23 patients with 2940 nm AFXL (180 J/cm2, 5% coverage) every Figure 2: The diagram shows columns of fractional ablated tissue with small drug molecules passing through it to reach deeper parts of the skin. other week with concomitant betametasone cream twice daily under occlusion until either complete flattening of the scar was Botulinum toxin achieved or no further improvement was seen.24 After a median Botulinum neurotoxin type A (BoNTA) is a neurotoxin secreted by of nine laser treatments, there was a median 50% improvement Clostridium botulinum, an anaerobic, Gram-positive bacterium and is in scar appearance, gauged through photographic evaluation by widely used to reduce the appearance of wrinkles and rejuvenate the two independent observers. Eight months after treatment, keloid skin. Recent work suggests that topical application of BoNTA (in its recurrence was 22%; all recurrences were noted within two months current form) may not penetrate the stratum corneum to elicit clinically of cessation of laser treatment. discernible endpoints compared with injected toxin.28 A split face study was conducted on 10 subjects involving C02-AFXL of the face Atrophic scars with application of topical BoNTA on one side and normal saline on Poly-L-lactic acid (PLLA; Sculptra) is commonly used as a the other side as a control.28 Compared with the control side, topical subcutaneous filler for facial volume restoration, which is purported application of BoNTA resulted in significant reduction in the number of to stimulate fibroblast proliferation and collagen formation. 19 patients periorbital wrinkles at one week and one month following treatment. with atrophic scars from various causes, including acne, trauma and These results suggest that BoNTA delivery can be enhanced pre- surgery, were treated with CO2-AFXL followed by topical application treatment with AFXL. Comparison with injectable BoNTA and newer of PLLA.25 The treatments appeared to be tolerated with post- topical formulations of botulinum neurotoxin remain to be performed procedural mild pain, while erythema and swelling were the most and will likely guide development of this novel method of delivery in commonly cited concerns. Each patient required an average of one the near future.29 single treatment. Four blinded observers reported improvements in scar contour, atrophy and colour three months after treatment.26 Non-ablative fractional laser Despite the above being a non-controlled study, PLLA is a large More recently, work has been undertaken using non-ablative fractional molecule and will not be able to penetrate the impermeable stratum lasers (NFXL), in which a controlled zone of thermal injury is generated, corneum.27 The improvement observed suggests the enhanced rather than a fully ablated MTZ. Pre-treatment with the non-ablative penetration was achieved through pre-treatment with AFXL. It is also 1550-nm erbium glass laser has been shown to enhance delivery possible that the AFXL effects on upregulating collagen synthesis may of Amino-levulinic acid in human subjects, as gauged by cutaneous have had a synergistic effect with PLLA. porphyrin fluorescence.30 Advantages of non-ablative devices are increased patient tolerability and reduced post-procedural downtime.31 Although there has been some use of this technology in combination with topical therapy (bimatoprost for hypopigmented scars for example),32 use of such technology is yet to be used in larger clinical Pre-treatment with the studies. In addition, it is unclear if the effect of pre-treatment with NFXL enhanced the penetration of the molecule, as the latter can penetrate conventional Er:YAG laser easily through the stratum corneum. prior to application of Platelet rich plasma Platelet-rich plasma (PRP) has gained a lot of popularity in recent topical 4% lidocaine has years and has been used in dermatologic practice in cases of scarring, alopecia, wound healing, and rejuvenation.33 PRP has been shown to reduce been used post AFXL in a number of studies although primarily as an adjunctive to enhance synergistic effect of the AFXL and sensation to needle prick to reduce post AFXL erythema.34 None of the published studies primarily looked at AFXL to enhance the delivery of PRP but it is within five minutes plausible that the combination of both modalities has synergistic effects.35 In clinical practice some practitioners routinely use the application of PRP post AFXL; primarily to speed up recovery and reduce post-procedural erythema.
Reproduced from Aesthetics | Volume 2/Issue 12 - November 2015 @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com
of patients and utilising various laser and topical medicament parameters, we will enhance our understanding of this nascent Key points modality of treatment delivery and better serve the patients.
1. The stratum corneum is the outermost layer of Dr Firas Al-Niaimi is a consultant dermatologist and laser surgeon, based at St Thomas’ Hospital, London. the epidermis and is impermeable to large and He is a group medical director at sk;n clinics and has hydrophilic molecules authored more than 95 publications and 120 scientific 2. Ablative fractional lasers create channels of presentations. Dr Al-Niaimi is also on the advisory board ablated tissue with islands of normal skin in of a number of respected journals.
between to hasten recovery REFERENCES 3. Laser-assisted drug delivery through the use of 1. Bloom BS, Brauer JA, Geronemus RG. ‘Ablative fractional resurfacing in topical drug delivery: an update and outlook’, Dermatol Surg 2013; 39:839–848. fractional ablative lasers has gathered increasing 2. Sklar LR, Burnett CT, Waibel JS, et al. ‘Laser assisted drug delivery: a review of an evolving interest in recent years technology’, Lasers Surg Med 2014; 46:249–262. 3. Brauer JA, Krakowski AC, Bloom BS, et al. ‘Convergence of anatomy, technology, and therapeutics: a 4. Currently, most of the evidence with review of laser-assisted drug delivers’, Semin Cutan Med Surg 2014; 33:176–181. this modality is with the combination of 4. Bos JD, Meinardi MM. ‘The 500 Dalton rule for the skin penetration of chemical compounds and drugs’, Exp Dermatol 2000; 9:165–169. photodynamic therapy and fractional lasers 5. Scheuplain RJ, Blank IH. ‘Permeability of the skin’, Physiol Rev 1971; 51:702-47. 5. Alternative methods of drug delivery include 6. Hruza GJ, Dover JS. ‘Laser skin resurfacing’, Arch Dermatol. 1996; 132(4):451-5. 7. Manstein D, Herron GS, Sink RK, et al. ‘Fractional photothermolysis: a new concept for cutaneous the use of ultrasound, radiofrequency, remodelling using microscopic patterns of thermal injury’, Lasers Surg Med 2004; 34:426-38. electroporation and iontophoresis 8. Stumpp OF, Bedi VP, Wyatt D, et al. ‘In vivo confocal imaging of epidermal cell migration and dermal changes post nonablative fractional resurfacing: study of the wound healing process with corroborated histopathologic evidence’, J Biomed Opt 2009; 14:024018. 9. Brisson P. ‘Percutaneous absorption’, Can Med Assoc J 1974; 110:1182–1185. 10. Wlodek C, Ali FR, Lear JT. ‘Use of photodynamic therapy for treatment of actinic keratoses in organ transplant recipients’, BioMed Res Int 2013:349526. 11. Haedersdal M, Sakamoto FH, Farinelli WA, et al. ‘Fractional CO2 laser-assisted drug delivery’, Lasers Future considerations Surg Med 2010; 42:113–122. Larger trials with greater numbers within treatment and control 12. Bachhav YG, Summer S, Heinrich A, et al. ‘Effect of controlled laser microporation on drug transport kinetics into and across the skin’, J Controlled Release 2010; 146:31–36. arms are required for each of the proposed therapies to 13. Ceilley RI. ‘Mechanisms of action of topical 5-flourouracil: review and implications for the treatment of corroborate efficacies and side effects of therapy. Future cohorts dermatological disorders’, J Dermatolog Treat. 2012; 23(2):83-9. 14. Micali G, Lacarrubba F, Nasca MR, Schwartz RA. ‘Topical pharmacotherapy for skin cancer: part I will need to account for differing body sites, and efficacy of Pharmacology’, J Am Acad Dermatol. 2014; 70(6):965.e1-12. treatments in varying ages, genders and ethnicities. Optimal 15. Lee WR, Shen SC, Wang KH, et al. ‘The effect of laser treatment on skin to enhance and control transdermal delivery of 5-fluorouracil’, J Pharm Sci 2002; 91:1613–1626. laser parameters, including fluence, density and scheduling of 16. Lee WR, Shen SC, Al-Suwayeh SA, et al. ‘Laser-assisted topical drug delivery by using a low-fluence treatments, need to be determined to facilitate maximal drug fractional laser: imiquimod and macromolecules’, J Controlled Release 2011; 153:240–248. 17. Lee W-R, Shen SC, Fang CL, et al. ‘Skin pretreatment with an Er:YAG laser promotes the transdermal penetration, whilst allowing rapid recuperation of the skin. As well delivery of three narcotic analgesics’, Lasers Med Sci 2007; 22:271–278. as selecting which drug within a category (such as corticosteroids) 18. Singer AJ, Weeks R, Regev R. ‘Laser-assisted anesthesia reduces the pain of venous cannulation in children and adults: a randomized controlled trial’, Acad Emerg Med 2006; 13:623–628. is likely to yield the best result, the optimal vehicle for topically 19. Koh JL, Harrison D, Swanson V, et al. ‘A comparison of laser-assisted drug delivery at two output applied medicaments, whether gels, patches, creams or ointments, energies for enhancing the delivery of topically applied LMX-4 cream prior to venipuncture’, Anesth Analg 2007; 104:847–849. together with duration and frequency of application and the 20. Yun PL, Tachihara R, Anderson RR. ‘Efficacy of erbium:yttrium-aluminum-garnet laser-assisted delivery necessity for occlusion is yet to be determined. Additional of topical anesthetic’, J Am Acad Dermatol 2002; 47:542–547. 21. Bachhav YG, Heinrich A, Kalia YN. ‘Controlled intra- and transdermal protein delivery using a minimally consideration needs to be afforded to potential toxicity from invasive Erbium:YAG fractional laser ablation technology’, Eur J Pharm Biopharm 2013; 84:355–364. medicaments, as already has been demonstrated with lidocaine 22. Qu L, Liu A, Zhou L, et al. ‘Clinical and molecular effects on mature burn scars after treatment with a 28 fractional CO(2) laser’, Lasers Surg Med 2012; 44:517–524. toxicity occurring following AFXL resurfacing. Furthermore, these 23. Waibel JS, Wulkan AJ, Shumaker PR. ‘Treatment of hypertrophic scars using laser and laser assisted drugs or molecules were designed for topical application and corticosteroid delivery’, Lasers Surg Med 2013; 45:135–140. 24. Cavalié M, Sillard L, Montaudié H, et al. ‘Treatment of keloids with laser-assisted topical steroid their current concentrations may prove too high or toxic for direct delivery: a retrospective study of 23 cases’, Dermatol Ther 2015; 28:74–78. dermal introduction. Rigorous health economic analysis comparing 25. Rkein A, Ozog D, Waibel JS. ‘Treatment of atrophic scars with fractionated CO2 laser facilitating delivery of topically applied poly-L-lactic acid’, Dermatol Surg 2014; 40:624–631. the efficacies and cost-effectiveness of these new modalities of 26. Mahmoud BH, Burnett C, Ozog D. ‘Prospective Randomized Controlled Study to Determine the Effect treatment compared to tested, longer-established treatments may of Topical Application of Botulinum Toxin A for Crowʼs Feet After Treatment With Ablative Fractional CO2 Laser’, Dermatol Surg 2015; 41:S75–S81. ultimately determine the take-up of these new technologies, at 27. Sherman RN. ‘Sculptra: the new three dimensional filler’,Clin Plast Surg 2006; 33(4):539-50. least in clinical practice. 28. Brandt F, OʼConnell C, Cazzaniga A, Waugh JM. ‘Efficacy and Safety Evaluation of a Novel Botulinum Toxin Topical Gel for the Treatment of Moderate to Severe Lateral Canthal Lines’, Dermatol Surg 2010; 36:2111–2118. Conclusion 29. Lim HK, Jeong KH, Kim NI, Shin MK. ‘Nonablative fractional laser as a tool to facilitate skin penetration of 5-aminolaevulinic acid with minimal skin disruption: a preliminary study’, Br J Dermatol 2014; Work on animal models and preliminary initial studies have 170:1336–1340. supported the use of AFXL technology as a future adjunct to 30. Massaki AB, Fabi SG, Fitzpatrick R. ‘Repigmentation of hypopigmented scars using an erbium-doped 1550 nm fractionated laser and topical bimatoprost’, Dermatol. Surg 2012; 38(7 pt 1)995-1001. topical therapies. Studies thus far suggest that AFXL improves 31. Narurkar VA. ‘Nonablative fractional laser resurfacing’, Dermatol. Clin 2009; 27(4):473-8. transepidermal absorption of topical agents and allows for a 32. Leo MS, Kumar AS, Kirit R, et al. ‘Systematic review of the use of platelet-rich plasma in aesthetic dermatology’, J Cosmet Dermatol 2015 July. EPub ahead of publication. much deeper penetration of drugs than is possible with topical 33. Kim H, Gallo J. Evaluation of the effect of platelet-rich plasma on recovery after medicaments alone. This may allow more efficacious action of ablative fractionalphotothermolysis.’, JAMA Facial Plast Surg. 2015; 17(2):97-102. 34. Zhu JT, Xuan M, Zhang YN, et al. ‘The efficacy of autologous platelet-rich plasma combined with current treatments, such that conventional duration of treatment can erbium fractional laser therapy for facial acne scars or acne’, Mol Med Rep. 2013; 8(1):233-7. be shortened or lower concentrations of active agents be used, 35. Marra DE, Yip D, Fincher EF, Moy RL. ‘Systemic toxicity from topically applied lidocaine in conjunction with fractional photothermolysis’, Arch Dermatol 2006; 142:1024–1026. potentially obviating side-effects of treatment. The prospect of using AFXL to facilitate transdermal vaccination and as an adjunct for inflammatory dermatoses and cosmetic indications remain in its infancy. As larger trials are published, involving greater numbers
Reproduced from Aesthetics | Volume 2/Issue 12 - November 2015
Not all HA dermal fi llers are created equal.
Cohesive Polydensifi ed Matrix® OPTIMAL (CPM®) Technology1,2
SKIN 2 INTEGRATION2 Optimal tissue integration Intelligent rheology design
Injectable Product of the Year3
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Date of preparation: September 2015 of preparation: Date The fi ller you’ll love
1. BEL-DOF-003 V2 Belotero® technology, June 2015. 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. Aesthetics Awards Supplement, December 2014. Injectable product
Adverse incidents should be reported. Reporting forms & information can be found Adverse incidents should be reported. to Merz Adverse incidents should also be reported at www.mhra.gov.uk/yellowcard. Pharma UK Ltd by email to [email protected] or on +44 (0) 333 200 4143. www.belotero.co.uk
BEL/13/SEP/2015/DS of the Year, pg 5.
MZ115 A4 BELOTERO ADVERT BEL-13-SEP-2015-DS.indd 1 18/09/2015 14:55 aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics
blanching, livedo reticularis, and a dusky blue-red discoloration that can be followed by blister formation and skin necrosis.9 Blindness is an ischemic event and devastating possible complication; it can be caused either from retrograde flow from canulating the supratochlear or supraorbital arteries, or from the anatomical anastomosis from the ophthalmic artery in the periorbita and nasolabial fold.10 Swift recognition is the most critical aspect in treating ischemic events. Arterial Not all HA occlusion can be apparent immediately, while venous obstruction may take hours Adverse Reactions to become evident.2 Having a proper dermal fi llers are protocol in place is imperative in providing your patient with the most advantageous to Hyaluronic Acid outcome. This includes: created equal. 1. Stopping the injection immediately if Injections any of the signs of ischemic events are Cohesive Polydensifi ed Matrix® present. OPTIMAL (CPM®) Technology1,2 Dr Maryam Zamani shares advice on how to 2. Injecting hyaluronidase locally. successfully manage HA filler complications 3. Placing Nitroglycerin paste on the skin SKIN 2 immediately if the patient is able to INTEGRATION2 Optimal tissue integration medically tolerate it. Nitroglycerin paste Hyaluronic Acid (HA) fillers are the most into a blood vessel or compression of vasodilates and improves flow in the Intelligent rheology design common and popular agents used to a blood vessel, dyspigmentation, and dermal vasculature, thereby decreasing treat a myriad of rejuvenation treatments; blindness.1,4 Park et al noted in their study and minimising compressive risk from filling in fine lines and wrinkles, on HA complications that, in descending causing ischemia.11 to volume restoration in the face, neck, order of frequency, affected locations 4. Give the patient oral acetylsalicylic acid chest and hands.1 HA fillers are often were the perioral area, forehead (including to help thin blood and minimise ischemic preferred because they are long lasting, glabella), nose, nasolabial fold, mentum, risk.9 less immunogenic and can be broken cheek area and the periocular wrinkles.1 5. Warm compression and vigorous down by hyaluronidase.1 Even in the most massage.9 experienced of hands, complications can Immediate onset complications 6. If the patient presents after the ischemic arise, and with the apparent relative ease Immediate onset complications can include event has begun and there is skin of treatment with high patient satisfaction, overcorrection, visibility of HA and vascular breakdown, topical and/or systemic a cavalier attitude towards fillers can compromise. Familiarity with the properties antibiotics can be started.2 Injectable Product of the Year3 increase the incidence of complications.2,3 of the HA filler used, proper technique and The focus of this article is to highlight plane of placement are essential to placing Such complications can be minimised by complications, symptoms and possible the correct amount of filler at the correct skin using the smallest needle, using a cannula treatment strategies for immediate, early depth to provide maximum correction with instead of a needle to minimise risk of and late onset complications (Figure 1). minimal possibility of overcorrection, visibility cannulising a vessel, injection of small Complications can be related to the actual or nodularity. When HA filler is placed too volumes of HA, aspirating before injecting Contact Merz Aesthetics filler itself but most often it can be attributed superficially, a bluish discoloration can occur and proper plane of injection.2 2 NOW and ask for Belotero to poor injector knowledge, patient or called the tyndall effect. The only treatment NEW region selection, and technique.2 for this is using hyaluronidase, an enzyme Early onset complications (3-14 days after Tel: +44 (0) 333 200 4140 that dissolves the HA in the skin, in order to injection) 5,6 Email: [email protected] Many common side effects are local and dissolve the filler. As all fillers are foreign bodies, it can be short lived, lasting between 2-72 hours. normal to be able to palpate the material in These include pain, tenderness, bruising, Ischemic events post HA injections are the first few days. If the nodularity persists, redness and swelling, and can often be rare but a known serious complication. however, it is important to evaluate for minimised with good technique. These Direct intra-arterial HA injection or venous pain, tenderness, and inflammation.2 transient effects can be normal sequelae occlusion or congestion can cause Non-inflammatory nodules are localised of placing a foreign HA implant within the significant tissue injury and necrosis.2,7,8 accumulation of HA that can initially be skin.3 Significant complications are events Two particular danger zones, vulnerable treated with massage and reassurance. If this Date of preparation: September 2015 of preparation: Date The fi ller you’ll love that should not occur after treatment and to tissue necrosis, include the glabella is not sufficient, these nodules can be treated can include infection, nodular masses, and nasal ala.1 Typical clinical findings with hyaluronidase, which is able to degrade
1. BEL-DOF-003 V2 Belotero® technology, June 2015. 2. Tran C et al. in vivo bio-integration inflammation, tissue necrosis from injection include disproportionate pain on injection, hyaluronic acid in the event of subcutaneous of three Hyaluronic Acid fi llers in human skin: a histological study. Dermatology DOI: 10.1159/000354384. 3. Aesthetics Awards Supplement, December 2014. Injectable product
Adverse incidents should be reported. Reporting forms & information can be found Adverse incidents should be reported. to Merz Adverse incidents should also be reported at www.mhra.gov.uk/yellowcard. Pharma UK Ltd by email to [email protected] or on +44 (0) 333 200 4143. www.belotero.co.uk
BEL/13/SEP/2015/DS of the Year, pg 5. Reproduced from Aesthetics | Volume 2/Issue 12 - November 2015
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to antibiotics, it is important to empirically Early / Immediate Complications Late Complications treat as an infection in order to prevent further complications.
Laser Erythema Cold compresses IPL Ecchymosis Apply pressure Telengiectasias Hyaluronidase Conclusion Edema Observe (for HA) The best way to manage complications is to try to avoid them. A solid knowledge
Massage Excision base is essential in preventing difficulties. All Clumping Unroofi ng / puncture Migration Hyaluronidase (for Superfi cial placement Hyaluronidase (for HA) HA) complications should be treated seriously with Tyndall eff ect Excision close patient follow up. The risks associated with HA injections can be minimised with solid Hypertrophic Scar Intralesional steroid Erythematous nodule knowledge of the anatomy, good technique Infection with a high quality product, and knowledge on
Non-infl ammatory nodule properly assessing and treating complications Granuloma if they arise. Fluctant Non-fl uctant Abscess Dr Maryam Zamani is a board Massage certified opthalmologist with Intralesional steroid experience in ocuplastic surgery I & D or aspiration Hyaluronidase for (HA) Culture Empiric antibiotics Excision and dermatology. She obtained Antibiotics her medical doctorate from George Washington University School of
No improvement Recovery Medicine in the US, and has worked at Cardiff University in facial aesthetics. Recovery No improvement REFERENCES Consider Factitious 1. Park TH, Seo SW, Kim JK, Chang CH., ‘Clinical experience with Consider Biofi lm lesion hyaluronic acid complications’, J Plastic Reconstr Aesthet Surg, Re-culture Change antibiotics 64 (7) (2011), pp.892-6. 2. Sclafani AP, Fagien S., ‘Treatment of injectable soft tissue Filler Culture (3 weeks) Complications’, Dermatologic Surgery, 35: s2 (2009) pp.1672- Two-drug Prevent contact with 1680. antibiotherapy lesion 3. Gladstone HB, Cohen JL., ‘Adverse Effects When Injecting Hyaluronidase Topical wound care 5-FU Surgical debridement Facial Fillers’, Seminars in Cutaneous Medicine and Surgery, Excision (2006) pp.34-39. 4. Park SW, Woo SJ, Park KH et al., ‘Iatorgenic retinal artery occlusion caused by cosmetic facial filler injections’, Am J 18 Figure 1: Advice chart on managing filler complications courtesy of Ozturk et al Ophthalmol 154 (2012) pp.653-662. 5. Brody HJ., ‘Use of hyaluronidase in the treatment of nodules or in ischemic events.6 monitoring. If at any point fluctuance is noted, granulomatous hyaluronic acid reactions or unwanted hyaluronic acid misplacement’, Dermatol Surg. 31 (2005) Non-inflammatory nodules need to be incision and drainage can be performed with pp.893-7. differentiated from granulomas and tissue culture.2 If the lesion does not respond 6. Cavallini M, Gazzola R, Metalla M, Vaienti L., ‘The role of 12 hyaluronidase in the treatment of complications from hyaluronic biofilms, which are inflammatory in nature. to antibiotic treatment, HA fillers should be acid dermal fillers’, Aesthet Surg J., 33(8) (2008) pp.1167-74. Granulomatous foreign body reactions to dissolved with hyaluronidase.14 7. Hanke C, Hingley R, Jolivette DM, et al., ‘Abscess formation and local necrosis after treatment with Zyderm or Zyplast collagen HA may be caused by allergy to the material Delayed complications such as persistent implant’, J Am Acad Dermatol, 25 (1991), pp.319-326. or immunogenic response to the protein erythema or delayed hypersensitivity that 8. Friedman PM, Mafong EA, Kauver ARM, et al., ‘Safety data of 5 injectable nonanimal stabilized hyaluronic acid gel for soft tissue in the HA preparation. Granulomas are is unresponsive to antihistamines may augmentation’, Dermatol Surg, 28 (2002), pp.491-494. exceedingly rare, occurring in 0.1% of the also require treatment with hyaluronidase 9. Delorenzi, Claudio., ‘Complications of Injectible Fillers, Part 2: Vascular Complications’, Aesthetic Surgery Journal, (2014) patients treated with all forms of injectable and, sometimes, oral steroids. In patients pp.584-600. fillers, not just HA fillers.3,13 with persistent edema unresponsive to 10. Lazzeri D, Agostini T, Figus M, Nardi M, Pantoaloni m, Lazzeri S., ‘Blindness following cosmetic injections of the face’, Plast Infection can have a devastating effect antihistamines, oral steroids can be used Reconstr Surg, 129 (2012) pp.995-1012. on patients as well, and infection control to help reduce inflammation.16 This can 11. Kleydam, K, Cohen JL., ‘Nitrogylcerin: A review of its Use in the Treatment of Vascular Occlusion After Soft Tissue Augmentation’, is essential to minimise contamination. commonly be seen with superficially placed Dermatologic Surgery, 38 12 (2012) pp.1889-1897. Research suggests that chlorhexidine is a HA, particularly because HA is hydrophilic.2 12. Charlson, Paul., ‘Aesthetic Dermatology: Complications of hyaluronic acid dermal fillers’, MIMS, 2015. better antiseptic compared to povidone- 13. Lowe NJ, Maxwell CA, Patnaik R., ‘Adverse reactions to dermal iodine because it is superior in preventing Delayed onset complications fillers: Review’, Dermatol Surg, 31 (2005), pp.1616-1625. 14,15 14. Krader, CG., ‘Facial Filler Complications Avoidable avoidable with injection site infection. Such reactions can If persistent erythema or telangiectasias careful injection Technique’, Cosmetic Surgery Times, (2012). lead to nodules, inflammation, swelling and occur, they can be treated with 15. Darouiche RO., Wall MJ JR, Itani KM, Otterson MF, Webb AL, Carrick MM ,Miller HJ, Awad SS, Crosby CT ,Mosier MC, Alsharif erythema. If HA is injected and becomes hyaluronidase, or 1064 nm Nd:YAG laser. A, Berger DH., ‘Chlorhexidine-Alcohol versus Povidone-Iodine coated with bacteria, a biofilm forms and the This type of long-pulsed laser is proven for Surgical Site Antisepsis’, N Engl J Med, 362 (2010) pp.18-26. 16. Funt, D, Pavicic., ‘Dermal Fillers in aesthetics: an overview bacteria secretes a protective matrix that to be a safe and effective therapy for of adverse events and treatment approaches’, Clin Cosmet gives rise to low grade chronic infection that treatment of face telangiectasias.17 Delayed Investig Dermatol., 6 (2013) pp.295-316. 12 17. Major A, Brazzini B, Campolmi, Bonan P, Mavilia L, Ghersetich is resistant to antibiotics. It can be difficult to inflammatory nodules and granulomas can I, Hercogov J, Lottit T., ‘Nd: Yag 1064 nm laser in the treatment differentiate biofilms from late hypersensitivity also form at a later stage and should be of facial and leg telangiectasis’, J Eur Acad Dermatol Venereol, 15(6) (2001), pp. 559-65. reactions. Empiric antibiotic treatment with treated as a foreign body infection in the first 18. Ozturk, Li, Tung, Parker, Piliang, Zins, ‘Complications following a macrolide or tetracycline antibiotic should instance with antibiotics and/or intralesional injection of soft-tissue fillers’, Aesthetic Surgery Journal, 33 be started for four to six weeks with close corticosteroids.2 While they may not respond (2013), pp.862-877.
Reproduced from Aesthetics | Volume 2/Issue 12 - November 2015
@aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com
note that it is shown to be most effective in those whom wish to combat generalised photoaged skin, where treatments such as botulinum toxin may not be as effective. The toxins cause deeper muscle paralysis and can help smooth out wrinkles, however superficial damaged skin can often require nutritional support too.4 Retinoic acid can be given to patients on a prescription, however it is usually reserved for use by dermatologists in the UK, given its high risk of side effects, especially teratogenic effects, and hence it may need tight monitoring.5
Vitamin B Vitamins in • Biotin B7 Biotin, (also known as vitamin H), is essential for cells throughout the body. Its main responsibility is the function of fat metabolism, and essential fatty acids that are required for the skin to keep Skincare 6 its appearance healthy. It is usually deficient in those who consume raw eggs as they contain an antagonist to biotin, which Dr Ahsan Ullah details the consequently can result in deficiencies. Such deficiencies normally importance of vitamins and how manifest as a dry and itchy dermatitis.6 • Niacin B3 they can enhance your patient’s Niacin (niacinamide) is useful in a skincare regime as it has shown skincare regime to have an antioxidant, anti-wrinkle, and skin ‘brightening’ effect.7 Deficiencies of niacin are quite rare but have been shown to contribute to pellagra, a disease seen in parts of Africa but rarely A magic youth pill? in the Western world.8 Topical application of niacin can exert Is there such a pill that can miraculously result in younger looking antioxidant properties that can remove Reactive Oxygen Species skin? As practitioners, I’m sure we’re all aware that the answer (ROS), which are free radicals causing skin cellular damage.7 is rather more complex than a simple yes or no. Patients tend to Consequently, niacin can help to improve and protect the skin look for an easy fix, and perhaps there may well be one released barrier with an improvement in overall anti-ageing effects and, in the future. For now, however, what consumers may see as given its vasodilative effects, it can help make the skin appear ‘youth pills’ can consist of many well known vitamins and minerals, more youthful and volumised.7 micro and macro nutrients and essential fatty acids, which all play an integral part in improving the skin’s natural dermatological Vitamin C function. It is often quite confusing as to what advice one should Ascorbic acid is the most commonly taken nutritional supplement in follow and subsequently give to our patients. What can actually the UK due to its variety of benefits, where consumers were recorded be beneficial for our patients needs? What does not have any to of spent £35.9 million in 2009 on the supplement.9 In terms of clinical benefits? New clinical data is always emerging so it is skincare, it has been shown to promote collagen synthesis and important to keep up with the most up-to-date research. Simple protect against photodamage by reducing free radicals. Results from factors such as a healthy lifestyle and dietary advice are essential, two studies demonstrated that vitamin C decreases the appearance of and then to optimise the treatment, one can add topical regimes fine wrinkles and improves overall skin texture and tone.10,11 Research in combination to help achieve the overall desired outcome. As has shown that vitamin C used topically can have various cutaneous vitamins play a fundamental role in good skincare, this article shall benefits, including collagen synthesis, photoprotection from UVA/UVB, focus on their advantages and detail which ones can be the most lightening of hyperpigmented areas and the improvement of a variety beneficial in promoting healthier skin. of inflammatory dermatoses.12
Vitamin A Vitamin E Vitamin A, in its simplest form, is a fat-soluble aliphatic vitamin Vitamin E consists of tocopherols and tocotrienols, which are both occurring in two main forms, ‘preformed vitamin A’, (Retinol and its found in a variety of skincare products and aim to improve the skin retinyl ester) – mainly found in animal products, and ‘pro-vitamin A’ and help the anti-ageing process. Deficiencies in vitamin E can result (usually carotenes) which can be found in plant-based foods such in poor anti-oxidation effects resulting in free radicals to damage the as fruits and vegetables.1 The role of retinol, or more specifically skin layers.13 The literature regarding vitamin E is extensive. What the oxidised form, retinoic acid, is involved in the control of cell we understand is that vitamin E has potent antioxidative properties proliferation and differentiation of keratinocytes into mature which have an obvious benefit on sun exposed skin, helping it epidermal cells, and results in the overall health of the skin.2 from ageing prematurely14 – this would suggest it to be a vital tool Its application has been used for many years by dermatologists in overall skincare. Studies have also suggested that, in the long for the treatment of acne, with research also showing its benefit term, vitamin E can reduce the risk of sunburn from exposure to as an ingredient in anti-ageing skincare as it can improve the UVB radiation,15 however this should not be a substitute for use of appearance of fine lines.3 There are many creams on the market a sunscreen. Medical research has also suggested that due to its which have retinol present in them, and the type you choose can antioxidative properties, vitamin E can aid the cell apoptosis process vary depending on the patient’s requirements. It is important to in skin cancers.16
Reproduced from Aesthetics | Volume 2/Issue 12 - November 2015 aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics
Vitamin K REFERENCES Vitamin K is a fat-soluble vitamin synthesised in the liver and 1. Reza Kafi et al, ‘Improvement of Naturally Aged Skin With Vitamin A’ (Retinol) (Michigan, Jama Dermatology, 2007)
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For further information about V-SOFT LIFT please contact: Medical Aesthetic Group on 02380 676733 or visit www.magroup.co.uk Reproduced from Aesthetics | Volume 2/Issue 12 - November 2015 MAGROUP V-Soft Lift Half Page Horizontal 125mm x 180mm Aesthetic Journal November 2014 Issue DISCOVERY PICO
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Treating Lips
Dr Sanjay Gheyi shares his approach to rejuvenating lips with hyaluronic acid and lasers
Introduction my opinion, as lips are very mobile, visible and have a vascular The rejuvenation of lips and the perioral area is of prime concern structure, there is no reason for using any non-HA injectable to many patients. The usual indications patients present to us implant. Non-HA fillers such as calcium hydroxylapatite (CaHA), with are loss of lip volume, perioral rhytids (many female patients can be used for volume augmentation of nasolabial folds complain their lipstick bleeds into these lines), smoker’s lines and marionette lines but, ideally, should not be used for lip and downturned corners of the mouth. Although patients want a augmentation. It has been suggested that this is due to CaHA’s solution to these aesthetic concerns, many fear the risks of side high viscosity and elasticity, as well as being classified as an effects, such as the ‘trout pout’ appearance, unnatural-looking adjustable filler rather than being reversible like HA.3 According to results and the potential need for repeat treatments. Emer and Sundaram, evidence-based and experiential consensus In this article, I shall explain my technique in treating lip concerns with suggests its avoidance in highly mobile areas such as the lips, hyaluronic acid (HA) dermal fillers and ablative lasers – these are the or in areas such as the periocular region where there may be an most commonly used treatments for lips and perioral rejuvenation in increased incidence of nodules.3 my clinic. In addition, I shall also explain how to achieve a successful aesthetic result and provide advice on how to avoid complications. Tools and techniques The approach described works well for me but may not for other The debate on the pros and cons of using a sharp needle practitioners; it is perfectly acceptable that different practitioners vs. a cannula has been discussed in great detail before. The use different techniques, however the main outcome in our field of advantage of a cannula is that there is supposed to be less medical aesthetics should always be patient satisfaction. risk of vascular injury.4 In my view, however, smaller cannulas are capable of vessel injury, especially in areas where tissue Patient analysis resistance to cannula passage is higher. In the perioral area and The ideal lip augmentation technique provides the longest period vermilion borders, the rhytids can be difficult to efface by using of efficacy, lowest complication rate, and best aesthetic result.1 a blunt cannula. Use of cannula also requires more filler volume In addition, a good treatment requires correct initial diagnosis. It as the filler is usually deposited in a deeper plane due to less is important that practitioners listen to the patient and determine tissue resistance.4 A cannula is very useful for patients who are what he or she desires at the outset. Our patients are often well worried about bruising, swelling and recovery time and, from informed and most will have an idea of what treatments and/ my experience, a 25 or 27g cannula works well for dermal filler or results they hope to achieve. Sometimes, however, they may injections. I have used an 18g cannula for lip injections but only not be aware of the intricacies of treatment, so their consultation at the time of full-facial fat transfer procedure, in which I inject should be taken as an opportunity for patient education. This will fat to add a little volume to the lips. I do not use fat injections establish a valuable practitioner-patient relationship and avoid a for lip augmentation as an isolated procedure as, in my opinion, mismatch between patient expectations and results achieved. If harvesting fat is not cost effective when a syringe of filler is readily you are concerned that the aesthetic results may not reach your available and much cheaper. I prefer a 30g sharp needle for lip patient’s expectations, it is important to remember that you do not treatments and use 2cc of lignocaine with adrenaline, distributing have to treat everyone who walks through your door – knowing when to say no is an Before After treatment with HA filler important part of our job.
HA dermal fillers HA fillers have one great advantage that no other implantable material provides – reversibility with hyaluronidase.2 Various dermal fillers are available, however, in
Reproduced from Aesthetics | Volume 2/Issue 12 - November 2015 @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com
it along 3-4 Lasers injection points Non-ablative lasers have a limited use, if any, in treatments along the of the lip and perioral area; mainly because we have better junction of the options available and results are often subtle and unpredictable. lip and gingival Vascular lasers are useful when patients present with a vascular mucosa (Figure abnormality or lesion. One such example would be venous lakes 1). This provides in the lips where long pulsed lasers can be used successfully profound (Figures 2 & 3). For skin rejuvenation, treatment of fine lines, Figure 1: Local anaesthesia injection points. These injections are made intra-orally at the junction of gingiva and lip mucosa. analgesia and wrinkles and skin textural improvement, ablative lasers are useful vasoconstriction and erbium and CO2 lasers are commonly used. My choice is a to minimise risk of intravascular injection. Various facial and/or lip CO2 laser because of the additional provision of skin tightening. proportion analysis techniques and mathematical models have been Before CO2 laser can be used proposed. I do not use these as, in my opinion, treating the lips is in fractional mode in light an artistic procedure and should not be based on pure science or skin or darker skin types, mathematics. I prefer to do what suits each patient and what makes such as patients of Asian him or her happy, still taking into account the most appropriate method or Mediterranean origin. of treatment. Usually only 1-2cc of dermal filler volume is required Lighter skin types are unless there is more volume loss and the nasolabial folds and/or suitable for a full ablative marionette lines are being treated at the same time. By using a sharp Figure 2: Venous lake before treatment laser resurfacing.8 This, needle at the outer border of the vermilion, sometimes it is possible to After however, does require see the filler run along the vermillion border and it is possible to treat use of lip blocks and/ the entire quarter or half of the length of lip from one injection point. I or oral sedation and try to use minimum injection points where possible, as each injection requires a longer point can increase your chances of causing a bruise. Commonly, I period of recovery.8 would inject the vermilion border, augment lip volume, attempt to Fully ablative CO2 laser efface perioral rhytids and support the angles of the mouth with 1-2 resurfacing involves the Figure 3: Venous lake after treatment with ND:Yag laser strands of filler material. Philtral columns can also be enhanced using removal of the entire linear threading. epidermis and upper portion of the dermis, providing significant stimulation to dermal nerve fibres.8 Prior to the advent of ablative Complications of dermal filler injections lasers, mechanical dermabrasion was a widely used treatment and provided excellent results. Laser ablation has, however, become a A degree of swelling, redness, tenderness and bruising can be more widely used technique in recent times. A prospective study considered normal side effects of dermal filler injections and usually of the clinical efficacy of the 950 microsec dwell time CO2 laser, to settle within a matter of days. A number of complications such that of a manual tumescent dermabrasion in the treatment of upper as infections, fibrosis, granulomatous inflammation, haematoma, lip wrinkles showed that both are equally effective.9 thromboembolism and product migration have been reported.5 The Long-term histologic effects of the CO2 laser have been well most feared complication is vascular compromise due to vascular documented. In a prospective study, biopsy specimens from compression or inadvertant intra-arterial injection.6 By following the the upper lip were taken preoperatively, then at six weeks, six measures listed below, I believe you can minimise the risk of filler months, and one year after CO2 laser resurfacing. Neocollagenesis complications, irrespective of where it is being injected. To do so, I advocate the following:6,7
• Use local anaesthesia with adrenaline. • Use a blunt cannula where possible. Non-ablative lasers have • Aspirate before injecting. • Inject small aliquots of filler with low injection pressure. a limited use, if any, in • Keep a watchful eye for tissue blanching which may be very transient. Vascular compromise can be preceded by a transient treatments of the lip and blanching of skin and this may be at a point distant from the injection site. perioral area; mainly because • Always have hyaluronidase available for use in an emergency. we have better options How to avoid a poor aesthetic result: available and results are often • Do no not overfill. • Keep the facial harmony and balance by treating other perioral subtle and unpredictable regions for volume loss rather than simply focusing on the lips. • Use fine particle HA fillers and not large particle fillers for lip augmentation to keep lips feeling soft.
Reproduced from Aesthetics | Volume 2/Issue 12 - November 2015 aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics
Before began at six weeks and and journals have described a variety of treatments for perioral progressively increased at rejuvenation. These include; mesotherapy, carboxytherapy, skin six months and one year.10 needling and PRP. I often use botulinum toxin for treatment of I have also personally dynamic rhytids, almost always in combination with other treatment observed this effect modalities discussed above. From my experience, two to four numerous times. An early units along lip borders and five to ten units of botulinum toxin follow-up appointment may injected along each depressor anguli oris can produce some nice not show outstanding results results in terms of lifting the downturned lip corners and softening
After but, with time, results should perioral lines. One of the benefits of working in a well-equipped improve. clinic with a variety of devices is that I can use treatments that are With ablative lasers, it is likely to give the most visible results. The combination of PRP with important to treat the entire other therapies is particularly interesting, with studies indicating cosmetic unit rather than it may play a role in reducing the downtime associated with laser the isolated small areas to resurfacing.20 In my opinion future studies should include controls, avoid lines of demarcation. including incorporation of split-face comparisons, to reduce It is imperative to know the intersubject variability.
Figure 4: After lip-lift surgery and C02 laser settings of your device, as resurfacing lasers made by different Conclusion manufacturers have different energies, pulse durations, spacing Each of the modalities presented has their unique advantages and and patterns. It is not a good idea to transfer settings of one device disadvantages when used for lip rejuvenation. However, through and use them on another, as they may not necessarily produce proper assessment and a thorough consultation to establish our the same results. The best way to learn about laser resurfacing is patients’ expectations, fears and tolerance to recovery periods, we through careful observation of tissue response, clinical endpoints can determine the best treatment or combination treatments for and observing your patient’s results at follow-up appointments. The their concerns. Doing so should allow us to achieve successful lip tissue’s response to the laser pulse may vary in different patients rejuvenation and happy, satisfied patients. even though you’re using the same settings. This is due to the Dr Sanjay Gheyi is the medical director and laser hydration levels of the patient’s skin as the target for C02 lasers is surgeon at the Coltishall Cosmetic Clinic in Norfolk and tissue water, and may be affected by use of local anaesthesia, either offers a range of laser, skin and vein care services to topical or by infiltration.11 For fully ablative CO2 laser resurfacing, a his patients. The clinic has been established for nine years variety of post-operative wound care techniques has been devised.12 and attracts patients from all over the UK and abroad.
These are, broadly speaking, closed and open techniques and REFERENCES involve wiping the lasered char away. The open technique means 1. San Miguel Moragas J et al, ‘Systematic review of “filling” procedures for lip augmentation regarding types of material, outcomes and complications’, J Craniomaxillofac Surg, 43 (2015) p.883-906. that no dressings are used, while occlusive dressings are used for 2. Pierre A, Levy PM, ‘Hyaluronidase offers an efficacious treatment for inaesthetic hyaluronic acid overcorrection’, J Cosmet Dermatol, 6 (2007), pp.159-62. the closed technique. I personally tend not to wipe the char away, 3. Emer J, Sundaram H, ‘Aesthetic applications of calcium hydroxylapatite volumizing filler: an evidence- as it can act like a biological dressing and flakes off when the based review and discussion of current concepts’, J Drugs Dermatol, 12 (2013) pp.1345-54. 4. DeJoseph LM, ‘Cannulas for facial filler placement’,Facial Plast Surg Clin North AM, 2 (2012), pp.215-20. underlying skin has healed up. 5. Grippaudo FR et al, ‘Diagnosis and management of dermal filler complications in the perioral region’, J Cosmet Laser Ther, 16 (2014), pp.246-52. 6. Beleznay K et al, ‘Vascular Compromise from Soft Tissue Augmentation’, The Journal of Clinical and Complications of laser treatment Aesthetic Dermatology, 7 (2014), pp.37-43. 7. Kim DW et al, ‘Vascular complications of hyaluronic acid fillers and the role of hyaluronidase in In patients with prior history of herpes labialis, anti-viral prophylaxis management’, J Plast Reconstr Aesthet Surg, 12 (2011), pp.1590-5. 13 8. Gaitan S, Markus R, ‘Anesthesia methods in laser resurfacing’, Semin Plast Surg, 3 (2012), pp.117-24. is useful for filler injections or laser resurfacing. I do not prescribe 9. Gin et al, ‘Treatment of upper lip wrinkles: a comparison of the 950 microsec dwell time carbon antibiotics for fractionated resurfacing, but for full laser resurfacing I dioxide laser to manual tumescent dermabrasion’, Dermatol Surg, 6 (1999), pp.473-4. 10. Rosenberg GJ et al, ‘Long-term histologic effects of the CO2 laser’,Plast Reconstr Surg, 7 (1999) prescribe antibiotic, antifungal, anti-viral prophylaxis. Although widely pp.2245-6. 14 11. Goldman MP, ‘The use of hydroquinone with facial laser resurfacing’, J Cutan Laser Ther, 2 (2000) used, the role of prophylactic antibiotics has been questioned. pp.73-7. Adverse effects of laser resurfacing include pain, erythema, bacterial, 12. Duplechain JK, ‘Novel post-treatment care after ablative and fractional C02 laser resurfacing’, J Cosmet Laser Ther, 16 (2014), p.77-82. viral or fungal infections, milia, pigment alterations such as post 13. Gazzola R, ‘Herpes virus outbreaks after dermal hyaluronic acid filler injections’,Aesthet Surg J, 6 (2012), pp.770-2. inflammatory hyperpigmentation (PIH), hyperpigmentation and/ 14. Walia S, Alster TS, ‘Cutaneous C02 laser resurfacing infection rate with and without prophylactic or hypopigmentation. Overly aggressive treatments can result in antibiotics’, Dermatol Surg, 11 (1999) P.857-61. 15. Metelitsa A, Alster TS, ‘Fractional laser skin resurfacing treatment complications: a review’, Dermatol scarring.15 It is very important to minimise sun exposure and use Surg, 3 (2010), pp.299-306. 16 16. Wanitphakdeedecha R, ‘The use of sunscreen starting on the first day after ablative fractional skin sunscreens in the post-operative period to minimise pigment issues. resurfacing’, J Eur Acad Dermatol Venereol, 11 (2014), pp.1522-8. Hyperpigmentation can be transient and can be treated with use 17. Goldman MP, ‘The use of hydroquinone with facial laser resurfacing’, J Cutan Laser Ther, 2 (2000), pp.73-7. of hydroquinone,17 but hypopigmentation can be very difficult or 18. Dover JS et al, ‘Lasers in skin resurfacing’, Semin Cutan Med Surg, 4 (2000), pp.207-20. 18 19. Waldman SR, ‘The subnasal lift’, Facial Plast Surg Clin North Am, 4 (2007), pp.513-6. impossible to treat. 20. Leo MS et al, ‘Systematic review of the use of platelet-rich plasma in aesthetic dermatology’, J Cosmet Dermatol, 23 (2015). Other treatment methods With increasing age the length of the upper lip increases.19 Gravity not only causes sagging of the lower face and neck, it can elongate the upper lip too.19 Pumping the lip with more filler can make this condition worse and should be avoided. A lip-lift procedure, however, can restore the original length of the upper lip (Figure 4). This is a surgical procedure that can be done under local anaesthesia.19 Practitioners
Reproduced from Aesthetics | Volume 2/Issue 12 - November 2015 Advertorial Lumenis @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com
Dr Miguel Montero talks vascular treatments with M22 M22 by Lumenis is a modular multi-application platform for the treatment of over 30 skin conditions and hair removal. Used by physicians around the world, M22 enables you to treat more types of patients and conditions with better outcomes. Dr Montero is one of the UK’s leading doctors on the subject.
The M22 has four different modules, which ones do you use? a sequence of pulses. Do you feel this has had an impact on I use the long pulsed Nd:YAG and the IPL as I mostly perform patient comfort and your ability to treat more safely and vascular treatments. With the IPL I can treat pigmentation, offer photo- achieve desired results? rejuvenation for sun damage and treatments for rosacea, acne, and The ability to cool the skin down in between pulses was a very telangiectasia. I use the long pulsed Nd:YAG to treat telangiectasia important deciding factor when I purchased the machine. In my practice anywhere in the body, including the face, as well as reticular veins in I use multiple pulses most of the time, I would say that about 90% of the legs. my treatments need MSP, since the targets are usually deep. It does allow me to use higher energy levels without causing any burns or With regards to the IPL, what treatments do you use it for blisters, whilst selectively targeting the deeper lesions. There are many and how do you rate its usability and results? IPL systems out there, which have also incorporated this technology I use it for a variety of indications, the most popular being rosacea, with more or less success, but to my knowledge the M22 is the only pigmentation and photo-damage. I have been using a Lumenis one which has specific vascular filters and settings, not forgetting the IPL very successfully for the last eight years and regard it as the possibility to add the long pulsed Nd: YAG. This is probably the most workhorse of my clinic. I chose it because it is the easiest device to underrated module in the system. In my opinion, it is an essential use, changing the filter is very simple, and the pre-set parameters complement to the IPL, which I use all the time to deliver consistent are pretty good starting points. I am very happy with the results, and vascular results. In addition, because of its ability to produce MSP, it my patients are also very satisfied as they keep returning for various delivers brilliant results very safely. The only exception in the use of MSP aesthetic treatments. with the Nd:YAG laser is the treatment of facial telangiectasia. For safety reasons, single pulses of no more than 90 J/cm² should be used in the How do you compare the Lumenis technology to other face, avoiding, if possible, the stacking of pulses, as this would defy the systems that you have used previously? objective. I have performed this treatment hundreds of times with only My Lumenis IPL was the first machine I ever bought eight years ago and bruising presenting as the main complication, and I have hundreds of it has since been an essential part of my clinic. The list of indications satisfied patients. Lumenis technology treats is pretty comprehensive, and the results that I have got through the years have been very good, so I’ve never needed Do you change the pulse duration and delay to suit your own a more expensive machine like a PDL. I am getting excellent results not specifications? only in vascular conditions but also in many pigmented ones. I don’t Yes. I find that the Lumenis pre-sets are usually a very safe starting need to produce purpura to achieve a great result, and many of my point, but for some patients we need to change the pulse duration, the patients who have been treated before with other systems comment pulse delay or both to be able to effectively treat the problem that they how easy it is to resume their activities with minimal downtime, while are presenting to us. The Lumenis interface allows me to very easily also emphasising how comfortable and effective the treatments are. change those parameters, so I can be more aggressive if I need to, or more conservative for the darker skin types if, for whatever reason, the Multiple-Sequential Pulsing (MSP), available in both the skin is reacting and needs more protection. In most cases, I increase the Nd:YAG and IPL modules on M22, enables cooling between fluence treatment on treatment, but I don’t alter the other parameters.
46 Aesthetics | November 2015 Advertorial @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com Lumenis
Before treatment After treatment Before treatment After treatment
™ Before treatment After treatment Before treatment After treatment M22 All you need. All in one. Do you use cooling post treatment; a) on all skin types and; viral warts and verrucae and also fungal nail infections, I have done b) do you think it reduces PIH? my own small trials to find out if I could replicate those with my As well as the cooling provided by the equipment in the form of cool equipment. I have had successful clearances of all the above,essential and I technologies light guides, and the pulse delays built-in in the MSP which allow skin am now offering these treatments as part of my treatment portfolio. enabling advanced combination treatments for cooling in between pulses, as an extra safety measure I use air cooling 4 over thirty skin conditions and hair removal provided by a Zimmer Cryo during and after the treatment for a few How do you typically treat rosacea? minutes in all skin types. I find that I don’t need to use any steroid Laser and IPL are only part of a more comprehensive treatment, ™ tablets, creams or masks by doing so. Occasionally I use a kojic acid- which includes, for some people, oral Everythingand topical antibiotics,You1 HaveResurFX topical Ever fractional Desired non-ablative skin resurfacing ™ ® based tyrosinase inhibitor when I treat skin type IV-V as a prophylaxis antioxidants and vitamin A, and mandatoryThe sunNew protection. Generation2 Multi-SpotEducating of Hair Nd:YAG Removal Systems against PIH for extra security. The combination of all these measures patients is essential as most of them don’t know about3 the Universalcondition, IPL UltraPulse has allowed us, through the years, to have a very low incidence of PIH, and I find that once they learn about it, they also learn to live with 4 Q-Switched Nd:YAG NEWThe Most Powerful CO2 Laser in even though more than 30% of our patients have a skin type V. it, and most of my patients cope much better with the symptoms of Aesthetic Dermatology
this chronic condition. I follow Dr Crouch’s protocol of triple pass, NEW Has the Nd:YAG module lived up to its promises treating leg triple pulse. Using the 560 or 590 nm filters, followed by the 615 and veins, telangiectasia, and haemangioma? Tell us about your 695 nm filters, from superficial to deep, we get a very comfortable Visit our FACE booth No.Stretching 47- 48 the limits of performance experience. and effective treatment which help Theus reduce Starting the Point severity to Yourof the Success
I have been treating telangiectasia and reticular veins practically from flushes as well as a reduction treatment on the facialJoin erythema our workshop: and the minute I got the machine. I use the Nd:YAG to treat reticular veins, telangiectasia. When I want to get an even faster reductionWhat is the in commonthe denominatorDeepFX ofTM ablative, | ActiveFX TM Fractional Modes LASER HAIR non-ablativeADVANCED and hair removalgreat treatments versatility for all your resurfacing needs feeder veins (which carry blood from the reticular or deeper veins to telangiectasia I combine the long pulsed Nd:1REMOVAL YAG using SYSTEM single2 pulses.TECHNOLOGIES 3 HANDPIECES the more superficial lesions) and some of the larger telangiectasia in by Dr. Tretti Clementoni, Dr. Patel and DeepestMrs. Nugawela Impact with SCAAR FXTM Mode Fri | 20th June | 11:30-13:00 | Room Chaucer the legs. I find that the combination of the MSP with the extra cooling up to 4mm in a single pulse allows me to use higher settings to treat the deeper veins and this has Born in Almeria, Spain, Miguel has practiced Best Ablation/Coagulation ratio Gold Standard 805nm diode laser for optimal clinical outcomes increased my success rate. I don’t treat any veins larger than 3 mm medicine in England since 1994. Initially working Fast and comfortable with laser, if there are any varicosities they need to first be corrected in North-West hospitals developing his surgical Shortest Pulse Duration for maximum patient safety and comfort and medical skills, MiguelIntuitive then and spent upgradable 11 years surgically to improve the chances of a successful laser treatment of the working as a GP in Burnley. He now combines more superficial veins.For some patients I also use microsclerotherapy his knowledge of surgery,Portable medicine, and affordable skin health to reduce the size of the larger reticular veins prior to laser. I’m finding and laser technology in his full timeHighest role returnas our on investment medical that since I’m doing this, the treatments are more comfortable as the director and principal practitioner. Miguel is a member of the European Laser Association, British size of the target is reduced. I combine the treatments of the long pulsed Medical Laser Association, British Medical Acupuncture Society Nd:YAG with the IPL, which allows me to treat the more superficial and British College of Aesthetic Medicine. He is the lead in CPD telangiectasia. I tend to also use MSP with the IPL, as recommended and one of only a few doctors to hold a Post Graduate Diploma in the settings preloaded in the system. I find that IPL is particularly in Cosmetic Medicine from the University of Leicester. Miguel is on the lecture team at UCLAN teaching Doctors and effective for the finer telangiectasia matting and is the only tool that Dentists on various aspects of Aesthetic Medicine; works closely safely can be used around and below the ankles. I have treated many with and presents for Lumenis, a world renown laser company; small haemangiomas, Campbell de Morgan spots, venous lakes in the is a speaker at medical aesthetics conferences worldwide and lips, spider angiomas and similar vascular lesions all over the body contributes to industry publications. safely and successfully using the 6 mm spot size of the Nd:YAG. Lumenis (UK) Ltd 418 Centennial Park, Elstree Lumenis (UK) Ltd Borehamwood, Hertfordshire WD6 3TN Have you discovered any other uses for the Nd:YAG module? Telephone: 020 8736 4110 Telephone: 020 8736 4110 e-mail: [email protected] e-mail: [email protected] Well, they are not my discoveries, but since it has been reported AESTHETIC.LUMENIS.COM in some papers that the long pulsed Nd:YAG can be used to treat
AESTHETIC.AESTHETIC.LUMENIS.COMLUMENIS.COM PB-1138330 Rev. B PB-1005737 Rev A
Aesthetics | November 2015 47 Expanding With Your Practice
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Identification and Management of Female Hair loss Salvar Björnsson discusses the various causes and treatments for female hair loss
While male pattern hair loss is widely accepted as the Demodex folliculorum mite, a tiny invertebrate that feeds on sebum.5 Sebum a normal part of the ageing process, the condition is a waxy substance secreted by sebaceous glands in the skin and within hair in women can carry a significant stigma. Society follicles, which helps maintain good hair condition. It’s also rich in nutrients, making it places a high premium on hair as part of a woman’s an attractive food source for specialised mites.5 When a large number of mites are self-image, and hair loss can have serious negative present, hairs can be deprived of nutrients, leading to early loss. Older people are consequences for quality of life. Stress and loss of more likely to carry Dermodex mites, with two-thirds of the elderly being infected.5 self-esteem are common outcomes.1 The adverse effects on sufferers mean that effective treatment, or a Drugs cosmetic solution, can be a high priority in these cases. A range of drugs can induce either temporary or permanent hair loss. Chemotherapy Fortunately, depending on the cause of the hair loss, is the best-known pharmaceutical cause but there are many others. Medicines used there is a variety of ways to reduce or even reverse it. to manage chronic conditions such as coronary head disease or hypertension may also lead to progressive hair loss, particularly those containing warfarin,6 as can Causes of female hair loss antifungals that incorporate fluconazole.7 There is a range of potential causes of hair loss in women. These can vary from congenital and dietary Diet factors, to mechanical damage caused by grooming. There is strong evidence that diet can lead to hair loss. Deficiencies of zinc,8 biotin9 and iron10 can all result in thinning. Poor metabolisation of iron may have the Androgenic alopecia same result. A diet high in animal fats (which increase testosterone levels)11 or with This is commonly referred to as male pattern baldness excessive vitamin A12 is another possible cause, as is general malnutrition.13 but is also the most common cause of female hair loss – around 40% of women will be affected at some point Alopecia areata in their lives, rising to 57% in those aged 80 and above.2 This is an autoimmune disorder, with no known cause, which induces dormancy From my experience of treating hair loss in women, in hair follicles. The effect can range from loss of hair in spots to the total loss I have noted that it does not follow the characteristic of all body hair, but spontaneous remission is common.14 Hair follicles cycle pattern of a receding hairline and thinning crown; hair through a number of phases of activity, one of which is a telogen (resting) phase is, in most cases, lost evenly across the top of the where no hair is present. Because each follicle’s cycle is independent, only a head. Androgenic alopecia is a hereditary component, small proportion is normally resting at any given time. Stress or psychological largely determined by the EDA2R Androgen Receptor trauma can, however, trigger early onset of the telogen phase in large numbers gene on the X chromosome.3 One specific, recessive of follicles, causing significant – and often very rapid – hair loss. This can occur variant of the gene is believed to trigger production following surgery, childbirth, fever, emotional stress or as a corollary to chronic of a highly potent form of testosterone known as illness or an eating disorder.15 dihydrotestosterone (DHT), which progressively degrades hair follicles to the points at which they Mechanical trauma cannot produce new hairs.4 The genes that cause There are several ways in which physical damage to hair can result in its loss. Women male-pattern hair loss are also believed to be linked to with cornrows or ponytails are often susceptible to traction alopecia, caused by the Y chromosome, causing female-pattern hair loss, pulling the hair with excessive force while brushing, braiding or fastening it. Individual which manifests as diffuse hair loss across the entire hairs may be broken off above the cuticle, reducing volume, or the cuticle itself crown.4 Women are more likely to be affected if either may be damaged. Trichotillomania, a disorder that involves compulsive pulling and parent suffered from the condition.4 bending of the hair, can cause permanent thinning due to repeated extraction of hairs at the root.16 Finally, radiotherapy applied to the scalp can damage follicles.17 Infection A number of bacterial, viral, fungal and parasitic Diagnosis organisms can lead to hair loss. These are usually Hair growth is cyclical, and loss of hairs is a normal part of this cycle. It becomes an transmitted by physical contact with people, animals issue when the rate of loss increases enough to cause significant thinning. There are or objects that carry the organisms.5 One example is several accepted diagnostic methods for abnormal hair loss:
Reproduced from Aesthetics | Volume 2/Issue 12 - November 2015 COMPOSED • CONFIDENT • MY CHOICE
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Bocouture® 50 Abbreviated Prescribing Information Please refer to the Summary of Product Post-Marketing Experience; Flu-like symptoms and hypersensitivity reactions like swelling, oedema
Characteristics (SmPC) before prescribing. 1162/BOC/AUG/2014/PU Presentation 50 LD50 units of (also apart from injection site), erythema, pruritus, rash (local and generalised) and breathlessness Botulinum toxin type A (150 kD), free from complexing proteins as a powder for solution for injection. have been reported. Overdose May result in pronounced neuromuscular paralysis distant from the Indications Temporary improvement in the appearance of moderate to severe vertical lines between injection site. Symptoms are not immediately apparent post-injection. Bocouture® may only be used the eyebrows seen at frown (glabellar frown lines) and lateral periorbital lines seen at maximum smile by physicians with suitable qualifi cations and proven experience in the application of Botulinum (crow’s feet lines) in adults under 65 years of age when the severity of these lines has an important toxin. Legal Category: POM. List Price 50 U/vial £72.00 Product Licence Number: PL 29978/0002 psychological impact for the patient. Dosage and administration Unit doses recommended for Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer Landstraße 100, Bocouture are not interchangeable with those for other preparations of Botulinum toxin. Reconstitute 60318 Frankfurt/Main, Germany. Date of revision of text: August 2014. Further information with 0.9% sodium chloride. Glabellar Frown Lines: Intramuscular injection (50 units/1.25 ml). available from: Merz Pharma UK Ltd., 260 Centennial Park, Elstree Hill South, Elstree, Hertfordshire Standard dosing is 20 units; 0.1 ml (4 units): 2 injections in each corrugator muscle and 1x procerus WD6 3SR.Tel: +44 (0) 333 200 4143 muscle. May be increased to up to 30 units. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. Crow’s Feet lines: Intramuscular Adverse events should be reported. Reporting forms and information can be found at injection (50units/1.25mL). Standard dosing is 12 units per side (overall total dose: 24 units); 0.1mL www.mhra.gov.uk/yellowcard Adverse events should also be reported to Merz Pharma UK Ltd at (4 units) injected bilaterally into each of the 3 injection sites. Injections too close to the Zygomaticus the address above or by email to [email protected] or on +44 (0) 333 200 4143. major muscle should be avoided to prevent lip ptosis. Not recommended for use in patients over 65 years or under 18 years. Contraindications Hypersensitivity to Botulinum neurotoxin type A or to 1. Bocouture 50U Summary of Product Characteristics. Bocouture SPC 2014 August available from: any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, Lambert-Eaton URL: http://www.medicines. org.uk/emc/medicine/23251. syndrome). Presence of infection or infl ammation at the proposed injection site. Special warnings 2. Imhof, M & Kühne, U. A phase III study of incobotulinumtoxinA in the treatment of glabellar and precautions. Should not be injected into a blood vessel. Not recommended for patients with frown lines. J Clin Aesthet Dermatol 2011; 4(10):28-34. a history of dysphagia and aspiration. Adrenaline and other medical aids for treating anaphylaxis 3. Data on File: BOC-DOF- 012 Bocouture® - Convenient to use August 2015. should be available. Caution in patients receiving anticoagulant therapy or taking other substances in anticoagulant doses. Caution in patients suffering from amyotrophic lateral sclerosis or other diseases Bocouture® is a registered trademark of Merz Pharma GmbH & Co, KGaA. which result in peripheral neuromuscular dysfunction. Too frequent or too high dosing of Botulinum BOC/6/SEP/2015/LD Date of preparation: September 2015 toxin type A may increase the risk of antibodies forming. Should not be used during pregnancy unless clearly necessary. Should not be used during breastfeeding. Interactions Concomitant use with aminoglycosides or spectinomycin requires special care. Peripheral muscle relaxants should be used with caution. 4-aminoquinolines may reduce the effect. Undesirable effects Usually observed within the fi rst week after treatment. Localised muscle weakness, blepharoptosis, localised pain, tenderness, itching, swelling and/or haematoma can occur in conjunction with the injection. Temporary vasovagal reactions associated with pre-injection anxiety, such as syncope, circulatory problems, nausea or tinnitus, may occur. Frequency defi ned as follows: very common (≥ 1/10); common (≥ 1/100, < 1/10); uncommon (≥ 1/1000, < 1/100); rare (≥ 1/10,000, < 1/1000); very rare (< 1/10,000). Glabellar Frown 1 2 3 Lines: Infections and infestations; Uncommon: bronchitis, nasopharyngitis, infl uenza infection. PURIFIED • SATISFYING • CONVENIENT Psychiatric disorders; Uncommon: depression, insomnia. Nervous system disorders; Common: headache. Uncommon: facial paresis (brow ptosis), vasovagal syncope, paraesthesia, dizziness. Eye disorders; Uncommon: eyelid oedema, eyelid ptosis, blurred vision, blepharitis, eye pain. Ear and Labyrinth disorders; Uncommon: tinnitus. Gastrointestinal disorders; Uncommon: nausea, dry mouth. Skin and subcutaneous tissue disorders; Uncommon: pruritus, skin nodule, photosensitivity, dry skin. Musculoskeletal and connective tissue disorders; Common: muscle disorders (elevation of eyebrow), sensation of heaviness. Uncommon: muscle twitching, muscle cramps. General disorders and administration site conditions; Uncommon: injection site reactions (bruising, pruritis), tenderness, Botulinum toxin type A Infl uenza like illness, fatigue (tiredness). Crow’s Feet Lines: Eye disorders; Common: eyelid oedema, dry eye. General disorders and administration site conditions; Common: injection site haemotoma. free from complexing proteins
MZ115 Bocouture AD A4 BOC-6-SEP-2015-LD.indd 1 18/09/2015 11:23 aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics
• The ‘pull test’ is carried out by gently pulling on groups of around cases of permanent hair loss, where significant scalp is exposed, hair 50 hairs, at three different locations on the scalp. If more than transplantation surgery offers a permanent solution. This procedure ten hairs come loose in an area, the rate of hair loss there is can be carried out under local anaesthetic and involves removing small considered abnormal. More than three, but fewer than ten, hairs plugs of skin, each containing a number of follicles, from unaffected may indicate a developing problem. Three or less indicates the areas of the scalp. These are then implanted into bald areas. The hairs normal hair cycle is operating.18 transplanted with the plugs will fall out shortly after the procedure but • Daily lost-hair counts may be undertaken when the pull test is then regrow permanently.27 inconclusive. Loose hairs are collected when the hair is first combed in the morning, for a period of at least 14 days. If the average number of Conclusion hairs lost per day is 100 or more this is considered an abnormally high While hair loss is generally associated with men, it also affects a loss rate.19 large number of women, and the impact on quality of life is much • Microscopic examination of the roots of plucked hairs can be used as more profound in this patient group. While acceptance of hair loss is a diagnostic aid. The appearance of hair roots varies according to their relatively simple for men, expectations placed on women about their stage of growth, and if the proportion of hairs in each stage deviates appearance make either clinical management or a cosmetic solution significantly from normal, this can narrow the range of possible causes.19 essential for most patients. Permanent reversal of hair loss is difficult • A scalp biopsy, usually taken from the border of the affected patch, to achieve without surgery, although there are a range of effective can be used to differentiate between forms of hair loss.19 treatments available, which can prevent further loss and may promote • Trichoscopy, using a dermatoscope to examine affected areas of hair regrowth in many cases. and scalp, may also aid in differential diagnosis.20 Salvar Björnsson is a certified surgical assistant in hair transplants from the International Society of Hair Prognosis Restoration Surgery and is the CEO of Vinci Hair Clinic, Some forms of female hair loss are temporary, and will cease when the which offers a range of hair loss solutions for men immediate cause is removed. Others may stem from permanent loss and women throughout the UK. He has worked with numerous surgeons and hair loss practitioners around the world and of working follicles and are not reversible. Management will depend has trained others entering the field. on the cause and may involve lifestyle changes, medication, use of a REFERENCES hairpiece or even transplant surgery. 1. Torres F, Tosti A, ‘Female pattern alopecia and telogen effluvium: figuring out diffuse alopecia’, Semin Cutan Med Surg, 34 (2) (2015) p.67-71. 2. Gan DC, Sinclair RD., ‘Prevalence of male and female pattern hair loss in Maryborough’, J Investig Management Dermatol Symp Proc, 10(3) (2005) p.184-9. Because of the potential psychological impact of female hair loss, it 3. Levy-nissenbaum E, Bar-natan M, Frydman M, Pras E., ‘Confirmation of the association between male pattern baldness and the androgen receptor gene’, Eur J Dermatol, 15 (5) (2005) p.339-40. is often necessary to begin managing the problem before a precise 4. Causes of Hair Loss (US, American Hair Loss Association, 2010)
Reproduced from Aesthetics | Volume 2/Issue 12 - November 2015 Advertorial SkinCeuticals @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com
What is the Science Behind Metacell Expert Opinion: Renewal B3? I’m passionate about pushing the The Secret of Prejuvenation boundaries of scientific knowledge within skincare and for Metacell Renewal B3 we truly went above and beyond, with with Metacell Renewal B3 six years of research and development. Many skincare products are only tested Q&A with Jim Krol, Scientific Director in vitro, with observations assumed to be of SkinCeuticals the same in live subjects. SkinCeuticals always conducts studies on live skin to fully So What Is Prejuvenation All About? an unprecedented level of R&D from understand the way our products work and Women are increasingly aware of how early SkinCeuticals and contains some of the to ensure they have a compounding effect. UV damage impacts skin, and are no longer most powerful ingredients on the market Without extensive testing of the products willing to wait until they need ‘rejuvenation’. in a high-concentration cocktail of multi- in human volunteers, we would have no Instead, they prefer to get ahead of the clock corrective actives; including niacinamide way of knowing what kind of results our and ‘prejuvenate’ skin before the effects of (5%), a tightening tri-peptide concentrate, consumers could expect. For Metacell, we photoageing such as rough, dull skin, fine and pure glycerin. also conducted skin imaging tests, biopsies, lines, blotchiness, and discolouration become and biomarker analyses. Results showed more visible or severe. While everyone’s How Does Metacell Work Differently statistically significant improvements in skin is different, it is never too early to From Other Anti-Ageing Moisturisers? key symptoms of photoageing, including focus on skin health by utilising a daily skin For me, the standout points of the Metacell clarity, radiance, smoothness, fine lines, 1 care regimen. Women in their mid-20s Renewal B3 formulation are the high and firmness, with an 18% improvement in want a one-stop solution: a highly-effective concentration of niacinamide and the unique hydration and a 24% improvement in skin corrective product which gives multiple patent-pending glycerin delivery mechanism. barrier function.i skin benefits within a cosmetically elegant Most anti-ageing products disrupt the skin formulation – and this is where Metacell barrier to encourage ingredient delivery: How Can Metacell Renewal B3 Fit Into
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How Does Metacell Renewal B3 Fit the well as causing irritation and itching. The types as a twice-daily moisturiser and Prejuvenation Solution? high concentration of glycerin in Metacell photoageing corrector, as it gives intense At SkinCeuticals, we are committed to rehydrates flattened keratinocytes, allowing hydration and optimised delivery of clinically- skin health and have built our expertise the delivery of potent ingredients while proven and highly potent actives within a on older skin, so now we are able to actually reinforcing the skin barrier, not fresh emulsion. It could also be used as a bring that higher-level scientific approach disrupting it – a paradox overcome with maintenance treatment between photofacials to a younger skincare market. Metacell years of investment into Metacell’s research and in conjunction with retinoid treatments,
Renewal B3 has been six years in the and development. Far from being sticky or so it fits seamlessly into an overall aesthetic making and is specifically designed for tacky, the glycerin formulation of Metacell skincare regimen to complement and younger skins (25+) to correct early signs Renewal B3 is very cosmetically elegant – maintain results of other treatments. of photoageing. Metacell represents it has a light, fresh emulsion consistency
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Metacell Renewal B3 doesn’t rely on surface www.skinceuticals.co.uk enhancing technology or optical diffusers like many entry-level moisturisers on the market. The changes to the skin in terms About Yevgeniy (Jim) Krol of brightness and plumpness can be seen Joined SkinCeuticals in 2012 to lead global clinical within minutes of the first application and research and scientific this is due to direct improvements in the affairs. Published author skin – not by any ‘makeup’ or brightening in top medical journals and frequent effects. In young skin, niacinamide really is lecturer on scientific innovation. He holds bachelor degrees in cell biology a ‘wonder’ ingredient because it effectively and neuroscience, and a master’s in addresses all the key signs of photoageing pharmaceutical management. to give multiple benefits with just one product, and Metacell has the highest concentration of niacinamide available in a REFERENCES 1. SkinCeuticals: A dermatologist-controlled 12-week clinical on 56 cosmeceutical formulation. subjects. Data on File
52 Aesthetics | November 2015 aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics
A summary of the latest clinical studies
Title: Current Status of Fractional Laser Resurfacing Title: Salicylic acid deposition from wash-off products: comparison Authors: Carniol PJ, Hamilton MM, Carniol ET of in vivo and porcine deposition models Published: JAMA Facial Plastic Surgery, September 2015 Authors: Davies MA Keywords: Resurfacing, ablative, fractionation, laser, treatment Published: International Journal of Cosmetic Science, October 2015 Abstract: Fractional lasers were first developed based on Keywords: Chemical analysis, fluorescence, salicylic acid, observations of lasers designed for hair transplantation. In 2007, deposition, spectroscopy, statistics ablative fractional laser resurfacing was introduced. The fractionation Abstract: Salicylic acid (SA) is a widely used active in anti- allowed deeper tissue penetration, leading to greater tissue contraction, acne face wash products. Only about 1-2% of the total dose collagen production and tissue remodeling. Since then, fractional is actually deposited on skin during washing, and more erbium:YAG resurfacing lasers have also been introduced. These efficient deposition systems are sought. The objective of this lasers have yielded excellent results in treating photoageing, acne work was to develop an improved method, including data scarring, and dyschromia. With the adjustment of microspot density, analysis, to measure deposition of SA from wash-off formulae. pulse duration, number of passes, and fluence, the surgeon can Full fluorescence excitation-emission matrices (EEMs) were adjust the treatment effects. These lasers have allowed surgeons to acquired for non-invasive measurement of deposition of SA treat patients with higher Fitzpatrick skin types (types IV to VI) from wash-off products. Multivariate data analysis methods, and greater individualise treatments to various facial subunits. parallel factor analysis and N-way partial least-squares Immunohistochemical analysis has demonstrated remodeling regression were used to develop and compare deposition effects of the tissues for several months, producing longer lasting models on human volunteers and porcine skin. Although results. Adjuvant treatments are also under investigation, including both models are useful, there are differences between them. concomitant face-lift, product deposition, and platelet-rich plasma. First, the range of linear response to dosages of SA was 60 μg Finally, there is a short recovery time from treatment with these lasers, cm (-2) in vivo compared to 25 μg cm (-2) on porcine skin. allowing patients to resume regular activities more quickly. Second, the actual shape of the SA band was different between substrates. The methods employed in this work highlight the Title: Validation of the Vitiligo Noticeability Scale: a patient-reported utility of the use of EEMs, in conjunction with multivariate outcome measure of Vitiligo treatment success analysis tools such as parallel factor analysis and multi-way Authors: Batchelor JM, Tan W, Tour S, Yong A, Montgomery AA, partial least squares calibration, in determining sources of Thomas KS spectral variability in skin and quantification of exogenous Published: The Journal of Dermatology, September 2015 species deposited on skin. The human model exhibited the Keywords: Vitiligo, pigment, treatment, VNS, repigmentation widest range of linearity, but porcine model is still useful up Abstract: Patient-reported outcome measures are rarely used to deposition levels of 25 μg cm (-2) or used with nonlinear in vitiligo trials. The Vitiligo Noticeability Scale (VNS) is a new calibration models. patient-reported outcome measure assessing how ‘noticeable’ the vitiligo patches are after treatment. The noticeability of vitiligo after Title: Obesity: a key component of psoriasis treatment is an important indicator of treatment success from the Authors: Correia B, Torres T patient’s perspective. This study aimed to evaluate the construct Published: Actabiomedica, September 2015 validity, acceptability and interpretability of the VNS. Our main Keywords: Psoriasis, obesity, safety, cardiovascular, efficacy, hypothesis was that the VNS would be a better and more consistent inflammatory indicator of treatment success than percentage repigmentation. Abstract: Psoriasis has been associated with several Clinicians (n=33) and patients with vitiligo (n=101) examined 39 cardiometabolic comorbidities as well as clinically significant image pairs, each depicting a vitiligo lesion pre- and post-treatment. increased risk of cardiovascular disease and mortality. Obesity Using an online questionnaire, respondents gave a global assessment seems to have a key role in linking psoriasis and cardiovascular of treatment success and a VNS score for treatment response. disease. There are a growing number of epidemiological studies Clinicians also estimated percentage repigmentation of lesions associating psoriasis and obesity. The mechanism responsible for (<25; 25-50; 51-75; >75). Treatment success was defined as ‘Yes’ this association is not certain, but it is probably multifactorial, on global assessment, a VNS score of 4 or 5, and more than 75% involving genetic, environmental and immune-mediated factors. repigmentation. Agreement between respondents and the different Nonetheless, the chronic inflammatory state associated with scales was assessed using kappa statistics. VNS scores were associated obesity appears to be a key component of this relationship. with both patient- and clinician-reported global treatment success (κ Obesity is, therefore, a major factor in the management of = 0.54 and κ = 0.47, respectively). Percentage repigmentation showed psoriatic patients, with implications in treatment efficacy a weaker association with patient- and clinician-reported global and safety. The aim of this review is to synthesize the current treatment success (κ = 0.39 and κ = 0.29, respectively). VNS scores of evidence on the association between psoriasis and obesity, 4 or 5 can be interpreted as representing treatment success. Images exploring the physiopathological mechanisms that link both depicting post-treatment hyperpigmentation were less likely to be diseases and highlighting the importance of obesity control in rated as successful. the efficacy and safety of systemic treatment of psoriasis.
Reproduced from Aesthetics | Volume 2/Issue 12 - November 2015 Last chance to book
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Also – beware of dressing up old news as ‘new’ – the media will not consider re-hashing old stories with no new angle. • Bad headline: Journalists often receive hundreds of releases each day and your release is a split-second decision away from the bin while they scroll through their email inbox. Make sure the headline (i.e. email subject) is short, snappy and to the point. • Jargon-tastic: Relevant for all industries, but particularly medicine where we can all catch ourselves speaking in jargon and acronyms – avoid wherever possible. • Corporate spiel: Stick to the news and why it matters to readers, Effective Press Releases: don’t regurgitate marketing brochures or wax lyrical on your business acumen. The Gateway to Increased • Typo overload: Bad spelling, structure or grammar will irritate journalists and make it less likely for them to read your whole Business Potential release. It’s probably a good idea to get a colleague to take a second look and spot these mistakes.
Julia Kendrick advises on effective Get writing methods of creating your own PR In my experience, a press release is rarely written in ‘one go’ from start to finish. It’s important to put yourself in the journalist’s shoes – test the material to achieve business and strength of your story by asking some key questions to help shape marketing needs your approach before starting, like “So what? Who cares? What does this story give me?” By making sure your release is newsworthy, timely and has a clear relevance for their readers, you can overcome those Introduction early hurdles as a journalist assesses your story. The media is without a doubt a key gatekeeper to increased business Overall, your release must answer the five Ws: the WHO, WHAT, potential: it can either let you pass – giving you exposure, credibility WHY, WHEN, WHERE and HOW. The more you can do to provide and marketing opportunities with their readers, or it can block the road the journalist all the information without them having to do additional – meaning reduced visibility for your business. Successful navigation research, the better your chances of coverage. It is also crucial through these gatekeepers requires effective communication that to keep your release clear and concise – just one page long and meets the needs of journalists. The press release is the mainstay clearly structured to capture interest. of any media outreach, and is designed to secure targeted media Other ways to strengthen your release could include linking to an coverage that supports your marketing objectives – such as driving existing story in the mainstream or local press, offering different new business, growing your market share or raising your media profile. opinions, insights or data. For example, if your release is talking External public relations (PR) support is not always a pre-requisite to about a new dermal filler product or technique, you could link to creating your own communications materials: this easy step-by-step recent stories talking about latest trends or statistics of increased guide will outline not only how to develop your own press releases, but cosmetic procedures. Case studies or quotes from other expert how and when to distribute these to target the media. sources can be compelling additions to underline your key messages. Press releases also don’t have to be text only: you Picture that headline! can improve your chances of grabbing attention by including First and foremost, a press release is a highly focused way of infographics, images and illustrations that you own the copyright communicating to your targeted audience through a source that for. Just beware of file sizes – compress any images to avoid they trust: the media. Picture what you want the headline to be in a overloading their inbox or being diverted as spam. newspaper, take the time to develop a high-quality press release which gives the journalist everything they need to develop a great The ideal press release structure piece, and you’ll maximise your chances of securing fantastic Now that we have finessed our approach and gathered our ‘raw coverage. A word of caution, however, as with all PR approaches, materials’, we can look at how to combine everything into a strong you do not have 100% editorial control of the final outputs. The release structure: journalist will take your release and implement their own perspective, experience and research angle, so you need to stick to some key • Headline: This must tell the whole story within a punchy five to six rules to ensure your messages pull through. word limit (i.e. email subject or desired newspaper headline). • Sub-header:This gives more context to the headline at a similar The five cardinal sins of press releases length. Before we get started, it might be useful to consider the most • Embargo, author, date: Stipulate when the news will be released common press release faux pas – as any journalist will tell you, (and should not be published before), and indicate the author of these mistakes are seen time and time again, despite being very this release and the date of issue. easy to avoid: • The first line: The first sentence is crucial and should encapsulate the whole story, but in no more than 25 words. Imagine if the • Not newsworthy: If your story is totally devoid of any news value journalist only read the first line – would they still understand and for readers or audiences, it will go straight to the ‘delete’ folder. care about your story?
Reproduced from Aesthetics | Volume 2/Issue 12 - November 2015 F
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Why choose 3D-lipomed? A complete approach Face and Body skin Cavitation (Overall Circumference Reduction) Cavitation is a natural phenomenon based on low frequency to the problem tightening ultrasound. The Ultrasound produces a strong wave of pressure to fat cell membranes. A fat cell membrane cannot Prescriptive Highly profitable withstand this pressure and therefore disintegrates into a liquid state. The result is natural, permanent fat loss. Multi-functional National PR support campaign Duo Cryolipolysis Inch loss (Superficial Targeted Fat Removal) Clinician use only Using the unique combination of electro and cryo therapy Cellulite 20-40% of the fat cells in the treated area die in a natural way and dissolve over the course of several months. Two areas can now be treated simultaneously. Complete start up and support package available from under £660 per month Radio Frequency (Skin Tightening) Focus Fractional RF is the 3rd generation of RF technology. It utilises three or more pole/electrodes to deliver the RF energy under the skin. This energy is controlled and limited to the treatment area. Key advantages of this technology are high treatment efficacy, no pain as less energy is required, shorter treatment services and variable depths of penetration.
3D Dermology RF Before After Before After (Cellulite Reduction) The new 3D-lipomed incorporates 3D Dermology RF with the stand alone benefits Treatment Equipment Supplier of the Year of the Year of automated vacuum skin rolling and radio 3D Lipomed 3D Lipo Limited frequency.
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o n • Paragraphs one to three: The rest of the release should contain publication. Maybe they wrote about a similar topic recently? Maybe the story’s key messages, answering the five Ws and providing their publication includes a regular ‘beauty’ or ‘medical’ focus section? some additional expert quotes or case studies to underline the The more specific you can be, the better – there’s nothing worse than lipomed importance/relevance of the story. a blanket approach of ‘Dear all’! Keep your email short and to the point, Skin Tightening • Notes to Editors: Include any additional useful information and don’t forget to include details of any further information available for the journalist such as a short description of the company, on request, as well as your contact details for any additional queries. A Powerful Three Dimensional Alternative to Liposuction service or product. It’s a good idea to paste your release into the email body, as well as attaching as a word file (preferably not a PDF) as sometimes there can be issues with attachments not opening or incompatible files. Be No other system offers this advanced combination of I always recommend a conscious of file size – 1MB is the maximum total for any attachments, technologies designed to target fat removal, cellulite personal approach: don’t so make sure you compress any files, and particularly images. and skin tightening without the need to exercise Get feedback underestimate the Resist the temptation to chase the journalist if you don’t hear anything This NEW advanced device is dedicated after an hour or two – they will get back to you if the story is of interest
exclusively to the clinical market Cellulite importance of addressing or if they need further info. If you still haven’t heard anything after a day or two, get in touch, (preferably by phone for a more personal the journalist by name approach), to check whether they received it and to ask for feedback. It’s always useful to understand their take on the release and what Distribution they might like to receive from you in the future. So you’ve drafted your release, proof-read it thoroughly and you’re ready to send it out to the media. Where do you start? Conclusion You should now feel more confident about creating your own press Contacts releases and leveraging these to drive your business marketing Why choose Nowadays, 99% of news releases are sent via email – you will either objectives. Whether it’s profiling a new treatment offering, highlighting 3D-lipomed? need to do this manually by building up your own distribution list, or a clinic launch or just developing your own media profile and A complete approach Face and Body skin Cavitation (Overall Circumference Reduction) alternatively there are a number of online distribution services which presence, the media represents a key channel to engage with both Cavitation is a natural phenomenon based on low frequency allow you to upload your release and send out to a pre-defined list new and existing patients in a credible way. By adopting a tailored to the problem tightening ultrasound. The Ultrasound produces a strong wave of pressure to fat cell membranes. A fat cell membrane cannot of media contacts. These distribution services can be free or paid- and personalised approach, as well as ensuring your releases are Prescriptive Highly profitable withstand this pressure and therefore disintegrates into a for – thus reflecting the quality of media outlets reached. They often structured, relevant and compelling – you will maximise your chances liquid state. The result is natural, permanent fat loss. share health and beauty news, connecting journalists, companies of successfully navigating through the media ‘gatekeepers’ to secure Multi-functional National PR support and PR professionals. However, the disadvantage is that you lose valuable coverage of your clinic and services. Ultimately, this approach campaign Duo Cryolipolysis a personal approach and connection with the media contacts, and will help you to build the foundation for ongoing media relationships Inch loss (Superficial Targeted Fat Removal) it can be difficult to find a service that targets the specific media and will eventually deliver benefits for your business. Clinician use only Using the unique combination of electro and cryo therapy Cellulite 20-40% of the fat cells in the treated area die in a natural that you need for a medical aesthetic story. Your media distribution way and dissolve over the course of several months. list should be tailored based on the content and relevance of your Two areas can now be treated simultaneously. news story. Consider which media contacts will want to receive your Expert Commentary Complete start up and support package release – be that medical trade press, regional newspapers, local “Like most journalists, I receive an enormous available from under £660 per month Radio Frequency (Skin Tightening) magazines or even national press. If creating your own list, you can number of emails a day. I do look at all of them – Focus Fractional RF is the 3rd generation of RF technology. research publications that have written about similar topics, find the but unless their headline message is very clear and It utilises three or more pole/electrodes to deliver the RF most appropriate journalist to contact and source their email address enticing, I am unlikely to read further than the first few lines. A energy under the skin. This energy is controlled and limited through Google. If you can’t find a relevant individual journalist, find out large number of releases are sent to me as image files – I am to the treatment area. Key advantages of this technology are high treatment efficacy, no pain as less energy is the contact details for the editorial team or newsdesks, who will then sure they are gorgeous but my laptop does not automatically required, shorter treatment services and variable depths of field your release to the appropriate contact. Of course, don’t forget to download them, so unless they have a particularly exciting penetration. add any media contacts with whom you have a personal relationship. message in the subject line, I am unlikely to stop and download these one by one. As such, they are, in effect, 3D Dermology RF Timings wasted. Ditto the releases that are sent as attachments. Really, Before After Before After (Cellulite Reduction) The new 3D-lipomed incorporates 3D An important consideration is finding out when the publications what I prefer is a personal email with the message kept short Dermology RF with the stand alone benefits targeted go to press – be this daily, weekly or monthly. If you can’t and sweet, pointing out why the story is right for me. If it’s of Treatment Equipment Supplier of the Year of the Year of automated vacuum skin rolling and radio find this information online, it’s best to give them a call as this will interest, I will follow up fast enough!” 3D Lipomed 3D Lipo Limited frequency. inform you of when you need to send your release to maximise the Alice Hart-Davis chances of it being seen and covered. The last thing you want is to Freelance beauty journalist Comes Highly Recommended send something just after the filing deadline, as not only will you miss “3D-lipo has revolutionised the cosmetic medicine industry. this window of opportunity, but your release could end up on the Efficacious and affordable, patients and doctors alike love Julia Kendrick has 10 years of experience in public this treatment - it is a win-win situation” bottom of the pile for next time as newer items come through. relations and communications, and is the founder of new Paul Banwell FRCS (Plast) Director, The Banwell Clinic. aestheticsawards.com aestheticsawards.com start-up Kendrick PR Consulting, which specialises in Approach medical aesthetics and healthcare PR. A previous winner I always recommend a personal approach: don’t underestimate the of the Communiqué Young Achiever Award, Kendrick is passionate about delivering award-winning client campaigns. importance of addressing the journalist by name and including some details of why you think this story is relevant to them, or their particular For further information or www.3d-lipo.co.uk Reproduced from Aesthetics | Volume 2/Issue 12 - November 2015 a demonstration call: 01788 550 440 @3Dlipo 3D-lipo smarter skincare skinade™ is a result-driven skincare drink that, taken daily, will enhance your everyday skincare routine real people real reviews
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connecting. An example of this is trying to increase social media presence by collecting followers, using incentives and competitions when, in fact, having fewer genuine fans that love the brand (not the freebies), is so much more valuable.
Avoid routine conversation It is crucial that all staff members are personable and engaging with patients entering their clinic. From the front of house staff, to the nurses and practitioners, everyone needs to exude enthusiasm and positive energy. A prime opportunity to get to know your patient base is in the Patient waiting room. This is the first opportunity you have to build rapport with your clients. The practitioner could be running late one Communication morning, so other clinic staff may have enough time to go beyond small talk and Victoria Smith discusses how effective delve into more impactful topics, such as communication with your patients can boost what the patient does as a career, making them feel genuinely valued. Patients will trade and your clinic’s reputation often require repeat treatments, so making them feel comfortable is fundamental to building a good relationship and Communication is an essential tool in last detail of your clinic and service skills of ensuring they keep coming back. achieving productivity and maintaining employees has been considered. Colours During the initial consultation it is strong working relationships at all levels like blue are said to increase productivity,1 expected that the receptionist asks routine of an aesthetic practice. Communication whereas lilac promotes a feeling of calm.2 questions and obtains contact details, goes beyond the spoken word; it It is worth remembering that there is no however a powerful spin on this routine includes visual aids, greeting patients second chance to make a first impression, procedure would be showing genuine and much more. Without effective so providing exceptional levels of interest in their lives outside of the clinic communication there can be no mutual communication and care from the very environment. Open-ended questions will understanding between the patient beginning is essential. always encourage conversation. Have and practitioner. When a patient first enters Word-of-mouth is the original social they had a busy day? Have they travelled a clinic, they will instantly form an opinion media tool. It involves people physically far to get to the clinic? Answers to these of their surroundings; is the reception and interacting and exchanging information, questions will help front-of-house staff build waiting room area warm and welcoming? Is which in turn can benefit a clinic’s an accurate picture of the patient, which the receptionist inviting and knowledgeable reputation. Word-of-mouth can also they can then pass on to practitioners to of clinic protocol and treatments create a positive or negative effect on a continue the conversation and avoid available? Is every member of the team clinic’s trade. Consumers will often believe repetition. For practitioners, another way dressed appropriately and do they recommendations from friends and family to avoid routine conversation is to take conduct themselves professionally? Even over all forms of advertising, marketing or detailed notes during the consultation, the colours of the walls can affect your PR. In recent years, businesses have been logging all of a patient’s concerns and mood, so it is vital to make sure every more focused on collecting rather than what they want to achieve. In a busy clinic environment, you will invariably be faced with a large number of individuals on a daily basis; therefore detailed notes logged into your system will help to ensure each Getting to know your patient on patient feels valued. a personal level is vital for building Building rapport The most valuable clinic commodity: rapport, even if they’ve only been trust. Trust is more important than ever in aesthetic businesses today, specifically to your clinic once when it comes to patients, employees, and all stakeholders in the clinic. Trust can be described as reliance on the character, ability, strength, or truth of
Reproduced from Aesthetics | Volume 2/Issue 12 - November 2015 @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com
and is not working. Sending text reminder messages to patients 24 hours prior to their appointment, giving them an option It is crucial that all staff members to cancel without having to pick up the phone, is also an effective way of reducing are personable and engaging with no-shows and keeping on top of the diary ahead of appointments. patients entering their clinic Social media, word-of-mouth, testimonials, treatment offers and literature such as treatment leaflets and brochures someone or something. Trust is imperative testimonials, and there is no better way all work together to increase a patient when it comes to building rapport at all to figure out if a treatment is going to be base. However, none of these avenues levels. Developing trust isn’t easy; it takes appropriate for you than to get another would be effective if it weren’t for human time, dedication, and most importantly, patient’s candid opinion. interaction and exceptional in-clinic humility. This is especially important in service. A successful way of promoting a a clinic environment as you are treating Keeping in contact with patients clinic’s key messages is through a social someone’s face or body and patients can Getting to know your patient on a personal media campaign, whereby the end goal feel very vulnerable during treatment. They level is vital for building rapport, even is for people to book in for consultations are putting total trust in all involved in the if they’ve only been to your clinic once. and treatments. Giving it a hook and a clinic to ensure their treatment is safe and If you are able to build a good rapport campaign title that sounds more appealing they leave unharmed. Building rapport and from the first meeting, keeping in touch really works to grab consumer attention. offering guidance and knowledge will help will be a lot easier. Always follow up with An example could be to create a Twitter to build trust, and leave patients feeling at the patient after an appointment to show campaign based around the winter months, ease in your care. It may seem obvious, an element of care, but also to make possibly promoting skin rejuvenation but listening intently to your patient can sure the procedure went to plan, and to treatments to prepare for the ‘office be very beneficial. If they feel they have address any concerns the patient may Christmas party’. your undivided attention, you will be able have. Social media is taking over as a main to build a stronger relationship than if they form of communication for businesses, Conclusion think you are too preoccupied to engage and some clinics have created a service In today’s society, we are fast becoming with them. The moment a patient enters where patients are now able to book disconnected from personal conversations the treatment room, a relationship should appointments through this medium, as in many ways. The convenience and have already been formed, giving them well as using platforms such as Twitter efficiency of our high tech, yet impersonal the chance to fully relax, ask any burning to champion or to complain about their ways of communication has left many of us questions and allow you to perform to the experiences. Social media creates yearning for human contact and interaction. best of your ability. instant attention and delivers immediate The aesthetic industry is one of the few feedback, allowing it to potentially make industries left that lends itself to meeting Individualisation or break a reputation. Communicate in a this need. This gives practitioners a very Offering bespoke treatments will way the patient prefers; some will like text special advantage that no machine, keep the clinic one step ahead of the alerts, others phone calls and some email technology or product can replace. It competition, and gives practitioners the updates. During telephone conversations provides you with the opportunity to offer opportunity to tailor treatments to the or initial consultations, it could be a personal service that goes far beyond individual, providing a service which beneficial to take notes and add to patient the ability to treat your patient’s needs, and is unique to them. This kind of service files for future reference. gives you the power to positively impact goes beyond the treatment menu, and Patient communication comes in many their clinic experiences more profoundly. offers a personalised experience. This forms, from the initial phone booking Victoria Smith is the clinic strategy also applies to any homecare to the treatment follow-up phone call, director of Absolute Aesthetics in products you stock; practitioners should there are several ways to reach out to Surrey. Her specialisms include aim to create a programme specific patients in order to collate feedback, non-invasive skin procedures, to the patient’s treatment in order to and to make sure their experience was a as well as the removal of complex lesions and cysts. Smith graduated maximise desired results and to encourage positive one. This also gives staff members from the University of Gloucester in 2002 the patient to come back for more the chance to resolve any issues or with a degree in Community Studies. personalised service. Introducing unique answer concerns and queries. A follow-up REFERENCES ways to engage with your patient base is call can be extremely effective, especially 1. Bailey, C, ‘The exact color to paint your office to become the a key component to remain or to develop if a patient feels too uncomfortable to most productive’ (2013)
Reproduced from Aesthetics | Volume 2/Issue 12 - November 2015 LIFT, CONTOUR & REJUVENATE1,2 with sustained collagen stimulation2
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Call Merz Aesthetics Customer Services now to find out more or to place an order Tel: +44 (0) 333 200 4140 Email: [email protected] www.radiesse.co.uk RAD/7/SEP/2015/DS Date of preparation: September 2015 Date of preparation: RAD/7/SEP/2015/DS
1. Sundaram H. J Drugs Dermatol. 2012 Mar; 11(3): S44-S47
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protection when buying a ball point pen than when having fillers.”2 So what has happened over the past five to ten years to attract such attention to the aesthetics industry, encouraging the government to create guidelines aiming to grow public awareness of good practice? Although a relatively young area of medicine, non- surgical treatments have grown exponentially over the past five years, worth an estimated £2.3bn in the UK alone in 2010 and predicted to reach £3.6bn by 2015.2 By the very nature of an industry that has seen such rapid growth, both in terms of the number of practitioners, clinics and patient numbers; the consultation has naturally evolved. All of the enquiry recommendations and professional guidance accepts and encourages the need for informed consent with a move towards duality of consent.
The Changing What does consent mean and how has it affected the consultation? A critical part of the consultation process is the Consultation discussion of the possible risks involved. A clear explanation of any inherent treatment risks must Dr Renée Hoenderkamp explains how the be fully explained. How many practitioners include ‘blindness’ as part of their filler risk profile? I am sure patient consultation has evolved in recent my colleagues, as do I, see patients who’ve had years and why this is working to improve fillers in the past but were never told of the risks. In aesthetic practice my opinion, the decision to undergo a non-surgical treatment is a journey that the patient is embarking Running an aesthetic clinic is an all consuming and ever-evolving process. on with the practitioner. The decision must be in line Never has this been truer than over the past five to ten years where we have with the recommendations and the patient needs seen an evolution of the non-surgical consultation. Many things have contributed to understand the risks involved. The practitioner to this change, ranging from informed consent, increasing treatment solutions and is also expected to explain that other treatments products, and new technology. An understanding of these developments and are available from other practitioners, if it is in the the desire to constantly grow, adapt and learn, make the challenge of running or patient’s best interests. For example, Roaccutane owning a clinic exciting and fulfilling; even though sometimes challenging. We must for acne could work as well, or even better than all strive to have an efficient, informative and legally satisfying consultation process a skin peel, and tear trough surgery may be more for the safety of our patients and longevity of the industry. beneficial for some patients than fillers. All professional bodies, such as the General Medical Consent Council (GMC) and the Royal College of Surgeons With the non-surgical market remaining largely unregulated, those practitioners (RCS), recommend that the person conducting the who aim to run ethical clinics have learnt from other areas of medicine how treatment must carry out the consent process.3 This important consent is. A major change in the consent process has seen the has therefore seen clinics, which have traditionally patient become an active and equal partner alongside the practitioner. This used different practitioners to consent the patient ‘duality’ of consent empowers the patient with full, understandable and digestible and carry out the procedure, having to consider and information, thus allowing them to adequately weigh-up the risks and benefits change their consultation process. of the treatment they are considering. The decision to embark upon a particular Finally, as the main consent method previously detailed treatment is made by the patient once in complete knowledge of the facts. is a one-off process, unless a new treatment is added, There should be no question unanswered, and recent litigation indicates that it is now becoming more common to have an ongoing however rare, all possible complications should be discussed.1 Only with such consent card that the patient signs at each visit to thoroughness can the patient make a fully informed decision. confirm that nothing has changed in their medical It is considered good practice to have clear consent pathways within the clinic history, no new medications are being taken and environment that satisfy basic levels of good practice, as identified in the ‘Review that they’re not pregnant.4 Clearly, if there were new of the Regulations of Cosmetic Interventions’, which was published in April 2013 medical issues to consider, the consent process would and led by Sir Bruce Keogh.2 Aimed at anyone delivering non-surgical treatments, need to be revisited and documented accordingly. practitioners and nurses now have guidance from their registration bodies, all of Crucially, once all of the above has been discussed and which focus on the consent process. The general tenet of all of this guidance is a treatment plan agreed, there must be a written record summarised in the ‘Professional Standards for Cosmetic Practice’.3 The Keogh and a form signed for consent. The patient should also Report garnered much publicity with the often quoted catch phrase, “You have more take away with them written aftercare instructions.
Reproduced from Aesthetics | Volume 2/Issue 12 - November 2015 Venn Aesthetics offers a broad range of high quality treatment devices to the aesthetic industry at affordable prices. Venn Aesthetics are proud to introduce Solari, Infini and Clattu.
SOLARI: Where CLATTU: Superlative Quality Meets INFINI: Results with Low IPL Affordability 2015 MyFaceMyBody Cryo Lipo Running Costs SOLARI™ is an IPL system Rejuvenation Finalist Clatuu is a non-invasive differentiated from all Infini is a clinically subcutaneous fat others by its cutting-edge technology proven treatment that reduction device which uses cold energy which guarantees precise treatment and provides results to address the 3 key to destroy fat cells. Natural body shaping minimised side effects. signs of skin ageing: skin laxity, wrinkles with no pain or down-time. • High Quality Square Pulse: The SOLARI & volume loss, in addition to offering • 360° Cooling Panel: World’s first 360° flashlamp produces a very stable, flat pigmentation, acne scarring & stretch cooling panel that is more effective to and homogeneous spectral output over mark improvement. deliver cooling energy that traditional the entire pulse without hot spots • Dual-action microneedle, bi-polar two-side models. Treats in nearly half • Spectral Distribution: Delivers more radio frequency treatment: Delivers the time light energy at precise wavelengths enhanced wrinkle reduction and skin • Strong and powerful cooling system: • Skin Cooling System and S-Toning: tightening results to volumise skin tissue Does not damage the surrounding Allows for pain-free treatment • Radio frequency energy: Delivered via tissues • Time Resolved Spectral Distribution: insulted gold-coated microneedles, • Dual Handpiece: Treat two areas at once Delivers an even distribution of the it creates precise fractionated • Two Types of Applicator: Wing and flat spectrum for each micropulse coagulation zones to successfully treat various body areas • Rapid Repetition Rate: Fast treatments • Adjustable treatment depth and power control: Allows for multi passes and treatment on delicate areas
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Within each treatment type, there are multiple choices of products A major change in the from a range of manufacturers. In regards to different filler treatments, the choice for the patient and practitioner depends consent process has seen on; the area being treated, desired effect, product structure and composition, longevity, and patient preference. Each product type the patient become an requires specialist training by the practitioner and often a different consent form. Such complexity and more demanding consent makes active and equal partner for a more time consuming consultation, with a detailed explanation covering which treatment of many might be most suitable, what it alongside the practitioner involves and the risks. The other transformation affecting products over the past five years Another recommendation from the Keogh report, which is supported has been the addition of lidocaine in fillers. This has changed the by the main professional bodies, such as the GMC and the RCS, is for requirement for topical anaesthetic prior to treatment, which ultimately consent and treatment to be a two-stage process to give the patient speeds up the process. time to consider the treatment fully.2 A ‘cooling-off’ period before treatment is also becoming more commonplace. For example, I The knowledgeable patient consult and consent for thread lifts at the initial appointment and carry The internet, social media and growing interest in the market has out the procedure at a future date. Clearly, this changes the timing and educated patients as to what is available and what to ask. Social planning of appointments and could potentially result in cancellations media has allowed engagement in a way never seen before and the or no-shows, but follows good practice guidelines. If this isn’t your sources of information are vast. It not only highlights new treatments practice, be satisfied that the patient fully understands the risks and technology quickly, it also addresses bad practice and enables and benefits and feels able to ask informed questions or say no to bad news to spread quickly and prompt questions. The engaged going through with the procedure. A possible method, which can be patient searches and follows practitioners and is able to ask worthwhile, is allowing patients 30 minutes back in the waiting room to questions and retrieve answers quickly. Social media empowers consider whether they would like to go through with treatment. the patient: they use it to gather information, research practitioners and interact purposefully. The more the patient knows, the more Technology understanding they bring to the consultation and the more questions It is clear that the consent process has altered the consultation they want answered to clarify areas of concern. dramatically, and, in addition, has added more time and paperwork to the process. There are, however, technologies which may help Conclusion streamline the process, and others that give you time back as they There is no doubt that the non-surgical consultation has changed aid the decision making process. For example, over the past three radically over recent times and will continually evolve. Change can be years, there have been mobile phone/tablet apps, which replicate the difficult to process, but when changes are in place for improvement, entire consultation process and serve to securely store the medical adaptation produces a superior experience for everyone involved. questionnaire, consent and photos together. These apps can negate The changing consultation has become more complex and somewhat the need for paper records and the associated risks of storing and crowded, but the options are vast, the tools ever expanding and the accessing confidential patient records. They could also solve the issue results that can be achieved keep on improving. The outcome should of uploading photos from a camera and either printing or collating with see happier patients, achieve better patient safety and a more skilled the patient record. Currently still relatively early in their uptake, they and regulated industry. hold the promise of streamlining the consultation. Dr Renée Hoenderkamp is a GP registrar based in There is also the use of 3D simulation to demonstrate the effects London, having qualified as a doctor in April 2010. With of non-surgical treatments. Already being used in the USA5 and a special interest in aesthetics and women’s health, she Australia,6,7 the simulation works as an addition to the consultation founded The Non Surgical Clinic in 2011, offering natural- that will allow both patient and practitioner to have a realistic idea looking solutions for facial ageing and deformity. of treatment results before committing – if the technology lives up REFERENCES to its promise. Such an advance may limit patient dissatisfaction or 1. Hart, D QC, ‘Supreme Court reverses informed consent ruling: Sidaway is dead’, (UK Human Rights Blog, 2015),
Reproduced from Aesthetics | Volume 2/Issue 12 - November 2015
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“You have to love aesthetics and strive to deliver good results for your patients” Dr Maria Gonzalez reflects on her career in medical aesthetics and highlights the need for more education within the specialty
Consultant dermatologist Dr Maria Gonzalez developed a passion teaching students in a university environment, Dr Gonzalez regularly for medicine when she was just a small child. “My friend’s father was presents at industry conferences and discusses an array of topics, from a doctor, and from the age of six or seven, he greatly influenced my achieving patient skin confidence and management of acne scarring, to career ambitions,” she explains. conducting laser and chemical peel workshops. She says that teaching In 1992, Dr Gonzalez moved from Trinidad to the UK to pursue a career and presenting also allows her to utilise her skill and passion for writing, in dermatology, before beginning her medical aesthetics career in explaining, “I like to provide my audiences with a creative perspective 2002. She now runs the successful Specialist Skin Clinic in Cardiff, when I’m teaching and presenting. Even through coming up with a witty which won Best Clinic Wales at the Aesthetics Awards 2014, and holds presentation title, education can allow you to express your creativity weekly consultations at the London Clinic in Knightsbridge. In 2002, effectively.” Dr Gonzalez notes that one of the negative sides of the a colleague who had purchased an Intense Pulsed Light machine industry is that many practitioners decide to enter aesthetics under encouraged Dr Gonzalez to join her in a private venture treating false pretenses, suggesting that the financial and glamour aspects can aesthetic concerns at St Joseph’s Hospital in South Wales. It was from overpower certain practitioners’ decisions. “I think a lot of people are this experience that Dr Gonzalez began introducing new aesthetic jumping on the bandwagon because it can seem like quick and easy technology to the hospital and developed an interest in setting up money – if that’s your motivation then it’s the wrong reason, you have her own services for the NHS. “I set up a service for hair removal and to get into aesthetics for all the reasons people do medicine. You have treating acne scars in an NHS hospital,” she says, explaining, to love aesthetics and strive to deliver good results for your patients.” “It was also established to help provide education for the postgraduate For anyone looking to develop a career in aesthetics, Dr Gonzalez doctors who may be tasked with treating these concerns.” Dr Gonzalez advises, “If you are a clinically trained practitioner, you need to always explains that creating these services enabled her to enhance patient uphold what a practitioner’s ethos is, which is to help patients improve results and offer a wider range of treatments aside from prescription their quality of life, and avoid negative outcomes. If you focus on these tablets and creams. As the director of all dermatology programmes values then success will eventually transpire.” at Cardiff University between 2000-2012, teaching postgraduate students how to use the machines she had introduced fuelled Dr Gonzalez’s passion for education. She stresses the importance What treatment do you enjoy giving the most? of continued education within the aesthetics industry, and continues I like treating pigmentation using lasers, which can be very to teach postgraduate dermatology students at Cardiff University. challenging. It requires a lot of patience, so I take great pleasure in performing it well and I always strive to get a In addition, Dr Gonzalez has created a 12-week online course for good result. the university, titled, ‘An Introduction to Dermoscopy’, which, she explains, has received very positive feedback from the university’s What technological tool best compliments your work? Department of Dermatology. “I hope the future of industry education Lasers – I like working with gadgets. My clinics are heavily will progress further as I do think that the aesthetic market in the UK based on lasers and my patients have always received very needs more educational support,” she says, adding, “I would also like good results. to see more dermatologists involved in teaching and I think that we should encourage juniors to look at this as a viable option.” Along with Do you have an industry pet hate? I don’t like the fact that the aesthetics industry in the UK is Even through coming up unregulated. It’s disappointing that it seems as though the UK, which usually has a very high standard of medical care with a witty presentation and education, has somehow neglected this part of medicine. What aspects of medical aesthetics do you enjoy the most? title, education can allow What makes my day fun is the interaction that I have with patients. Without that, my typical day would be too hard, and, you to express your luckily, compared to when I used to work in the NHS, private medicine allows you to spend more time getting to know creativity effectively your patients.
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A move in this direction for the aesthetics industry would help to prevent unsafe and inefficient counterfeit devices becoming available on the market. This is where the Government needs to take action and ensure appropriate regulations are introduced to help protect patients. However, it is also important for us, as practitioners, to help educate our patients. Communications are often sent directly to us offering treatments cheaper than the market value.11 Some products and accompanying marketing materials look almost identical to those of the genuine brands, and as healthcare professionals we need The Last Word to be aware of these counterfeits as our patients will not always be. Although many companies have the best intentions, I have seen numerous examples of counterfeits of cryolipolysis, the fat Dr Farid Kazem argues the freezing treatment that is already patented worldwide. A patient who need for more education on the visited my clinic after receiving what she thought was a genuine difference between genuine and cryolipolysis treatment, suffered fourth-degree burns from frostbite as the counterfeit device had no safety mechanism in place. Even counterfeit products if treatments do not cause lasting physical damage, there is a high chance results will be ineffective, leading to disappointment and an increase in financial cost if the individual then moves forward with the The aesthetics market is booming. Market researcher, Key Note, genuine treatment. Distrust of practitioners is also commonplace, with expects the industry to reach a total value of £913m by next year, doubt over the effectiveness of even genuine treatments following up from £725m in 2014.1 Helping to fuel this growth – despite a bad experience with a counterfeit device. These factors damage the number of people choosing traditional plastic surgery falling the reputation of legitimate brands and the aesthetics industry as a by 3.6%2 – is the increase in the number of people undergoing whole. As mentioned, it would be advisable to have a register for minimally invasive aesthetic procedures. In the UK, non-surgical those who perform cosmetic interventions. However, this would treatments currently make up 75% of the market value, with nine in provide no guarantee that those listed do not use counterfeit devices. ten procedures undertaken being non-surgical;3 while in the US, 13.9 To solve the ongoing problem with counterfeit devices, a register of million out of a total 15.6 million cosmetic procedures are minimally centres where approved or patented treatments are available would invasive.4 This development has been acknowledged by the British be a good starting point. It may seem that this problem is too great for Association of Aesthetic Plastic Surgeons (BAAPS), an organisation just one group to tackle alone. Indeed, I believe that the aesthetics that has spoken regularly about the new aesthetic ideal of ‘tweaked, industry and the Government have a combined responsibility to not tucked’, with a demand for more subtle treatments now educate the public and enforce restrictions to protect individuals at risk outperforming the more traditional and invasive treatments.5 However, from these harmful devices. this boom in demand and growing market for non-invasive treatments Dr Farid Kazem completed his medical studies at is not all good news for the industry, as, subsequently, there has been a the Zuiderziekenhuis in Rotterdam and specialises in rise in the number of counterfeit aesthetics treatments.6 plastic surgery. He has extensive experience in breast A counterfeit product can be described as something made in exact enhancement, eyelid corrections, tummy tucks and skin rejuvenation. imitation of something valuable with the intention to deceive or 7 defraud. The rise of counterfeit treatments is a problem that needs Disclosure to be addressed, and the Government, regulatory bodies and the In his clinic in the Netherlands, Dr Kazem provides CoolSculpting®, aesthetic industry should work together to educate the public on the owned by ZELTIQ® who patented Cryolipolysis®. dangers of these devices and protect them from the risks. REFERENCES Currently in the EU, there are limited restrictions in place to prevent the 1. Lauren Davidson, Have we reached peak plastic surgery?, 2015
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70 Aesthetics | November 2015 LOOK HOW YOU FEEL
Azzalure Abbreviated Prescribing Information (UK & IRE) site(s) or when the targeted muscle shows excessive weakness or (twitching of muscles around the eyes). Uncommon (≥ 1/1,000 to Presentation: Botulinum toxin type A (Clostridium botulinum toxin A atrophy . Patients treated with therapeutic doses may experience <1/100): Dizziness, Visual disturbances, Vision blurred, Diplopia, haemagglutinin complex) 10 Speywood units/0.05ml of reconstituted exaggerated muscle weakness. Not recommended in patients with Pruritus, Rash, Hypersensitivity. Rare (≥ 1/10,000 to < 1/1,000): Eye solution (powder for solution for injection). Indications: Temporary history of dysphagia, aspiration or with prolonged bleeding time. Seek movement disorder, Urticaria. Adverse effects resulting from distribution improvement in appearance of moderate to severe glabellar lines immediate medical care if swallowing, speech or respiratory difficulties of the effects of the toxin to sites remote from the site of injection seen at frown, in adult patients under 65 years, when severity of these arise. Facial asymmetry, ptosis, excessive dermatochalasis, scarring have been very rarely reported with botulinum toxin (excessive muscle lines has an important psychological impact on the patient. Dosage & and any alterations to facial anatomy, as a result of previous surgical weakness, dysphagia, aspiration pneumonia with fatal outcome in Administration: Botulinum toxin units are different depending on the interventions should be taken into consideration prior to injection. some cases). Prescribers should consult the summary of product medicinal products. Speywood units are specific to this preparation and Injections at more frequent intervals/higher doses can increase the characteristics in relation to other side effects. Packaging Quantities are not interchangeable with other botulinum toxins. Reconstitute prior risk of antibody formation. Avoid administering different botulinum & Cost: UK 1 Vial Pack (1 x 125u) £64.00 (RRP), 2 Vial Pack (2 x 125u) to injection. Intramuscular injections should be performed at right angles neurotoxins during the course of treatment with Azzalure. To be used for £128.00 (RRP), IRE 1 Vial Pack (1 x 125u) €93.50, 2 Vial Pack (2 x 125u) to the skin using a sterile 29-30 gauge needle. Recommended dose is one single patient treatment only during a single session. Interactions: €187.05 (RRP). Marketing Authorisation Number: PL 06958/0031 50 Speywood units (0.25 ml of reconstituted solution) divided equally Concomitant treatment with aminoglycosides or other agents interfering (UK), PA 1609/001/001(IRE). Legal Category: POM. Full Prescribing into 5 injection sites,: 2 injections into each corrugator muscle and one with neuromuscular transmission (e.g. curare-like agents) may Information is Available From: Galderma (UK) Limited, Meridien House, into the procerus muscle near the nasofrontal angle. (See summary of potentiate effect of botulinum toxin. Pregnancy & Lactation: Not to 69-71 Clarendon Road, Watford, Herts. WD17 1DS, UK. Tel: +44 (0) 1923 product characteristics for full technique). Treatment interval should not be used during pregnancy or lactation. Side Effects: Most frequently 208950 Fax: +44 (0) 1923 208998. Date of Revision: March 2013 be more frequent than every three months. Not recommended for use occurring related reactions are headache and injection site reactions. in individuals under 18 years of age. Contraindications: In individuals Generally treatment/injection technique related reactions occur within first week following injection and are transient and of mild to moderate Adverse events should be reported. Reporting forms and with hypersensitivity to botulinum toxin A or to any of the excipients. information can be found at www.mhra.gov.uk/yellowcard. In the presence of infection at the proposed injection sites, myasthenia severity and reversible. Very Common (≥ 1/10): Headache, Injection site gravis, Eaton Lambert Syndrome or Amyotrophic lateral sclerosis. reactions (e.g. erythema, oedema, irritation, rash, pruritus, paraesthesia, Adverse events should also be reported to Galderma (UK) Ltd. Special warnings and precautions for use: Use with caution in patients pain, discomfort, stinging and bruising). Common (≥ 1/100 to < 1/10): with a risk of, or clinical evidence of, marked defective neuro-muscular Facial paresis (predominantly describes brow paresis), Asthenopia, transmission, in the presence of inflammation at the proposed injection Ptosis, Eyelid oedema, Lacrimation increase, Dry eye, Muscle twitching
Date of preparation: March 2013 AZZ/019/0313
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