Managing Obesity

VOLUME 2/ISSUE 5 - APRIL 2015

Launched in 2011, Juvéderm VOLUMA® with lidocaine is the first and only FDA approved product with VYCROSS™ technology indicated for the restoration of facial volume including cheeks, cheekbones and chin.1

Noticeable results long after treatment, up to 24 months.2

97.4% of patients reported satisfaction as “improved to very much improved” with the cosmetic effect of JUVÉDERM® VOLUMA® with lidocaine immediately after treatment.3

REFERENCES: 1. Juvéderm® VOLUMA® with lidocaine Instructions for Use (IFU). 2. Jones D, Murphy DK. Dermatol Surg. 2013: 1-11 3. Dormston W. Poster presented at 8th European Masters in Aesthetics and Anti-Aging Medicine (EMAA). 12-14 Oct 2012. Paris, France.

Allergan, Marlow International, 1st Floor, The Parkway Marlow, Buckinghamshire SL7 1YL, UK Date of Preparation: March 2015 UK/0171/2015

15367 UK VYCROSS Ad Aesthetics Journal March 2015_Front Cover.inddAdvances 1 in Treating the Lips Seasonal16/03/2015 12:02 Managing Lasers Aesthetic practitioners Marketing Dr Elizabeth Raymond share their advice, Charlotte Moreso Obesity CPD Brown provides an methods and on how to create a Dr Sotirios Foutsizoglou gives an update on lasers in techniques for lip summer marketing overview of approaches and treatment aesthetics augmentation campaign Not all HA dermal ﬁ llers are created equal. Cohesive Polydensiﬁ ed Matrix® OPTIMAL (CPM®) Technology1,2 TISSUE INTEGRATION Optimal tissue integration1,2 Intelligent rheology design

Injectable Product of the Year

Contact Merz Aesthetics NOW and ask for Belotero NEW Tel: +44 (0) 333 200 4140 Email: [email protected]

The ﬁ ller you’ll love

MZ078 A4 BELOTERO ADVERT BEL2020315LD.indd 1 16/03/2015 11:27 Contents • April 2015 06 News The latest product and industry news 12 Production in Pringy We visit Allergan’s manufacturing and R&D facility in Pringy, France Special Feature 14 Conference Reports Treating the Lips Reports from the annual AAD meeting and Interventional Cosmetics Page 23 meeting at the RSM 16 On the Scene Out and about in the industry this month 18 News Special: Aesthetics Conference and Exhibition A review of the hugely successful ACE 2015 Marketing Not all HA CLINICAL PRACTICE Creating a seasonal campaign 23 Special Feature: Treating the Lips Page 57 Aesthetic practitioners share their approaches to lip augmentation dermal ﬁ llers are 28 CPD Clinical Article Clinical Contributors Dr Sotirios Foutsizoglou explores obesity management with an Dr Sotirios Foutsizoglou specialises in minor created equal. overview of treatments and approaches cosmetic surgery and aesthetic medicine. Founder and medical director of SFMedica, he has 35 Topical and Oral Antioxidants extensively lectured and presented at national and Cohesive Polydensiﬁ ed Matrix® Ms Rozina Ali and Eva Escofet address the use of topical and oral international conferences and meetings. antioxidants Ms Rozina Ali is a consultant reconstructive ® 1,2 OPTIMAL (CPM ) Technology and aesthetic surgeon, specialising in facial 41 Advances in Lasers aesthetic surgery. Graduating from St Thomas’

TISSUE Hospital Medical School, she now holds numerous INTEGRATION 1,2 Dr Elizabeth Raymond Brown provides an update on the latest Optimal tissue integration qualifications. advancements in aesthetic lasers Eva Escofet is a highly established nutritional Intelligent rheology design 45 The Importance of Skin Texture therapist with 12 years of clinical experience. She Dr Sharon Crichlow discusses the importance of skin texture in owns a multidisciplinary clinic in Surrey, and is also co-owner of Aneva Nutraceuticals, specialists in aesthetic treatment nutraceutical products. 49 Case Study: Treating Filler Complications Dr Elizabeth Raymond Brown is a laser Frances Turner Traill on her experience of managing a dermal filler specialist, currently academic lead for the MSc. in Non-Surgical Facial Aesthetics (NSFA) at UCLan, complication Preston, and a professional trainer with an array of laser experience. 51 Treating the Perioral Area Dr Sharon Crichlow works as a consultant Dr Souphiyeh Samizadeh details the treatment of perioral ageing dermatologist at the Skin to Love Clinic in St. 54 Advertorial: AestheticSource Albans, UK. Her interests include treatment of acne scarring and pigmentary disorders commonly seen A chance to find out more about the scientific research behind in patients with skin of colour. NeoStrata skincare Frances Turner Traill is an independent nurse 55 Abstracts prescriber and runs her own aesthetic clinics in Injectable Product of the Year Scotland. An active board member of the British A round-up and summary of useful clinical papers Association of Cosmetic Nurses (BACN), she leads the Scottish Regional Group’s educational meetings. IN PRACTICE Dr Souphiyeh Samizadeh is a dental surgeon with a special interest in aesthetic medicine. 57 Seasonal Marketing She is an honorary clinical teacher at King’s Charlotte Moreso looks at the best methods of creating a summer College London and clinical director of Revivify London clinic. marketing campaign Contact Merz Aesthetics 61 Building Patient Loyalty NEXT MONTH NOW and ask for Belotero NEW • IN FOCUS: Lifting and Tightening • CPD: Vitamin A Pam Underdown outlines useful strategies for retaining patients • Treating the Gluteus Maximus • Review of Electronic Tel: +44 (0) 333 200 4140 64 Handling a Legal Complaint Record Keeping Systems Email: [email protected] Dr Askari Townshend shares his experience of dealing with a legal complaint 66 In Profile: Constance Campion Entry for the Aesthetics We talk to aesthetic nurse Constance Campion about her passion for Awards opens May 1st. the anti-ageing specialism The ﬁ ller you’ll love 68 The Last Word: Photography Full list of categories Dr Steven Dayan argues for patient awareness around image distortion in next month’s issue

1. BEL-DOF3-001_1. Belotero® technology, March 2014. 2. Tran C et al. in vivo bio-integration of three Hyaluronic Acid ﬁ llers in human skin: a histological study. BEL202/0315/LD Date of preparation: March 2015 March of preparation: Date BEL202/0315/LD Dermatology DOI: 10.1159/000354384. www.belotero.co.uk Subscribe to Aesthetics, the UK’s leading free-of-charge journal for medical Subscribe to Aesthetics aesthetic professionals. Visit aestheticsjournal.com or call 0203 096 1228

MZ078 A4 BELOTERO ADVERT BEL2020315LD.indd 1 16/03/2015 11:27 NeoStrata: Scienti fi cally advanced, clinically proven dermatologist developed skincare to target specifi c pati ent needs. NeoStrata professionals: Leading medical aestheti c clinics. Practi ti oners requiring eff ecti ve skincare. Building successful business soluti ons. Aestheti c Source: Multi award winning UK distributor. World renowned proven skincare opti ons for professional aestheti c clinics. We deliver: Comprehensive training and support. Focussed marketi ng and PR campaigns. Skincare you and your clients will love:

NeoStrata Skin Acti ve NeoStrata Skin Acti ve Aestheti c Source Best Cosmeceuti cal Range Best Cosmeceuti cal Range 2014 Best Customer Service 2014 WINNER in both 2013 & 2014

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

A4-NeoStrata-No Show.indd 1 26/02/2015 15:05 Editor’s letter

The highly anticipated ACE 2015 was truly a proud moment for us, proving that the scientific and non- weekend came and went, and it was brilliant. clinical agendas that we had assembled succeeded in providing We have had the most positive feedback ever, incredibly engaging and high-quality learning for a huge range of so my thanks to all of you for attending and interests and professional needs. If you missed out this year, see participating to make ACE the best conference pages 18-21 for a review of some of the event’s highlights. Amanda Cameron of its type. The free education on offer proved With many exhibitors booking immediately for next year’s event, Editor extremely popular, with packed Expert Clinics and speakers already planning exciting sessions for the educational NeoStrata: and Masterclasses featuring live demonstrations agenda, work for ACE 2016 is already underway. from top practitioners, while the Business Track offered imaginative So what do we look forward to next? This issue features some Scienti fi cally advanced, clinically and effective ways for augmenting business. Delegates also had the great topics that continue our focus on high quality education – proven dermatologist developed skincare chance to meet with suppliers and distributors who shared exciting these include the second part of Dr Sotirios Foutsizoglou’s weight to target specifi c pati ent needs. innovations, and the exhibition floor was a hub of activity throughout management CPD article. This detailed feature is relevant to all the weekend. The new format Conference programme attracted great practitioners as, in caring for our patients’ health and wellbeing, we numbers of delegates seeking thorough, interactive learning from deal with weight matters and body issues on a daily basis. This month NeoStrata professionals: international speakers. The four modules provided comprehensive is our Smile issue, and we explore this area in a roundtable discussion guides to key areas of medical aesthetics, utilising novel approaches from leading practitioners on their best techniques for treating the lips Leading medical aestheti c clinics. for maximising engagement, with the voting technology stimulating (p. 23) and in a detailed overview by Dr Souphiyeh Samizadeh into Practi ti oners requiring eff ecti ve skincare. some interesting debates. perioral ageing (p. 51). I would also like to remind you that entry is open , Building successful business soluti ons. A special thanks must go to Mr Dalvi Humzah who, as chair of the ACE for the Aesthetics Awards as of May 1 and you will be able to find all Steering Committee, played a huge part in the seamless execution the categories and entry information in the next issue of Aesthetics. and high quality of the educational programme. Let us know what you think of this issue by tweeting Aestheti c Source: To see packed sessions right up to the close of the event on Sunday @aestheticsgroup or emailing [email protected] Multi award winning UK distributor. World renowned proven skincare opti ons for professional aestheti c clinics. Editorial advisory board We are honoured that a number of leading figures from the medical aesthetic community have joined Aesthetics Journal’s We deliver: editorial advisory board to help steer the direction of our educational, clinical and business content Dr Mike Comins is fellow and former president of the Dr Raj Acquilla is a cosmetic dermatologist with over 11 years Comprehensive training and support. British College of Aesthetic Medicine. He is part of the experience in facial aesthetic medicine. UK ambassador, global cosmetic interventions working group, and is on the faculty for KOL and masterclass trainer in the cosmetic use of botulinum toxin Focussed marketi ng and PR campaigns. the European College of Aesthetic Medicine. Dr Comins is also and dermal fillers, in 2012 he was named Speaker of the Year at an accredited trainer for advanced Vaser liposuction, having the UK Aesthetic Awards. He is actively involved in scientific audit, Skincare you and your clients will love: performed over 3000 Vaser liposuction treatments. research and development of pioneering products and techniques.

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

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

Dr Christopher Rowland Payne is a consultant Dr Sarah Tonks is an aesthetic doctor and previous dermatologist and internationally recognised expert in cosmetic maxillofacial surgery trainee with dual qualifications in both dermatology. As well as being a co-founder of the European medicine and dentistry. Based at Beyond Medispa in Harvey Society for Cosmetic and Aesthetic Dermatology (ESCAD), he was Nichols, she practises cosmetic injectables and hormonal- also the founding editor of the Journal of Cosmetic Dermatology based therapies. and has authored numerous scientific papers and studies.

PUBLISHED BY FOLLOW US EDITORIAL ADVERTISING @aestheticsgroup Chris Edmonds • Managing Director Hollie Dunwell • Business Development Manager T: 0203 096 1228 | M: 07867 974 121 T: 0203 096 1228 | M: 07557 359 257 Aesthetics Journal [email protected] [email protected] Suzy Allinson • Associate Publisher Sadia Rahman • Customer Support Executive Aesthetics 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 Sadia Rahman; [email protected] Betsan Jones • Assistant Editor Helen Batten • Events Manager NeoStrata Skin Acti ve T: 0207 148 1292 | M: 07741 312 463 T: 0203 096 1228 | [email protected] © Copyright 2015 Aesthetics. All rights reserved. Aesthetics NeoStrata Skin Acti ve Aestheti c Source Best Cosmeceuti cal Range [email protected] Kirsty West • Assistant Events Manager Journal is published by Synaptiq Ltd, which is registered Best Cosmeceuti cal Range 2014 Best Customer Service 2014 WINNER in both 2013 & 2014 Chloé Gronow • Journalist T: 0203 096 1228 | [email protected] as a limited company in England; No 3766240 T: 0207 148 1292 | M: 07788 712 615 DESIGN [email protected] Peter Johnson • Senior Designer Meeting the needs of your business, Hazel Murray • Journalist T: 0203 096 1228 | [email protected] T: 0207 148 1292 | M: 07584 428 630 Chiara Mariani • Designer DISCLAIMER: The editor and the publishers do not necessarily agree with the views delivering high satisfaction to your patients [email protected] T: 0203 096 1228 | [email protected] expressed by contributors and advertisers nor do they accept responsibility for any errors in the Call us on 01234 313130 [email protected] www.aestheticsource.com transmission of the subject matter in this publication. In all matters the editor’s decision is final.

A4-NeoStrata-No Show.indd 1 26/02/2015 15:05 @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

Awards Talk #Aesthetics Entry for the Aesthetics Awards 2015 opens in May Follow us on Twitter @aestheticsgroup From May 1, practitioners, clinics, distributors and manufacturers are invited to submit their entry for the prestigious Aesthetics #Safety Awards ceremony, to be held in London on December 5, 2015. Good Surgeon Guide @goodsurgeon Just because he/she is a #plasticsurgeon doesn’t mean he/she is Last year’s event saw more than 500 members of the medical an expert in every single procedure. Do your #research well. #gsg aesthetics profession celebrate the great achievements of our speciality in 2014, in an elegant ceremony and an evening of #Learning entertainment which proved a huge success amongst attendees. Dr. Ahmed Al-Qahtani Consultant plastic surgeon Mr Dalvi Humzah, who won the Training @aqskinsolutions Initiative of the Year award, said, “The Aesthetics Awards is one of the During our #AQ #growth #factor premier awards events for aesthetics, recognising excellence and the training in #Indonesia. Great turnout. outstanding achievements of practitioners, surgeons and suppliers.” The Aesthetics Awards categories cover all aspects of the specialty, #Media including awards for Medical Practitioner of the Year, Best Customer Emma Bedford @MissEmmaBarlow Service by a Manufacturer or Supplier, Treatment of the Year and Good to see the fabulous @drtapanp giving advice on burns Product Innovation. treatment on tonights @BBCCrimewatch. Feel for the poor Each category submission requires a thorough and high-quality victims of acid attacks. written entry that meets the criteria for submission. Entries are then #Journal judged by an expert panel or decided upon via a combination of Medico Beauty @medicobeauty judging and votes from industry professionals. Details for each @aestheticsgroup I just got my copy! Look forward to reading all category will be available on the Aesthetics Awards website. the great articles this evening. Can’t wait for #ACE2015 Dr Maria Gonzalez of the Specialist Skin Clinic in Cardiff, and winner of the Sinclair IS Pharma Award for Best Clinic Wales, said, “As the #Aesthetics medical director of a new clinic, it was a moment of great pride to Dr Rita Rakus @DrRitaRakus receive an Aesthetics Award. The entire process was motivating for We featured in the Aesthetics magazine from a SkinCeuticals the team of clinic staff whose work was rewarded by this success. All event we attended in February. in all, an excellent night.” #SkinCeuticals #aesthetics This year, two new categories have been added to the line up. Awards will be presented to the Best Clinic Group made up of three or more #Training clinics, and the Best Clinic Group comprising ten clinics or more. Luisa Scott @Nurse_Luisa Sponsors for three categories have already been announced. Great @EllanseUK training day with @Dr_AskariT and the team Sterimedix will support the Injectable Product of the Year, whilst #Interview NeoCosmedix will once again sponsor the award for Association/ Lorna Bowes @LornaBowes Industry Body of the Year. HealthXchange will continue to support The With lovely Betsan of @aestheticsgroup after interviewing Leigh Janeé Parsons Award for Sales Representative of Year, in memory of Ann Catlin and Cathy Mueller of NeoStrata Co. Great questions. their colleague and her outstanding work within the industry. #skinfitness The eagerly anticipated event will be held at the Park Plaza Westminster Bridge Hotel in Central London. #Equality Submit your entries via www.aestheticsawards.com from May 1. PHI Clinic @PHIclinic Let’s hear it for the girls @PHIclinic. How blessed we are to have such talented, brilliant women on board #InternationalWomensDay Standards

#Education BSI ‘Aesthetic Non- Dr Chrysopoulo @mchrysopoulo @cpelletiere @DrRothaus No single “best procedure” for everyone. Surgical Standard’ update Patient education re ALL options key to ensuring fully informed decisions A public consultation on the draft European Standard for non- #Clinic surgical aesthetic treatment has begun. Dr Ravi Jain @DrRaviJain Covering a wide range of non-invasive treatments, the new standard, Looking forward to a day of male titled, ‘Aesthetic medicine services – Non-surgical medical procedures cosmetic surgery @Riverbanks. (EN 16844)’, aims to address a variety of aesthetic procedures. We have #gynecomastia & Vaser all Carried out across Europe, professional organisations and the general day #surgeonselfie public can comment via the British Standards Institute, who are responsible for the UK consultation. Open until May 4, 2015, the public can have their say on www.bsigroup.com.

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015 aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics

LED Phototherapy News in Brief Aesthetic Technology launches 3D-lipo opens Kuwait head office Aesthetic device manufacturer 3D-lipo Dermalux Tri-Wave Compact device has launched a new head office in Kuwait. The office, which will focus Aesthetic device manufacturer Aesthetic Technology has added a new product to on providing support to their Middle its Dermalux LED Phototherapy range. The Dermalux Tri-Wave Compact device uses Eastern distributors, has six 3D-lipo non-thermal light energy to naturally stimulate skin rejuvenation and aid skin conditions, treatment rooms, a reception area and aiming to safely and effectively treat a wide range of indications; including ageing, acne offices to handle distribution in the and pigmentation. The non-invasive device delivers narrowband wavelengths at optimised region. Managing director of 3D-lipo Roy intensity and dose with red 633 nm, blue 415 nm and new infra-red 830 nm. According to Cowley said, “It offers a fantastic bridge the company, the Dermalux Concurrent Modality Treatment feature allows for individual to conquer expansion into the entire wavelength treatments, or simultaneous use of all wavelengths to accelerate results and middle-eastern territory.” reduce treatment visits. Using the latest LED technology, the manufacturer claims the device is also a significant development in the treatment of inflammatory skin conditions. Seppic launches first cosmetic Managing director of Dermalux Huw Anthony said, “With our development programme ingredient derived from now in full swing and with more systems to come over the next 18 months, plus our recent their macroalgal cell culture launch into the export markets, we are excited by what the future may hold for Dermalux.” innovations The Dermalux Tri-Wave Compact device is available in the UK from April. BiotechMarine, a subsidiary of specialty ingredient developer Seppic, are to Patient safety launch Ephemer in April at the in- cosmetics trade fair in Barcelona. BAPRAS launches patient safety The new ingredient is a gametophyte extract taken from macroalgal cells, campaign extracted at an ephemeral stage in the life cycle of Undaria Pinnatifida seaweed. The British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS) has Seppic claims the macroalgal cells launched a campaign to persuade patients to think carefully about aesthetic treatment. accumulate anti-oxidant molecules, BAPRAS created the campaign ‘Think Over Before You Makeover’ in response to results creating an ingredient that can be of their research into cosmetic surgery choices. The major study indicated that two million manipulated for use in skin protection. people in the UK are considering or will undergo cosmetic surgery in the next year. It showed that, on average, a quarter of patients don’t check the credentials of their surgeon, Jan Marini launches new face and while a fifth aren’t aware of the risks associated with the procedure they are undertaking. neck creams The results further suggested that a fifth aren’t clear on the potential outcomes of their Skincare company Jan Marini has procedure before going ahead. BAPRAS president and consultant plastic surgeon Nigel added two anti-ageing creams to its Mercer said, “Cosmetic surgery is not something to be taken lightly and yet thousands of product portfolio. The updated Age people are putting themselves at serious risk by rushing into major procedures recklessly, Intervention Face Cream and the new without consideration for their own safety.” Members of BAPRAS hope that this campaign Marini Juveneck aim to reduce the signs will ensure patients carry out the appropriate research on prospective treatments and of ageing on the face and neck. Director prospective practitioners, before making the decision to undergo surgery. Mercer added, of Outline Skincare Clinic Mary White “‘Think Over Before You Make Over’ is not here to promote cosmetic surgery; we recognise said, “Harnessing the use of peptides, that thousands of people will choose to have surgery this year and we want all these people along with Vitamin E and hyaluronic acid to read our campaign advice so they can make informed choices and protect themselves to deeply hydrate, Marini Juveneck is from bad practice.” giving my ladies a noticeable lift.”

Fat reduction Molecular-based skincare products launched New statistics reveal surge in non- Aesthetic practitioner Dr Gabriela Mercik has launched a molecular-based facial surgical fat reduction procedures skincare line. The products include the Advanced Molecular Face Mask and The American Society for Aesthetic Plastic Surgeons (ASAPS) has announced that Magic Beauty Face Lift, which aim to non-surgical fat reduction procedures rose by 43% in 2014. Since they began recording moisturise, hydrate and replenish skin. figures, it’s the first time that more than 100,000 non-surgical fat reduction procedures were After conducting research into the performed in one year. ASAPS president Michael Edwards said, “Non-surgical fat reduction indications of molecular water, Dr Mercik is a new frontier in the realm of cosmetic procedures. The rise in its popularity is indicative of claims she has created a formulation that the public’s desire for non-surgical alternatives in lieu of their invasive counterparts.” will protect the skin from ageing due to However, he added, “Not everyone is a candidate for non-surgical treatment as well. Many its hydrating properties. will still be better served from a surgical approach to include liposuction.”

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015 @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

Television Industry BBC commissions series Actavis completes based on Harley Street acquisition of

The BBC has commissioned a three-part series based on Harley Street’s medical Allergan neighbourhood and history. The programmes, called ‘Inside Harley Street’, will give viewers the opportunity to Allergan has announced that the pending learn about the world of private medicine and explore the types of treatments avail- acquisition of the company by Actavis is now able today. Directed by ‘Welcome to the World of Weight Loss’ director Vanessa complete. The news comes following the confirmed Engle, the programme will be broadcast on BBC Two, and each episode will feature clearance by the European Commission three days interviews with both practitioners and patients. Episode one will look at private earlier, which satisfied the final regulatory conditions healthcare, the second will focus on aesthetic medicine and the final episode will to the closing of the pending acquisition. address complementary and alternative medicine. The confirmation of completion rounds up a Kim Shillinglaw, controller of BBC Two and BBC Four, said, “With Vanessa Engle’s $70.5 billion cash and equity deal, which began trademark warmth and humour, this series takes us behind the closed doors of this in November 2014, combining the companies to very British institution to give a revealing insight into some very modern concerns, create one of the world’s top 10 pharmaceutical from the role of private healthcare to the lengths we’ll go to for the latest cosmetic companies by sales revenue. The companies have and alternative treatments.” predicted combined annual pro forma revenue of more than $23 billion in 2015. “The combination Prescribing of Actavis and Allergan creates an exceptional global pharmaceutical company and a leader in a HealthXchange launches new industry model – Growth Pharma,” said Brent Saunders, CEO and president of Actavis. “Anchored online pharmacy by world-renowned brand franchises, a leading global generics business, a premier pharmaceutical Medical supplier development pipeline and an experienced HealthXchange Pharmacy has management team committed to maintaining highly launched an online prescribing efficient operations across the organisation, we system. The new service will are creating an unrivaled foundation for long-term allow practitioners to process growth.” He added, “With the acquisition now prescriptions online, create and complete, we will immediately begin implementing sign orders, pay online and our comprehensive integration plans to ensure that have the ability to re-order using we leverage our strengthened global organisation a one-click process. Once an to generate sustainable organic earnings growth order is made, it will be stored from our newly expanded base, and continue in a computer system to make future orders more efficient and build an order our ascent into the fastest-growing and most history. HealthXchange claim the system is suitable for sole practitioners as well as dynamic growth pharmaceutical company in global larger corporate businesses. The e-pharmacy is compliant with the Medicines and healthcare.” It has also been announced that Actavis Healthcare Products Regulatory Agency (MHRA) regulations and will be available to intend to use ‘Allergan’ as their corporate name. use on any mobile device. Managing director of HealthXchange Pharmacy Karen Hill Saunders said, “By adopting the Allergan name for said, “For too long practitioners, clinic owners and pharmacies have had to rely on the corporation we will ensure that our corporate paper-based prescribing and be at the mercy of the fax, scanner or email account.” identity reflects the dramatic evolution of our The system is available now. company within the pharmaceutical industry.”

Crystalys is a new calcium hydroxyapatite based ller with an amazing cost to bene t ratio. This new Crystalys ller has long lasting e-ect; it is based on synthetic Calcium Hydroxyapatite Sterile Gel Injectable implant for soft tissue augmentation calcium hydroxyapatite and is completely biodegradable. Indications for use: Crystalys is intended for deep and sub dermal tissue augmentation at the facial area. It is used for general restoration of the face, and speci-cally for -lling deep wrinkles and lines. www.luminera-derm.com Maayan Haim LTD, 20 Trumpeldor st., Beit Dagan, Israel, For Panaxia LTD - Tel: +972 72 2744144 Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015 aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics

Brand development Skincare 5 Squirrels adds products Medico Beauty to Your Signature Range launches

Private label cosmeceutical supplier LUNA Fusion 5 Squirrels has added three new products to its Your Signature Range Skincare distribution company Medico Beauty has portfolio. The additions to the existing launched a treatment that combines the CosMedix five-product line are C-10, Refine and skincare range with the Foreo Dual T-Sonic Wave. Protect 45. The C-10 is a Vitamin C LUNA Fusion is a new skin treatment protocol aimed serum containing 10% L-ascorbic at the treatment of dry, sensitive and rosacea skin. The acid, which the company says is essential to achieving optimal skin health. Refine Foreo Dual T-Sonic Wave is a hand-held device that is an intensive eye cream that contains Vitamin E and Lactic Acid, which aims to pulsates 8,000 times per second. It sends sonic waves improve the appearance of periocular ageing. Protect 45 is an SPF 45 daily tinted across the body, with the purpose of cleansing the moisturiser. The product includes a small amount of mineral makeup, which conceals treatment area. The CosMedix formulations, used in any undesired SPF residue without making a significant change to the natural skin conjunction, utilise a process called Chiral Correction complexion. Co-founder of 5 Squirrels Gary Conroy explains that the products to purify active ingredients and aid in the treatment of contain clinically proven and tested ingredients, which have been developed with sensitive skin. Medical aesthetician Caroline McLean leading UK healthcare professionals. The range can be branded specifically to your of La Belle Forme clinic in Glasgow offers the LUNA clinic, which the company claims reduces the burden of development and regulatory Fusion treatment to her patients. She said, “In our clinic issues. Conroy said, “The importance of brand development in clinical practice has we often meet patients who experience sensitive skin never been so crucial as the UK medical aesthetics market enters a more mature and rosacea. The LUNA Fusion fully integrates with era. UK leading clinics have adopted this approach and have seen huge benefits in all advanced services and supports the successful patient retention, recruitment and brand recognition.” resolution of these conditions.”

Dermal filler Radiofrequency Study suggests polycaprolacton- Viora launches V20 based dermal filler induces multi-technology neo-collagenesis platform

Aesthetic distribution company AZTEC Services has announced the launch of the V20 multi- technology platform. The V20 consists of light and radiofrequency technologies, which enable practitioners to offer patients multiple treatment options using A new study suggests that polycaprolaction-based (PCL) dermal fillers may be one system. able to induce neo-collagenesis when injected into human tissue. The three handpieces The study aimed to show that Ellansé, a novel PCL-based dermal filler by Sinclair on the device include Pharma, would be able to revive collagen in human tissue. the V-IPL, which aims to enhance IPL treatments, the Previous clinical studies indicated that Ellansé was capable of encouraging neo- V-ST to aid skin tightening treatments, and the V-FR, collagenesis in rabbit tissue. The new pilot study, however, published in the Journal which aims to improve fractional radiofrequency of Cosmetic and Laser Therapy, suggested that the filler may also be capable of treatments using Viora’s SVC technology. inducing neo-collagenesis when injected intra-dermally into human tissue. Board-certified plastic surgeon Dr Daniel Man uses The study monitored two patients who undertook a temple-lifting procedure using the device in his clinic. He said, “With different Ellansé, injected intra-dermally into the tissue. Biopsies were analysed to show the technologies within one system, and Viora’s use improvement of collagen formation around the PCL particles, which, according to the of combination protocols, the treatment of difficult researchers, maintained their original state 13 months post treatment, and showed conditions such as stretch marks and scars, can be that tissue migration of the PCL particles had not occurred at this stage. addressed with more efficacy and success.”

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015 @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

Dermal filler Events diary FDA recommends expanded 10th – 12th April 2015 use of Radiesse for hand International Master Course on Ageing Skin – IMCAS Annual Meeting, China augmentation www.imcas.com/en/china2015/congress The Food and Drugs Administration (FDA) Medical Devices Advisory 30th April – 2nd May 2015 Committee has announced a majority vote in recommending the expanded Cosmetex 2015 Conference, Melbourne use of Merz Aesthetics’ Radiesse dermal filler to include volume correction www.cosmetex.org in hand augmentation. The FDA’s General and Plastic Surgery Devices Panel of the Medical Devices Advisory Committee voted the hand treatment as safe, 14th – 19th May 2015 with a majority of 11 to three. According to clinical studies conducted by Merz over 12 months, it was indicated that Radiesse had produced a statistically American Society for Aesthetic Plastic significant improvement of volume loss in the hands after three months, Surgery (ASDS) Annual Meeting, Montréal remaining stable over time, with effectiveness after treatment similar to that www.surgery.org/downloads/microsite/ seen following initial treatment. meeting2015/welcome.php Merz further claimed that the results showed no detrimental effect on hand function post-treatment, and no new safety issues had been identified. 7th – 9th July 2015 “The data presented show Radiesse is safe, effective and non-invasive, and British Association of Dermatologists we support its approval process,” said Dr Lawrence Green, a board-certified (BAD) Meeting, Manchester dermatologist, speaking on behalf of the American Society for Dermatologic Surgery Association (ASDSA). The panel further voted that the available data www.bad.org.uk/events/annualmeeting was sufficient to characterise hand function post injection, though it was suggested that more hand function tests for daily living should be undertaken Topicals in future studies. They also recommended that the photographs from the study should be evaluated by unbiased, blinded healthcare professionals, rather than No-needle on-site. In addition to including long-term study data on those with severe hand- hyaluronic acid filler volume loss, the panel advised that the study guidelines in the future should evaluate patients who receive surface treatments in order to determine where treatment launched applicable time lags between treatments should exist. In 2006, Radiesse received FDA approval for the use of the dermal filler in treating indications of A Swiss-developed subdermal implantation for restoration and/or correction of the signs of facial topical gel filler has been fat loss in people with HIV, as well as for the correction of moderate-to-severe launched in the UK with facial wrinkles and folds. the aim of plumping skin without the use Cellulite of needles. Fillerina comprises a blend of six hyaluronic acids, which aim Exilis Elite receives FDA to increase tissue volume in cheeks and lips. The gel also contains peptides that aim to stimulate collagen clearance for cellulite treatment production and soften the appearance of fine lines and wrinkles. The Food and Drugs Administration (FDA) has approved Exilis Elite as a The at-home kit contains 14 doses of 2ml gel filler, treatment for the temporary reduction of cellulite. 14 doses of 2ml nourishing film and two precision The non-surgical radiofrequency device from BTL Aesthetics has been applicators, which can be used to aid successful primarily used to reduce wrinkles and tighten skin. The device uses application of the topical gel. According to Labo, the monopolar technology to heat the skin, which aims to remodel, tighten and Fillerina manufacturers, the treatment should be used firm collagen tissues. With the new FDA approval, practitioners will now also once daily for 14 days. be able to use the technology as a cellulite reduction device. Three different grades of gel strength are available, UK-based practitioner Dr Kannan Athreya said, “The fact that the Exilis Elite as well as a range of creams in lower strength doses has received FDA approval as far back as 2009 for non-surgical treatment of than the gel. Dr Elisabeth Dancey of Bijoux MediSpa wrinkles, and then this year for the reduction in the appearance of cellulite, said, “I recommend Fillerina to my patients for two is a testament to its power and reliability to provide consistent and reliable reasons. For use if they have a fear of needles, or for results.” a skin ‘boost’ between their botulinum toxin or filler Scott Mills, the US vice president of sales at BTL Aesthetics, added, “We are treatments.” Following a double blind, randomised committed to working closely with our partners in the aesthetics community clinical trial, results have been proven to be effective to build on the initial results and continue to improve our capabilities for and last between two and a half to three months. treating cellulite.”

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015 aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics

Aftercare Episciences launches new post-procedure care kit 60 Roy Cowley, founder and managing Skincare manufacturer Episciences has launched an aftercare range director of 3D-lipo Ltd: for patients who have undergone moderate to deep skin rejuvenation procedures. Why did you create 3D-lipo? The Essential Recovery Kit will be added to the Epionce skincare range and I regard the 3D-lipo device and aims to address skin irritation post-procedure, soothe the skin to minimise brand as a culmination of my stinging, boost hydration and reduce downtime. 25 years of experience within The manufacturer claims the ‘take-home’ care kit will address patients’ needs the industry. I strove to create after treatments such as micro-needling, fractionated laser and mid-depth to something fundamentally different, results driven and affordable to both deep chemical peel treatments. Priming Oil, Enriched Firming Mask and Medical clinic and customers. Our point of difference is Barrier Cream are included in the kit. CEO of Episciences Dr Carl Thornfeldt that we do not stand behind a trend that would said, “After a deeper resurfacing procedure, the skin is so sensitive and make us directly comparable to competition vulnerable. Most of the products on the market do not fully address what the in the market, but created a multi-technology skin needs to heal quickly, completely and without negative side effects such as platform that meant that we had the ability to stinging, long-term sensitivity or even dark spots.” The Essential Recovery Kit is treat fat removal, loose skin and cellulite from available in the UK now. one amazing machine. The key to this was also to ensure that all individual technologies were Industry comparable or better than that of stand-alone devices. Once I had achieved all of this, we VENN Healthcare launches stood behind our differences, being the unique 3D approach, and embarked on a national PR awareness campaign. Lutronic in UK What do you attribute to 3D-lipo’s vast success? VENN Healthcare has acquired the UK-distribution rights to global aesthetic There are several factors that have contributed to device company Lutronic. our success, those being fantastic results, multiple The main products in the distribution company’s initial offering will include treatment applications and affordability. These microneedling radiofrequency device Infini, long-pulsed Alexandrite and Nd:YAG are the foundations. However, without a doubt laser Clarity, and dual-pulsed Q-switched Nd:YAG laser Spectra XT. the success built from these foundations is wholly Managing director of VENN Healthcare Jim Westwood said, “Lutronic is not only down to the massive national media exposure challenging competitors, but in some instances we believe the systems offer that the brand has achieved. This has highlighted better results and a more versatile device for customised treatments. As we our results and point of difference, creating massive awareness not only within our industry know, the aesthetic market is growing at a rapid rate and with patient demand on but also to consumers nationwide. the rise, we enter the UK market in a strong position with a range of high quality, proven systems.” How does 3D-lipo support its customers? As a company we pride ourselves on our Skincare support, which at times has been difficult due to the vast expansion in the UK and overseas. It Scandinavian Skincare all starts with great training and local marketing assistance and continues with our constant Systems UK launches new efforts to gain national exposure behind our unique devices, which in turn drives patients skincare range through our customer’s doors from our clinic finder on our website. During the week that Amy Childs launched 3D-lipo in her own clinic, Scandinavian Skincare Systems UK has launched MÖ Scandinavian we were getting more than 3000 hits on our Cosmeceuticals, a range of products that includes professional strength peels. website per day from the social media activity According to the company, the cosmeceutical range targets skin on a molecular and national media articles from customers level, speeding up the cell renewal process. hungry for the 3D-lipo treatment. Our branding The company’s flagship product is the Stem Cell Corrector, which uses the stem and USP ensures that it is only 3D-lipo cells of a Swiss apple to aim to regenerate cells in patients’ skin. customers that benefit from this support. CEO of Scandinavian Skincare Systems Paul Olavesen-Slabb explained that the formulations are clinically tested to reduce wrinkles, improve elasticity, enhance This column is written and supported by collagen production, balance sebum properties and smooth irritated skin. The new range is paraben-free, natural and organic, and vegan certified with no animal ingredients. The products are available to aesthetic medical professionals via the company’s online shop, which is closed to the general public.

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015 @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

Data Associations Survey indicates one in five US BACN announces women intend to have cosmetic new board member

treatment The British Association of Cosmetic Nurses A survey has suggested that one in five women are currently pursuing or (BACN) has announced intending to have cosmetic treatment. Conducted on behalf of RealSelf by Zeitgeist that former Wigmore Research, the survey comprised 5,053 women in the US between 18 and 64 Medical chairperson years old. It explored the trends of the US market for beyond-the-counter beauty David Hicks will take procedures and the potential for expanding the industry. a position on their The results found that of the women surveyed, one in five are currently pursuing board. A pharmacist by or planning to have cosmetic surgery. During the survey, it was also indicated profession, Mr Hicks actively supported nurses at that of 87% of women who were unhappy with at least one area of their body, the Wigmore Medical, and the BACN expressed their trend to seek cosmetic treatment has risen by more than 200%, with these women delight at his appointment. representing an estimated market of more than $75 billion. Of those who were willing The move has been announced among several to seek treatment beyond the retail floor, 62% would also consider surgery. The changes currently happening at the BACN, which 24% of women who are planning for less invasive treatment represent an estimated includes an office move to Bristol. market of $12 billion. Another area explored in the survey was motivation, which Sharon Bennett, BACN chairperson, said, “He stated that 65% of women wanted to feel more comfortable with themselves, whilst brings with him a pair of safe hands, a wealth one third (29%) were also considering cosmetic work due to a milestone life event. of experience, and will strengthen the current “While the total market has previously been calculated by the procedures performed committee with his knowledge of our specialist in the past year, we can see that the total addressable market is actually far greater,” area of medicine and his business acumen.” said Tom Seery, CEO of RealSelf. “As cosmetic procedures continue to become Current BACN board members supported the mainstream, millions of women are overcoming social stigma to pursue cosmetic move unanimously. Of his new position, Mr Hicks changes they have been researching, often for years.” said, “I am honoured to be part of the BACN.”

R&D Report since 2000. The approach at Pringy is a holistic one. “One of the big strengths we have in Pringy is the proximity of the R&D and Production at Pringy manufacturing,” explains senior general director Claudie Allaire. “This proximity provides a great sense of collaboration, reactivity Aesthetics visit the production site and flexibility.” Inspecting this notion closer, director of engineering Pascal Brice notes that, in fact, three worlds combine together at and R&D hub for Allergan’s cross- Pringy, “Here we are manufacturing a medical product, whereas linked family of hyaluronic acid the syringe is a pharmaceutical device, yet the packaging belongs dermal fillers to the luxury industry.” As a pharmaceutical company, Allergan has five plants across the world – in Texas, Costa Rica, Brazil, The Allergan Medical site in Pringy, France, was acquired in 2007. Ireland and France – and more than 10,000 employees. With the Currently, it houses 240 employees, 33 of which carry out the confirmation of an acquisition by Actavis in place, this network vital research and development work that has secured Allergan’s is set to expand. A theme of continual expansion is evident in place as one of the forerunners in the manufacturing and Pringy, where plans are in place to increase capacity and automate distribution of dermal fillers. Pringy is what Allergan employees processes in order to increase quality control; next year they will refer to as the ‘centre of excellence’. This is because the site in introduce a state-of-the-art camera system to inspect syringes. France works as the base for all of Allergan’s manufacturing and “We will be the first pharmaceutical company to inspect syringes R&D activity for Juvéderm – the company’s diverse range of with gel using technology,” says Brice. This type of approach aims cross-linked, hyaluronic acid dermal fillers. In its two neighbouring to eliminate human error, he says, and it is this approach of careful buildings, the site has produced around 28 million syringes monitoring and continual development of technologies that puts the manufacturing and development of the Juvéderm range in line with regulatory standards closer to that of the pharmaceutical requirements for prescription-only- medicines (POMs). The mission at Pringy, emphasises Brice, is to exceed customer expectations and quality control is evidently a key term. “We are proud of our strong commitment to quality which influences everything we do,” says Allaire. “From sourcing our ingredients, to manufacturing through to our suppliers – it’s all designed to deliver the highest quality product possible.”

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015 Unlimited Options. One Easy Choice 1 Platform. 70 FDA Approved Treatments.

Featuring ClearLiftTM celebrity’s choice: “Hollywood Facelift”

HarmonyTM Laser360° The most complete anti-ageing innovation

IMPACTTM Deep Ultrasound clinically proven to improve skin texture including lines, wrinkles and scars

See us at Stand B27

25th & 26th April

0845 170 7788 www.abclasers.co.uk [email protected] INNOVATION. RESULTS. SUCCESS www.abclasers.co.uk | 0845 170 7788 @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

much debate from the audience as delegates conferred both the RSM ICG-7: International clinical and ethical aspects of gynaecological rejuvenation treatments. Dr Taylor-Barnes said, “The audience was very receptive to my Multidisciplinary Annual presentation and asked me challenging questions. Non-surgical rejuvenation of the female genitalia is often deemed a controversial Meeting, London area in aesthetic medicine development, but all agreed that it will become more mainstream and popular with the average woman More than 130 aesthetic medical in the future as there is a genuine need for these treatments.” professionals attended the Royal The meeting hosted international speakers, including those from Society of Medicine’s Interventional Switzerland and Morocco, and their international knowledge and Cosmetics Group’s 7th International perspective impressed both organisers and delegates. Dr Rowland Multidisciplinary Annual Meeting (RSM Payne commented that Mr Alain Tenenbaum, a Swiss-based plastic ICG-7) on February 27-28. The two-day surgeon, gave a particularly thought-provoking talk on intramuscular Dr Kathryn Taylor Barnes and Dr Kate Goldie following their event featured unique presentations carbolic acid gluteoplasty and gluteopexy, which was supported by presentations from a range of practitioners, who Dr Taylor-Barnes who said his presentation was “most memorable”. discussed everything from treating filler complications to managing Closer to home, UK-based consultant plastic and reconstructive your online reputation. Former president of the European Society surgeon Mr Dalvi Humzah impressed delegates with his anatomy for Cosmetic and Aesthetic Dermatology (ESCAD) Dr Christopher expertise during his ‘Essential anatomy to avoid complications from Rowland Payne chaired a number of sessions, where he aimed to injectables’ presentation. ensure the high level of scientific content was maintained. Following Nurse practitioner and delegate Constance Campion said, “I am the meeting, he said, “It was a really great multi-disciplinary, highly always happy to hear Mr Humzah speak as he is a specialist. Plastic scientific discussion. We had international speakers from all parts of surgeons aren’t always integrated enough into aesthetics, so I the world and a very focused audience – comprising people from the was glad he presented and I fully supported our plastic surgeon cutting edge of aesthetics – interacting and engaging with each other colleagues who were there.” Following the close of conference and the speakers.” Each day was divided into four and five sessions, on the Friday, speakers were invited to a dinner in the Toynbee respectively, between which delegates could discuss their learning Mackenzie ENT Room at the RSM, which Dr Taylor-Barnes described with fellow speakers and attendees. as a “real highlight of the meeting as it took place in such a beautiful On Friday afternoon, general practitioner and aesthetic medicine and prestigious venue”. According to Dr Rowland Payne the meeting specialist Dr Kathryn Taylor-Barnes presented ‘Aesthetic treatments was a huge success and the best measure of this was delegates in gynaecology – casting light “down under”’. This session invited expressing their desire to attend again next year.

science of cosmeceuticals for acne and skin lightening, as well as the The American Academy of science and cutaneous effects of nutraceuticals. One main theme of this session was getting to the core of the clinical evidence behind Dermatology (AAD) Annual a product line – the importance of asking whether there is science- based, published data with reliable sources behind it – as well as Meeting, San Francisco reviewing ways to battle misinformation. Lorna Bowes offers an aesthetic A session by Dr Heidi Waldorf on ‘Aging gracefully’ looked at glimpse of the AAD 2015 annual defining the parameters of ‘graceful aging’ from a consumer versus a medical perspective, making suggestions for therapeutic plans for meeting in San Francisco preventions, rejuvenation and maintenance, including reviewing the San Francisco was always going to attract an impressive number choices and timings of cosmeceuticals, injectable neuromodulators, of dermatologists – this year it was confirmed that the event had soft tissue fillers and various devices for non-invasive rejuvenation. received more than 18,000 registrants. With this number in mind, Perhaps the hottest topic of this year’s annual meeting was robotic it’s unsuprising that three distinct sites were needed for the AAD hair transplants from Artas, which, with 35 million men experiencing 2015 annual meeting; even then its lecture theatres and exhibition hair loss, is a growing area of commercial development. Though halls were full and buzzing. One aptly named ‘Hot Topics’ session balding is itself not harmful, the emotional effects can be both addressed photoprotection, with board-certified dermatologist Dr frightening and traumatising. In discussion was a new system Henry W. Lim (chairman of the department of dermatology at Henry enabling physicians to harvest healthy follicular units in a minimally Ford Hospital in Detroit), warning that although some authorities invasive procedure suggest a little sun exposure is acceptable, “There is no safe dose delivering a healthy, of ultraviolet exposure.” It was further emphasised that, “The regular intact graft. Providing use of photoprotection prevents photoageing and cancers.” Joining a wealth of topics over Dr Lim in the same session was Dr Zoe Draelos, private practitioner the five days, the AAD and consulting professor of dermatology at Duke University, North meeting proved yet Carolina, to discuss the conundrum of cosmeceuticals; bemoaning again a crucial source the lack of dosage information supplied by most manufacturers. This of educational activity same topic resurfaced in the session ‘The Science of Cosmeceuticals within the field of and Nutraceuticals’, with a panel including Dr Draelos looking at the dermatology.

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015 The Multi-Award Winning

New Innovation of The Year Soprano ICETM Alexandrite for unrivalled efficacy & SPEEDTM

The ONLY laser ever to double clear by the FDA

1. All skin types (I-VI)-----

2. Treats sun tanned skin

ONLY SopranoTM will treat ALL year round

See us at Stand B27

25th & 26th April

INNOVATION. RESULTS. SUCCESS www.abclasers.co.uk | 0845 170 7788 Secure Ordering e-prescriptions User Friendly Time Saving @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com Lumenis ResurFX Skin Geeks Image Welcome to your new Workshop, London Skincare Worldwide

Aesthetic practitioners were Launch Party, Brighton Healthxchange e-pharmacy invited to an afternoon of learning, courtesy of Clinic owners and aesthetic international energy-based practitioners met at Stanmer medical company Lumenis, on House, Brighton, for the Skin March 19. Held at the PHI Clinic, Geeks Image Skincare Worldwide Harley Street, the event brought Launch Party on March 16. The together both inexperienced and event introduced three new well-practised laser users. First, Image Skincare products added delegates enjoyed a light lunch and networking session, followed by to the Skin Geeks distribution portfolio, including the ILUMA an introduction to the Lumenis devices and the UK sales team. Intense Brightening Eye Cream, the MAX stem cell masque and Dr Tapan Patel then discussed his experience of using the new the ILUMA Intense Brightening Exfoliating Powder. Attendees ResurFX device. For the laser beginners present, Dr Patel offered were able to test the skincare, whilst education specialist Victoria a beginner’s description of how the system should be used, whilst Hiscock gave a thorough explanation of the science behind the ensuring he also gave an advanced explanation to the more ranges. One attendee, Dr Dev Patel, clinical director of Perfect experienced attendees present. Delegates then participated in Skin Solutions in Portsmouth, said, “Although I’m already familiar an engaging question and answer session, allowing the Lumenis with Image Skincare, I’m always impressed by the clinical research team and Dr Patel to address all concerns from the audience. that goes into creating these products and enjoy coming to these Questions queried patient suitability, modes of treatment, suggested events to learn more.” At the close of the launch party, managing anaesthesia and recommended lengths of time between ResurFX director of Skin Geeks Don Maree said, “Our core value at Skin procedures. Of the meeting, aesthetic practitioner Dr Askari Geeks is science-based education so, for us, this is a must attend Townshend said, “Hearing Dr Patel talk is always a fantastic industry event. We are showcasing our new technology and it’s a opportunity to learn about the nuances of advanced laser treatments. fantastic opportunity for us to meet our clients to update them with Seeing how he’s treating acid burn victims’ scars with the new all the new products.” fractional non-ablative device by Lumenis has been amazing.” PicoWay workshop, Eden Aesthetics business London seminar, London Hosted by Syneron Candela, Eden Aesthetics Distribution international practitioners Secure, online ordering for Healthxchange customers. invited aesthetic practitioners were invited to attend a one- to a one-day business seminar day workshop on the PicoWay Order, sign and pay online with your simple to use e-prescription service. at the Academy of Medical laser at PHI Clinic, London, Creating orders online frees you up to concentrate on what is really important to you... Sciences in London, on on March 6. The day began ...your patients February 26. Welcomed to with an introduction, followed the free seminar with coffee by a detailed discussion and cake, attendees were of the science behind presented with a selection of talks covering various business topics. PicoWay from Dr Jayant Bhawalkar, vice president of research During the two-hour lunch break, they also had the opportunity at Syneron Candela. Attendees were invited to watch tattoo www.healthxchange.com to watch live demonstrations of treatments and test products removal demonstrations in the clinic’s treatment rooms, whilst being discussed. Topics covered included the importance of a qualified practitioners had the opportunity to test the laser. Hamish & register for your e-pharmacy account today clinically proven range with Epioncé, and how to market your brand Mcnair, director of clinical education EMEA at Syneron Candela, for optimum results, courtesy of digital marketing agency Blow discussed clinical protocols and Food and Drugs Administration Media. In the afternoon aesthetic practitioner Dr Mervyn Patterson data before breaking for lunch. In the afternoon, aesthetic demonstrated how to maximise facial lifting with Voluma using a practitioner Dr Tapan Patel performed another live treatment cannula. Of the demonstrations, he said, “I think there were a lot of demonstration, which was followed by practice marketing advice very interested people present, and they’re seeing some cutting and time for questions to round up the day by 4pm. “Venues like edge technology, new ways to combine micro-needling treatments this are really useful, because they’re so big we can communicate and the very latest in quadrapolar radiofrequency skin tightening.” the benefits of this device and this technology to the physician Reflecting on the business talks, attendee Ayse Suleyman said, “It’s community,” said Dr Bhawalker. “Having a forum like this, which is UK WINNER 2014/15 quite informative to know what the next step would be for long- an all-day session, the physicians not only get to hear the science Cosmeceutical of the year term retention of your patients. That’s really important for us as a behind Pico, but really understand why those parameters are business.” important.”

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015 Secure Ordering e-prescriptions User Friendly Time Saving

Welcome to your new Healthxchange e-pharmacy

Secure, online ordering for Healthxchange customers.

Order, sign and pay online with your simple to use e-prescription service. Creating orders online frees you up to concentrate on what is really important to you...... your patients

www.healthxchange.com & register for your e-pharmacy account today

UK WINNER 2014/15 Cosmeceutical of the year @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

ACE 2015 in Review We look at the highlights from the Aesthetics Conference and Exhibition 2015

The Aesthetics Conference and Exhibition (ACE) 2015 has been guest appearance on Saturday from Canadian aesthetic doctor and hailed a huge success following overwhelmingly positive feedback international speaker Dr Arthur Swift, to present two main Conference and requests to attend next year from delegates, speakers and sessions over the weekend, exploring the anatomy of the face and exhibitors alike. treatment with injectables. Reflecting on the sessions, Mr Humzah The conference, held on March 7 and 8 in Central London, was the said, “It was exhilarating, we had great fun with each other and great perfect opportunity for aesthetic professionals to come together over interaction with the audience. There were questions asked on some one weekend and enjoy the vast range of learning and networking interesting and challenging topics. I was delighted to work with Raj, opportunities available at ACE. Tapan and Arthur Swift, and each of us have been able to contribute ACE attracted more than 2,500 visits to watch the 61 outstanding a different perspective.” A key focus was facial anatomy, a concept clinical and business sessions, delivered by 71 speakers throughout which Mr Humzah feels is crucial to safe injection. “I am very keen on the two-day event. With such an extensive offering, ACE attracted a making sure people working in this area know about the anatomy variety of industry specialists, statistics showing 33% to be cosmetic and relate back to this in their practice,” he said. “I have an interest doctors, surgeons, dermatologists and GPs, and 26% aesthetic nurses. in anatomy, and I thought this way we could bring the subject to life Of the remaining delegates, 13% were found to be dentists, while 10% on stage, using the videos, using the demonstration and using the made up aestheticians and 18% clinic managers. models, so practitioners could see that this really is the way forward.” Alongside a comprehensive exhibition floor, which featured 100 top exhibitors, the weekend’s educational programme incorporated four Dr Arthur Swift also presented on behalf of Merz Aesthetics at the agendas: interactive Conference modules, live demonstration Expert Merz Aesthetics Live Demonstration Zone, where he launched the Clinics, Masterclasses and a Business Track. Each agenda featured new Belotero Volume with Lidocaine filler. He noted the importance respected and experienced speakers from across the aesthetics for delegates to understand the scientific background of products and industry, who shared invaluable advice and knowledge on a variety of techniques, while retaining a focus on the overall goal – beauty. treatments, techniques and business insight, with more than 63 CPD “I think when you start to understand the science behind the product points available across the weekend. and how the product works, sometimes it’s very easy to go ahead and lose your focus on what we’re trying to achieve,” he said. “These Amanda Cameron, Aesthetics editor and ACE 2015 programme conferences aren’t just important, they’re crucial. Conferences like this organiser, said, “This year we saw an increase in attendance over are really the fibre of how we do our work.” both days of the conference, with packed demonstration theatres and business workshops right up until the last session on the Sunday. We Alongside the injectables sessions, the Conference agenda also received overwhelmingly positive feedback from delegates, who really included ‘The role of FAT in medical aesthetics’, which drew together enjoyed the interactivity of the sessions, such as the individual voting a vital debate about how fat should be managed in the aesthetics keypads utilised in the main conference auditorium.” During sessions, industry. Panellists took to the stage to discuss the latest and most delegates were able to interact with the speakers via the latest effective ways of managing weight loss, and, with the use of audience conference technology and throughout the event had free access to interaction, found that attendees were divided 50/50 on whether the Exhibition, Expert Clinics, Masterclasses and Business Track. plastic surgeons should be the only ones to perform liposuction. A board of industry experts were then invited to present their lipolytic The Conference programme featured four dynamic and interactive technology to the audience, offering a wide overview of what is modules which explored the entire patient journey across available in the industry today, allowing the audience to decide on different areas of aesthetics, including the role of fat, injectables their preferred technology. Mr Taimur Shoaib, consultant plastic and dermatology. Mr Dalvi Humzah, renowned consultant plastic surgeon and co-chair of the fat session, said, “I think the strongest surgeon and ACE 2015 Steering Committee chair, joined his fellow point of the session was the variety of the people in the audience and practitioners and friends Dr Tapan Patel and Dr Raj Acquilla, with a on the panel.” He continued that the Conference brought together

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015 aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics

“a multidisciplinary team of people, where we can discuss patient concerns by asking people from a variety of different backgrounds.”

Sunday’s ‘Aesthetic Dermatology Clinic’ provided delegates in attendance with an insight into the newest innovations and skin treatments available in aesthetic dermatology in 2015. During the three-hour session, aesthetic nurse Anna Baker argued for the use of photodynamic therapy (PDT) for the treatment of basal cell carcinoma, which was supported by respected dermatologist Dr Stefanie Williams, who said, “In my opinion, this seems to be one of the best methods we can use.” the treatment were divided, all panellists agreed that thorough “This conference is a very exciting, multidisciplinary one which brings consultations prior to vitamin drip treatments were crucial for together all different aspects of cosmetic practice,” said Dr Christopher maintaining patient safety. Of the Expert Clinic agenda, Dr Simon Rowland Payne, who chaired the dermatology session alongside Ravichandran, who presented a session on advanced injectables to a Dr Williams. “It’s the opportunity for multidisciplinary discussion and packed audience with Dr Emma Ravichandran, said, “The delegates talking about different treatments and developments and has a very seem to be quite interactive here, they were quite open and asking interactive audience who participate in everything.” questions – and they’re asking the right questions.” He added, “Often Set on the busy exhibition floor, the two Expert Clinic live we practice independently. It’s a very lonely industry for those of us demonstration theatres saw consistently full benches throughout who don’t have colleagues, friends and peers who we can turn to, but the entire event. Within the programme, which offered independent events like this not only allow people to attend lectures and get all the and sponsored classes, sessions were presented by Lynton Lasers, best advice and latest training, but find other people to discuss ideas Rosmetics, AestheticSource, Medico Beauty, Fusion GT, Sinclair and get their advice from.” Pharma, HealthXchange, BTL Aesthetics, 10 Laser, Skinceuticals and NeoCosmedix, covering topics from chemical peels to lasers. Another popular aspect on the educational programme were the Amongst the vast array of topics, debates, techniques and treatments sponsored Masterclasses, a group of seminars and workshops where presented by esteemed speakers, Mr Humzah was joined on stage attendees could learn key best practice guidance for leading products by Dr Elizabeth Raymond Brown to address the importance of good from the top company KOLs. photography within aesthetics. Within the broad Masterclass agenda, Mr Shoaib discussed the patient While highlighting ethical issues around consent of use with patient experience in a session sponsored by Allergan. He stressed the images, Dr Raymond Brown offered delegates key guidance in image importance of asking vital questions of patients during consultation taking. During the session, She said, “If you do one thing today – and told the audience, “We need to explore their fears and anxieties.” check your white balance. It will make a huge difference to your image Other Masterclasses, sponsored by Sinclair Pharma, Medical Aesthetic results,” also reinforcing the idea that spending money on a decent Group, Institute Hyalual, Adare Aesthetics, 3D-lipo Ltd and Galderma, camera would provide more detailed and effective images. addressed acne treatment, the benefits of multi-platform treatment In particular, the Vitamin Infusion Debate garnered a huge amount approaches, thread lifting, injectables and skin rejuvenation. of interest. The Expert Clinic panel was chaired by nurse practitioner For those looking to build on their non-clinical skills, the ACE Business Sharron Brown and comprised Dr Martin Kinsella, Richard Sikkel, Track, sponsored by Church Pharmacy, gave delegates the chance Dr Jacques Otto and Constance Campion. Though views on to enhance their clinics and provide the ultimate patient experience.

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015 103168 Endocare Ad:Layout 1 23/03/2015 17:31 Page 1

Visibly and physically rejuvenates aged skin

EXCELLENT CLINICAL EFFICACY FIRMING, BRIGHTENING & Clinical studies have shown dramatic MOISTURISING visible and physical improvements in aged Each of the products in the range are and photo-damaged skin in just 60 days' expertly formulated with diﬀering levels of use, improving lines and wrinkles, skin SCA Biorepair Technology, combined with elasticity, texture, tone and skin evidence-based peptide, moisturising and brightness1,2. brightening ingredients to enhance results.

THE SCIENTIFIC SNAIL EVIDENCEBASED Our scientific snail helps to make the key PROGRAMMES A SKINSYNERGY® product: the medigrade ingredient in the Endocare® Tensage™ With a range of formulations suited to skincare range designed to work in harmony range, SCA Biorepair Technology; a morning or evening use, products can be to deliver clinically significant results. naturally derived, highly refined complex of used alone or combined in our 12 week growth factors, glycosaminoclycans Deep Skin Regeneration Programme; and anti-oxidants. The Endocare® Tensage™ designed to maximise results before Concentrate has the highest SCA Biorepair moving onto an ongoing regime to further index with a huge 50%, and is great for enhance outcomes. giving skin a real rejuvenating boost.

FOR FURTHER DETAILS or SCIENTIFIC AND CLINICAL INFORMATION PLEASE CONTACT US

www.aestheticare.co.uk email [email protected] or call FREE on: 0800 0195 322

total!” She added, “For me the highlight, as last year, was the industry debate – time for people to air views and raise contentious issues. Congratulations on providing a platform like this to our industry.” David Gower of Med-fx, registration and consumables partner of ACE 2015, also praised the quality of the exhibition, which drew in huge numbers of professional attendees. “We see this year a much more professional, much more vibrant exhibition,” he said. “I feel that there has been a lot of interest in products, not just the products that we’re offering but in general, and people who are approaching have been very business-like and professional in manner.” Among the exceptional feedback that was received during and after ACE, one of the most prominent points that delegates consistenly praised was Sessions provided a broad range of learning opportunities for how well the event addressed the need to keep up to date with the delegates, which included how to give a great first impression, latest treatment techniques and new innovations. One plastic surgeon marketing skills, using social media, and VAT and insurance guidance. emphasised that, “We need to update ourselves and learn what is US author and international commentator Wendy Lewis presented available to give the best possible service to the patient.” This was two sessions over the weekend, which highlighted the importance widely agreed by attendees, with a cosmetic doctor adding, “Products of social media and visual content. Reflecting on her talk, she said, change, techniques change, knowledge changes and unless you’re “People were really engaged and interested – social media is a really keeping up to date you are really not being the best practitioner you hot topic right now and marketing your clinic is of utmost importance. can be – and you’re not really giving your patients the best. So that’s The attendance really showed that.” the reason you need to attend conferences like this.” Reflecting on Following the successful programme, co-director of Church Pharmacy a weekend packed with extensive, high quality education, a nurse Zain Bhojani said, “The delegates have been very interested in prescriber further commented, “This is actually one of my favourite what the speakers have to say, so it’s nice to know they are getting something out of it and learning something that is a bit different to the clinical side of things. Without a doubt ACE is my favourite show.”

KEY ISSUES IN 2015 The exclusive Question Time debate on Saturday evening, free to all attendees and sponsored by 3D-lipo Ltd, aimed to highlight this year’s most current and important industry issues. Former BBC presenter Peter Sissons chaired the event, with a panel that included Wendy Lewis, Mr Dalvi Humzah, plastic surgeon Mr Paul Banwell, professional body chairs Sharon Bennett and Dr Paul Charlson, and Health Education England (HEE) modality lead Andrew Rankin. The HEE recommendations for qualification requirements were first to be discussed, with Mr Humzah insisting that it is “up to us as conferences; ACE squeezes so much into the time we have, it’s been an industry to set up official qualification courses,” while Bennett said very beneficial on all levels. I’m an experienced nurse prescriber and “If Europe can agree a consensus I can’t see a problem.” Regulation have been injecting for 16 years, but I still learn a lot every time I come and accreditation were major factors in the debate, with Dr Charlson and would definitely recommend ACE to colleagues. I’ll be back again arguing that the General Medical Coucil are interested in accreditation next year.” for cosmetic practitioners, in contrast to many opinions, while Lewis The success of this year’s event has firmly cemented ACE as the raised the importance of policing your online reputation. One audience leading medical aesthetics conference and exhibition in the UK and, member questioned whether the panel felt positive about the potential as such, planning for ACE 2016 is already underway. for change in the industry, to which Rankin said, “The commitment Cameron concluded, “In view of this success, we are now already we all have to improving standards is inspiring.” Bennett was also working on next year’s event to ensure that delegates once again adamant that the future is bright and that “the climate will change and will be given the opportunity to attend a conference that perfectly the consumer will be looking for accredited practitioners.” To conclude complements their practice, and inspires them to push innovative Question Time, each panelist offered a final thought. Bennett told boundaries within aesthetics.” delegates, “Join an association, lone practitioners are dangerous.”

LATEST INNOVATIONS The exhibition floor was the perfect opportunity for delegates to meet with the top suppliers, gain valuable business partners and discover the latest product innovations. Lorna Bowes, director of headline sponsor AestheticSource, said, “The Expert Clinics seemed packed each day with a variety of topics covered, and the format of ‘clinic sessions’ on the main agenda packed the auditorium. This was particularly impressive given that the Merz sponsored sessions with Dr To stay up to date with the latest news and developments Arthur Swift were also packed – there were an awful lot of delegates in for ACE 2016, register at www.aestheticsjournal.com.

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015 LIFT, CONTOUR & REJUVENATE with long-term collagen stimulation

The Lifting Filler

Call Merz Aesthetics Customer Services now LESS INTACT to find out more or to place an order COLLAGEN Tel: +44 (0) 333 200 4140 Email: [email protected] STOP REDUCED LACK OF www.radiesse.co.uk COLLAGEN STRUCTURAL SYNTHESIS SUPPORT

LOSS OF FIBROBLAST ACTIVITY

RAD144/0215/LD Date of preparation: February 2015 Date of preparation: RAD144/0215/LD The Lifting Filler

MZ066 Radiesse AD A4 RAD144-0215-LD.indd 1 20/02/2015 10:23 aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics

Treating the Lips Seldom does a week go by when we’re not subjected to media propaganda about lip enhancement procedures. Whether it’s hype about the latest celebrity to appear with a suddenly-plumper pout, or denigration of the trend when something goes publicly wrong; there is no denying that aesthetic lip procedures have received scrutiny unrivalled by other similar minimally invasive treatments. Allie Anderson talks to practitioners about the different ways to treat this area of the mouth.

There has been great public awareness of lip rejuvenation non-surgical procedures, so the availability and accessibility procedures since the infamous Leslie Ash case in 2002, which means more people are having the treatment.” led to coining of the now-familiar phrase ‘trout pout’. The actress Lip treatment also appears to be particularly popular in certain had her top lip injected with permanent filler to make it appear geographical areas, as Dr Lee Walker, clinical director of Liverpool- fuller, but an allergic reaction caused permanent swelling and based B City Clinics, attests. “It’s probably the second-most resulted in the product fusing with the muscles between her lips requested treatment after botulinum toxin, because it’s a unique and nose.1 While her story is extreme, she was to be the first of demographic in Liverpool,” he says. “There’s an incredibly media- many celebrities whose lips have made it firmly into the spotlight. driven image that’s projected with young females in the city; when Media portrayal of lip enhancement has a profound influence on I speak to colleagues around the country, none of them perform its popularity in clinics, in a number of ways. According to a 2014 the amount of lip treatments that I do.” Dr Walker explains that survey of 1,000 women, 63% would like fuller lips, yet 78% say they around 95% of the lip treatments he carries out are to introduce would avoid lip fillers due to fear of ‘trout pout’ and the health risks, as well as the cost of treatment.2 On the other side of the coin, fuller lips are constantly According to Dr Acquilla, age-related restoration commonly involves the presented as desirable and achievable, and the following points: trend for fuller, more defined lips has translated 1. Oral commissure: to correct sad mouths and give positivity to the smile. to an increase in the number of lip procedures 2. Lateral upper lip depression: often associated with previous lip filler but being carried out in clinics across the UK. “Lips are also exacerbated by ageing. incredibly popular [as a treatment area] due to the 3. Vermilion border: to promote eversion and external rotation of the lip rise of lip augmentation in the media and ‘celebrity and therefore increase mucosal culture’. The most common demographic are the show. budget-conscious young female patients (18-25), 4. Peri-oral rhytids: erasing who have £150 to spend and request lip fillers lines and wrinkles associated to give them a sexy, glamourous pout,” explains with ageing of the skin and aesthetic practitioner Dr Raj Acquilla. orbicularis oris. As demand has grown, so has supply, adds Dr 5. Glogau Klein points and Kieren Bong, clinical director of Glasgow’s Essence philtral columns: for definition Medical Cosmetic Clinic. “Unfortunately we’ve seen of the apex of the Cupid’s bow the general public trivialise medical procedures like and philtral concavity. this and underestimate the risks and the potential 6. Volumetry: precise side effects,” he comments. “It’s not helped by volumetric augmentation to an the fact there are a lot of practitioners who also upper-to-lower lip ratio of 1:1.618, underestimate the risk and fail to convey it to which is commonly distorted by the general public. The market is saturated with novice injectors. Image courtesy of Dr Raj Acquilla practitioners from all sorts of backgrounds offering

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015 2879 Aesth_Journey Ad:Layout 1 24/03/2015 15:22 Page 1

Julia 47 Annie 58 Let’s do things di erently Clara, 39 Rachel, 38

Claire, 51 Marie, 44 Together on the journey to better looking skin

Wherever you are on your journey we can be with you and your clinic every step of the way, in a strong, supportive business partnership. Our clinically proven medigrade skincare products, devices and treatments are world leaders at eectively treating ageing skin and work synergistically to deliver natural, long-lasting results for Penny, 58 your clients, and excellent returns for your business. So let us join you on the journey and we’ll work together to build the best business through great clinical results.

Lets talk. We’d love to discuss the next steps.

www.aestheticare.co.uk Or, call free on: 0800 0195 322 aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics

Before After The clinician’s expertise and skill play a crucial part. Indeed, practitioners have a duty to guide patients on what to expect, and what outcomes can be achieved with different procedures – and there is often a mismatch between the treatment patients initially seek, and those that are recommended. “Of the 100-120 patients I treat per week, more than half request lip fillers and only 20-30% actually need and receive them,” comments Dr Acquilla. Treatment with Juvéderm Volbella. After image shows patient two weeks post treatment. For those patients who do, he uses low Images courtesy of Dr Sarah Tonks. molecular weight hyaluronic acid fillers dermal fillers for a plumper and more defined look. “owing to their excellent tissue integration and soft, natural results While lip shaping and augmentation seems to be particularly at rest and on animation of the lips,” he explains. “In addition, I popular among the under-35s, a proportion of patients undergoing also complement fillers with fractional CO2 laser resurfacing of the treatment are seeking to address or reverse the signs of ageing. perioral skin to remove pigment and fine textural lines,” says Dr “The lips are a focal point of the face, and our eyes are drawn to Acquilla. Filler containing hyaluronic acid is a popular choice among this area when we are talking. They are part of the central triangle many practitioners to enhance and plump the lips, alongside peels and can distinguish our age quite easily,” explains Sharon Bennett, and botulinum toxins in the perioral region, particularly to address independent nurse prescriber and clinical director of Harrogate ‘smokers’ lines’. However, the precise formulation and treatment Aesthetics. “As we age, and through environmental and extrinsic will depend on the patient and their desired result. Dr Bong says factors, our lips will become thinner and wrinkly, with downturned that while a large number of his patients are seeking a plumper lip corners (oral commissures), and lack the shape and support we (to varying degrees of fullness), others are increasingly seeking to once enjoyed. The Cupid’s bow drops down and is no longer reinstate hydration, which is often also a casualty of ageing. “We upright and defined, and the philtral columns flatten.” have a range of products that restore hydration and improve the texture of the lips without increasing the volume,” he explains. Dr Sarah Tonks, who practices at Omniya clinic in Knightsbridge, “We inject a product that has a concoction of ingredients such as says that lip treatments are often carried out as part of – or as a vitamins, antioxidants, and hyaluronic acid, which has a very high result of – anti-ageing procedures or treatments to the rest of the affinity for water and attracts up to 1,000 times its own molecular face. “I do a lot of whole-face rejuvenation in one appointment weight in hydration.” with my patients, and when you rejuvenate the whole face this While there are manifold topical products available over every can make the lips appear smaller, as the rest of the face has more high street counter, particularly aimed at rehydrating the lips, Dr volume. I warn my patients of this and tell them they will probably Bong suggests that these do not provide the long-term results that need to do the lips too, although they don’t often believe me injectable treatments do. “With all our technology, it still has not until they look in the mirror,” she explains. “A lot of people are advanced far enough to produce a topical substance with a small frightened of looking ‘too done’, and there is an association that if enough molecule that will penetrate the deep layers of the skin and you have your lips done, you will always look fake.” provide sustained hydration,” he says. “Hence, a moisturiser will To counter this, and to manage a patient’s expectations, it’s only work when you apply it and won’t result in any cellular changes imperative to conduct a thorough consultation and to consider that will provide sustained improvement.” Similarly, Dr Tonks says of the anatomy of the perioral area. “The skin, musculature and even topical, volumising lip treatments: “It’s like replacing missing teeth the bone structure change as part of the ageing process,” says with a denture.” It is common, however, to use a topical anaesthetic Dr Bong. “So, first I have to listen to what patients are hoping to before treating the lip area, such as LMX 4% (lidocaine). “This is achieve, before analysing the anatomy. Then, I consult with my effective at taking about 70% of the discomfort away, and makes the patients and make them aware of what’s achievable and more procedure manageable for the patient,” says Dr Walker. Alternatively, a importantly, what’s not achievable, as a result of the constraints of the anatomy.” Similarly, to achieve Before After natural and age-appropriate results when using filler, product choice is important. “We don’t use a one-size-fits-all filler; the problem with doing so is that it could be too heavy for some parts of the face, and too light for other parts of the face,” Dr Bong explains. “We only use lip filler that has been exclusively formulated for lip contouring and enhancement. Within this range, there are different grades – there’s no point giving someone a thick grade of filler who doesn’t want too much treatment. Also, if it’s an older patient, we want to emphasise contour rather than volume, so we’d use a different grade again.” Images courtesy of Dr Kieren Bong

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015 @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com The lips, though a focal point of a person’s face, are of course one part of the whole canvas dental block can be used to completely numb the area. The lips, though a focal point of a person’s face, are of course one part of the whole canvas. As such, it’s important that patients are made aware that treating the lips in isolation without attending to the facial and Image courtesy of Dr Kieren Bong labial skin may well have inadequate results. According to Bennett, addressing the skin of the lips before star or celebrity – Kylie Jenner is very ‘of the moment’ – and they tend to prefer undertaking a procedure is important. “If there is any an almost 50/50 ratio. We have few men requesting lip treatments and those who evidence of ageing, [tackling the skin] can improve do are not often wishing to have anything noticeable to others.” Dr Tonks, on the the lip itself greatly and reduce the need for significant other hand, has a lot of Arabic patients, and reports that their preferences are quite work,” she says. “Also, if you only treat the lip, but the different, as is their tolerance to more product and the way she approaches lip surrounding skin is aged, sagging and wrinkly, lacking treatments. “Patients from the gulf have naturally larger lips that can absolutely eat support and structure, then the lip will probably look product,” she says. “You can easily use 2ml in a patient in one sitting if they are after somewhat incongruous and very evident. A young- something glamorous. They don’t have the problem that Caucasian patients often looking plump, hydrated and shapely lip surrounded do, with very thin, almost non-existent upper lips, which are very hard to do that with by a wrinkling face and mouth can look odd. It will not in one treatment sitting.” Bennett adds that Arabic patients don’t like a wide mouth make the patient look particularly younger if the lip is look, which can be the result of filler injected under the oral commissures to elevate the only area on an ageing face to be treated.” them. People from African Caribbean backgrounds also tend to have fuller lips, and A holistic approach should be taken to halting or often prefer treatments concentrated on definition at the corners of the lips, says reversing the effects of ageing – and that, according Dr Bong, while in the Asian community, the perception of beauty is more focused to Dr Bong, ought to incorporate a number of factors. on the shape of the face. Religion and culture also have an influence, with some “Emphasis should be on the canvas of the face, which patients reluctant for friends and family to know that they have had treatment due to is the skin, because it’s part of looking good that we a negative perception of cosmetic interventions. “Therefore, it’s much more common have radiant, healthy looking skin,” he comments. that they want treatments performed in stages and a result that is much more natural “Ageing is a multi-faceted, multi-factorial process, and subtle” he adds. and you need to look at ageing in its entirety. To In order to fulfil each patient’s cultural and personal requirements, a thorough achieve a natural result, we need to look at everything understanding of both is necessary. Dr Acquilla comments, “I travel all around the simultaneously, including hair, teeth and skin.” world teaching injection techniques in different genetic backgrounds. There is As such, patients who seek and undergo procedures definitely a strong link between genetics and aesthetics, such as strong lips in the on the lips should also be given guidance on the how Middle East and Asia with deficiencies in Caucasian populations. The key to success the area will look against the backdrop of an untreated here lies in accurate assessment and treatment of the whole face in good balance face, and how treating other areas around and beyond and proportion.” Despite its share of negative press, the case evidently remains the lips could enhance the overall result. In addition, that lip treatment is growing in demand. Mass marketing has created the illusion patients having lip treatments should be encouraged that lip augmentation is a quick and easy way for people to conform to the latest to support good skin health through protecting against beauty fad with few consequences. This is perpetuated by a concerning trend in sun damage, topical application of antioxidants, such procedures being offered at discounted rates or as prizes. The Keogh Review retinoids and peptides, and maintaining a good daily described such advertising practices as “socially irresponsible” and recommended skincare regime. they be “prohibited by the professional registers’ code of practice”,3 but unless Different cultures and ethnicities have conflicting these recommendations are wholly embraced by the aesthetics industry, patients perceptions of beauty – including what is considered are potentially being put at risk. Practitioners must ensure they market and perform both attractive and undesirable in terms of the lips and treatments ethically, embracing the Keogh recommendations rather than just paying mouth. Dr Walker’s mostly white European patients them lip service. in Liverpool seek a very noticeably enhanced lip. Similarly, practicing in a northern spa town, Bennett REFERENCES 1. Emine Saner, A brave face (The Guardian, 12 September 2008) [Accessed on 16 March 2015] “The majority of patients are looking at a one third 2. Naomi Greenaway, Out with the ‘trout pout’: Three quarters of women would AVOID lip fillers for fear of ending up with the fish-look recently spotted on ulisaT (MailOnline, 2 September 2014) measure,” she comments. “Younger women often 3. Department of Health, Review of the Regulation of Cosmetic Interventions (London: gov.uk, 2013), page 43.

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015 Volumisation by SCULPTRA® www.sculptra.co.uk

Enhancement by ELLANSÉ® www.ellanse.com

Lift & definition by SILHOUETTE SOFT® Rejuvenation by www.silhouettesoft.com PERFECTHA® www.perfectha.com

Everything you need for natural looking, long lasting results.

Shaping the face of aesthetics

Sinclair IS Pharma. 1st Floor Whitfield Court, 30-32 Whitfield Street, London W1T 2RQ. www.sinclairispharma.com Date of preparation: March 2015 one point @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com Managing Obesity: Approaches and Treatment In the second instalment of a two-part weight loss special, Dr Sotirios Foutsizoglou looks at methods of managing and treating obesity

In last month’s first instalment on managing obesity, we explored Figure 2: The National Heart, Lung, and of >102 cm, and in women Blood Institute Overweight and Obesity the physiology and the role of fat, looking at its function within the Classification by BMI (in kg/m2): >88cm, is associated with body, whilst also observing current obesity trends and statistics high risk to health.3 Although • Normal weight 18.5–24.9 from across the globe. It has been suggested that even modest waist circumference and • Overweight 25.0–29.9 reductions in weight may be associated with health benefits, with BMI are interrelated, waist • Obesity class 1 30.0–34.9 reductions in blood pressure, cholesterol and triglycerides achievable circumference provides an • Obesity class 2 35.0–39.9 with just a 5-10% reduction in initial body weight.1 Therefore, as independent prediction of risk • Obesity class 3 ≥ 40.0 healthcare professionals, it is our role to aid our patients in the over and above that of BMI. understanding, management and treatment of obesity. A wide range It is particularly useful in patients who are categorised as normal or of interventions are available for the management of weight and overweight on the BMI scale. It’s important to note here that in South obesity. These include work/school/community programmes (for Asian patients (of Pakistani, Bangladeshi and Indian origin) living in primary prevention), dietary modification, exercise programmes, England, a large waist circumference is more likely to be associated behaviour modification programmes, pharmacological agents, with features of metabolic syndrome, compared to patients deriving commercial programmes (e.g. Weight Watchers) and alternative from Europe; for example, higher triglycerides and lower high-density therapies. Surgery is usually reserved for those suffering from very lipoproteins (HDLs) in female patients from South Asia, and higher severe obesity (BMI greater than 40 kg/m2), for whom less invasive serum glucose in male patients from South Asia.5 methods of weight loss have failed. In this second instalment I will discuss various weight management strategies that may be used Lifestyle changes alone or in a combination. The next step in assessment is to understand the patient’s lifestyle (in terms of their relationship with food, exercise and attitude to weight Assessment and classification and wellbeing), and to suggest interventions. Interventions should: When conducting an initial consultation with a patient who is over- • Always be delivered by healthcare professionals who have weight or obese, it is vital to assess their lifestyle, comorbidities (e.g. relevant competencies and appropriate training. hypertension, diabetes, dyslipidaemia, cardiovascular disease, sleep • Include behaviour change strategies – such as goal setting and apnoea) and their willingness to change. This can be done both self-monitoring of progress – in order to increase patients’ physical verbally, and through written Figure 1: Metric activity levels, and improve eating behaviour or quality of diet. BMI Formula assessment, with the aid of a • Take into account the person’s needs, preferences, social Table: Metric BMI Formula questionnaire. The next step circumstances, degree of obesity, comorbidities, physical fitness weight in kilograms is to utilise the BMI scale, and any previous or concurrent anti-obesity over the counter (OTC) BMI = ———————————— referred to in the previous and prescribed medication. ( kg/m² ) height in metres² article,2 in order to classify the • Include exercise (preferably cardiovascular), even if this does not degree of obesity. lead to weight loss, as it has other health benefits such as reduced When carrying out this assessment, it is important to consider the risk of type II diabetes and cardiovascular disease.6 Recent studies following factors: suggest that individuals who commute to work by active means • BMI may be less accurate in muscular people. Although BMI (cycling or walking) have significantly lower body mass index and correlates with the amount of body fat, BMI does not directly percentage body fat than people who use private transport.7 measure body fat. As a result, some people, such as athletes, Dietary advice is crucial in this process. As slow weight loss is may have a BMI that identifies them as overweight due to their associated with more sustainable results, aim for a maximum weekly increased muscle mass, even though they do not have excess weight loss of 0.5 -1kg.8 For this kind of approach, the National Institute body fat. for Health and Care Excellence (NICE) recommends diets that have a • For Asian adults, risk factors may be of concern at lower BMI as a 600kcal/day deficit (that is, they contain 600kcal less than the person given BMI tends to be associated with higher percentage body fat needs to stay the same weight), or it is advised to reduce calories than in European populations.3 by lowering the fat content (utilising low-fat diets).3 Depending on • For older patients, risk factors may be significant at higher BMIs the patient, another consideration would be to use low-calorie diets due to a lower correlation with percentage body fat in the old (1000-1600kcal/day), or very-low-calorie diets (< 1000kcal/day). This than in the young, and a weaker association with cardiovascular approach may be used for a maximum of 12 weeks continuously,3 or mortality and morbidity.4 intermittently with a low-calorie diet (e.g. two to four days/week), if the For patients with BMI less than 35kg/m2 we are able to assess health person is obese and has reached a plateau in weight loss. Any diet of risks by using waist circumference.3 A waist circumference in men less than 600kcal/day should be used only under clinical supervision.

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015 aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics

Pharmacological management • Treatment can be continued beyond three months only if weight Current treatment of obesity consists primarily of health behaviour loss since commencement of Orlistat exceeds 5% of initial body modification (diet, exercise and behavioural therapy) for all patients, weight (target is lower in Type II diabetes patients). and bariatric surgery for a minority of selected severely obese • Orlistat has been studied in long-term clinical studies of up to four people. Because health behaviour modification can be limited in years’ duration, hence it has a good safety profile.12 its effect in many patients, and the availability of bariatric surgery is • Orlistat 120mg should be taken before, after, or up to one hour after restricted, additional adjunctive, effective and safe obesity treatments each main meal. Dose can be omitted if the meal contains no fat. are required. To date, anti-obesity drugs have not adequately Maximum dose 360mg a day. filled this therapeutic void. The serotonergic agents fenfluramine • It is recommended that orlistat treatment should be discontinued and dexfenfluramine were withdrawn in 1997 due to association after 12 weeks in patients who lose less than 5% of their initial body with cardiac valvulopathy and pulmonary hypertension.9 After the weight. 12 withdrawals of rimonabant (Acomplia) in 2009 for depression and • European prescribing guidelines state that the duration of treatment suicidal ideation,10 and silbutramine (Meridia, Reductil) in 2010 because with orlistat should not be longer than two years.13 of increased cardiovascular risk, 10 orlistat became the only agent available for long-term weight management. In 2012, two new oral Methylcellulose agents – phentermine and extended release (ER) topiramate (Qsymia) • Methylcellulose is a bulk-forming laxative. and lorcaserin (Belviq) – were approved by the US Food and Drugs • It is claimed to reduce food intake by producing a feeling of Administration (FDA) as adjuvants to health behaviour modification in satiety.14 However, there is very little evidence to support its patients with a BMI greater than 30, or greater than 27 with an obesity use in the management of obesity. related comorbidity, such as hypertension, dyslipidaemia, or type 2 diabetes. 10 The European Medicines Agency did not approve either Chromium Picolinate agent, citing toxicity concerns and a lack of morbidity and mortality Chromium is an essential trace mineral found in various foods. It has data in 2012.11 NICE has advised that patients with a BMI > 30kg/ been used as a dietary supplement as there are claims that it can aid m2 should receive treatment. Therefore, pharmacological treatment weight loss through regulating blood sugar levels, thus suppressing of obesity should form a part of a wider assessment of a patient’s appetite and food cravings. However, studies examining a potential lifestyle and risk factors for cardiovascular disease. In patients who are association between chromium and insulin concentrations have motivated to lose weight, drug treatments can increase the amount of yielded mixed results.15 In 1999, following a study conducted by the weight loss as part of a diet and exercise programme. Any drugs used University of Alabama, initial concerns were raised that chromium in the treatment of obesity should be prescribed by an experienced picolinate is more likely to cause DNA damage and mutation than doctor who should comply with NICE guidance on the prevention, other forms of trivalent chromium.16 However, in December 2004, the identification, assessment and management of overweight and obese Committee on Mutagenicity published its findings, which stated that, patients.3 In the UK, all anti-obesity drugs, or ‘slimming pills’, other than “Overall it can be concluded that the balance of the data suggest that orlistat, are widely known to be in use off license. chromium picolinate should be regarded as not being mutagenic in vitro,” and that, “The available in-vivo tests in mammals with chromium Anti-obesity drugs acting on the gastro-intestinal tract picolinate were negative.”17 400μg chromium picolinate, preferably at Orlistat mealtimes, can be used as a food supplement to suppress cravings Following the withdrawal of fenfluramine and dexfenfluramine, interest and insulin spikes. has focused on orlistat, currently the only licensed anti-obesity drug in the UK. Centrally Acting Appetite Suppressants (CAAS) • Orlistat inhibits the action of the pancreatic lipase within the gut There are hundreds of clinics in the UK that use CAAS, among other lumen. It can be given as an adjunct to diet and exercise in the anti-obesity drugs, under ‘Specials License’. ‘Specials’ are unlicensed treatment of obesity when BMI > 30Kg/m2 or > 28Kg/m2 associated medicines for human use which have been specially manufactured with other risk factors for cardiovascular disease such as diabetes, or imported for the treatment of an individual patient after being hypertension, hypercholesterolaemia, etc. ordered by a: • It should be taken with a well-balanced calorie-controlled diet that • doctor is rich in fruit and vegetables and contains an average 30% of the • dentist calories from fat. • nurse prescriber • Orlistat can reduce the absorption of fat-soluble vitamins, therefore • pharmacist independent prescriber long-term treatment vitamin supplementation, especially of vitamin • supplementary prescriber A (β-carotene), is recommended. Other lipid-soluble vitamins By law, private clinics who prescribe CAAS must be registered include D, E and K. Most patients however, are not at risk of vitamin with the Healthcare Commission. Patients should be aware of any deficiency. ‘Specials’ or ‘off licence’ use of their prescribed medication, be given • No dosage adjustment is usually required in hepatic or renal full explanation of risks and benefits and sign a consent form. Failure insufficiency. to do so contravenes the General Medical Council’s (GMC) ‘Good • Orlistat is barely absorbed, so the risk of systemic adverse effects Practice in Prescribing Medicines’.18 is low. • Inhibition of fat absorption commonly causes oily stools, abdominal Phentermine pain and faecal incontinence (minimised by reduced fat intake). • Phentermine is an amphetamine analogue that enhances Some patients may find them intolerable; therefore need to be satiety by increasing hypothalamic noradrenaline warned in advance. (norepinephrine) levels.

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015 @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

• The European Medicines Agency (EMA) decided in 2010 that Pharmacokinetic data Sibutramine must follow the example of Rimonabant (a cannabinoid Bioavailability Peak plasma levels occur within 1 to receptor antagonist used as an adjunct in metabolic syndrome), 4.5 hours Absorption is usually complete by 4 which was withdrawn in 2008 because of safety concerns to 6 hours including severe depression and suicidal thoughts.2.5 Protein binding Approximately 96.3% • On 21 January 2010, the Medicines and Healthcare products Metabolism Hepatic Regulatory Agency (MHRA) announced the suspension of the marketing authorisation for Sibutramine (Reductil). Half life 16 to 31 hours

Excretion Urinary elimination Topiramate • Phentermine first received approval from the FDA in 1959 as an • Topiramate is approved for epilepsy and migraine prophylaxis. appetite-suppressing drug. • Putatively reduces weight by decreasing food intake, decreasing • Phentermine Hydrochloride then became available in the early lipogenesis, increasing thermogenesis, improving insulin sensitivity 1970s. and increasing secretion of adiponectin.26 • Phentermine is an appetite suppressant. It can help reduce weight in obese patients when used short-term and combined Lorcaserin with exercise, diet and behavioural modification. • On 27 June 2012, the FDA approved lorcaserin as an adjunct to a • Fen-Phen (a combination of Fenfluramine and Phentermine) was reduced-calorie diet and exercise for chronic weight management withdrawn from the market in 1997 after 24 cases of heart valve with initial BMI ≥30 kg/m² (obese) or ≥27 kg/m² (overweight), disease were attributed to the Fenfluramine component of Fen- with one weight-related comorbid condition (e.g. hypertension, Phen. There has been no strong evidence that Phentermine is dyslipidemia, type 2 diabetes mellitus). also associated with cardiovascular or valvular disease.19 • Lorcaserin is a selective agonist of serotonin (5-hydroxytryptamine • Phentermine is available on prescription in most countries or 5-HT) 2c receptors. including the US and UK (off licence). • It stimulates proopiomelanocortin (POMC), producing neurones • It is a sympathomimetic amine and works by stimulating the in the hypothalamus, resulting in generation of α-melanocortin release of norepinephrine.20 In a very small minority of cases stimulating hormone which acts on melanocortin receptors to increments of more than 20mmHg in systolic or diastolic BP and decrease food intake and enhance satiety.27 more than 20 beats/min in pulse rate may be shown. Therefore • Lorcaserin is metabolised in the liver to multiple inactive metabolites regular monitoring of BP and heart rate is strongly advised – that are renally excreted. every two weeks for the first four months and then monthly • Lorcaserin appears to be well tolerated in patients and the thereafter. If large rises in BP and/or pulse rate are observed then most common adverse events reported did not include serious CAAS should be discontinued. complications. Common adverse effects include headache (18%), • Phentermine appears to be well-tolerated, producing mild side upper respiratory tract infection (15%), dizziness (8%), nausea (8%), effects consistent with catecholamine-releasing properties constipation (7%), dry mouth (5%).28 through sympathomimetic pathways.21 • Lorcaserin has not been associated with depression or suicidal ideation. Amfepramone • The potential for recreational use is low.29 • Amfepramone is commonly known as Diethylpropion in the UK. • The safety and efficacy of lorcaserin (10 mg twice daily) for ≥ • Amfepramone is a sympathomimetic amine. 52 weeks has been evaluated in three separate Phase 3 trials. • Is a stimulant drug of the phenethylamine, amphetamine, Lorcaserin demonstrated a satisfactory safety profile according to and cathinone chemical classes that is used as an appetite FDA criteria but patient outcomes in the trials failed to achieve the suppressant.22 FDA mean benchmark of patient weight loss.30 • Is a selective norepinephrine-releasing agent (NRAs). Data examining the effect of CAAS on death and cardiovascular • Is believed to have relatively low habituation potential.23 events is not currently available and is needed before the benefits of • Delivered as a regular and extended-release (long-acting) tablet. these drugs can be fairly assessed. Diethylpropion is usually taken three times a day, one hour before meals (regular tablets, 25mg), or once a day in mid-morning Drugs with conflicting evidence (extended-release tablets, 75mg). Growth hormone It is believed that Growth Hormone (GH) secretion is markedly blunted Sibutramine (Reductil) in obesity.31 The role of GH in obesity is complex and somewhat • Sibutramine is an inhibitor of the reuptake of serotonin and controversial. Although primary GH deficiency leads to centripetal noradrenaline. adiposity, visceral obesity per se also results in a secondary reduction • Originally developed by Boots as an antidepressant, Sibutramine in serum GH concentrations. The GH response to pharmacological was sold as an anti-obesity drug to Knoll and then Abbott (Reductil). (growth hormone releasing hormone, L-Dopa) and physiological stimuli, • An interim analysis of the SCOUT (Sibutramine Cardiovascular such as sleep, physical exercise, insulin-induced hypoglycaemia Outcome Trial) study found that the drug increased morbidity from and corticosteroids, is impaired in obesity.31 Some of the theories on cardiovascular disease.24 the cause of altered GH physiology in obesity involve the increased • SCOUT does not clarify whether the increased risk was caused by concentrations of leptin, insulin, free fatty acids (FFAs) and IGF-1.32 the specific properties of Sibutramine or by the modest degree of Recent evidence suggests that leptin, the product of adipocyte weight loss achieved. specificob gene, exerts a stimulating effect on GH release in rodents;

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015 aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics should the same hold be true in humans, the coexistence of high Types of bariatric procedures leptin and low GH serum levels in human obesity would fit in well The first bariatric procedure in wide use, performed from the 1950s with the concept of a leptin resistance.33 Concerning the influence of through to the 1970s, was known as the jejunoileal bypass, and it metabolic and nutritional factors, an impaired somatotropin response involved an intestinal bypass in which the proximal jejunum was to hypoglycaemia and a failure of glucose load to inhibit spontaneous bypassed into the distal ileum. This resulted in extreme weight loss and stimulated GH release are well documented in obese patients; by way of profound malabsorption and was eventually abandoned furthermore, drugs able to block lipolysis and, thus lowering serum- some years later after many people developed severe protein- free fatty acids (NEFA), significantly improve somatotropin secretion energy malnutrition.40 The next major bariatric procedures to in obesity. Caloric restriction and weight loss are followed by the be introduced were the horizontal gastroplasty and the vertical restoration of a normal spontaneous and stimulated GH release. banded gastroplasty, which were thought to be purely restrictive On the whole, hypothalamic, pituitary and peripheral factors appear procedures made possible through the development of surgical to be involved in the GH hyposecretion of obesity. Treatment with stapling devices. Both procedures have now been abandoned biosynthetic GH has been shown to improve the body composition and because stoma tended to enlarge, leading to weight regain.38 the metabolic efficacy of lean body mass in obese patients undergoing The gastric bypass was originally introduced in 1969 by Mason therapeutic caloric restriction.32 According to Scacchi M et al, GH and Ito,41 and it was later modified into a Roux-en-Y gastric bypass and conceivably growth hormone releasing peptides (GHRPs) might configuration for drainage of the proximal gastric pouch to avoid therefore have a place in the therapy of obesity.34 However, the bulk of bile reflux. The next major procedure to be introduced was the studies indicate little or no beneficial effects of GH treatment of obesity, adjustable form of gastric banding.42 The adjustable gastric band is despite the low serum GH concentrations associated with obesity. a silicone belt with an inflatable balloon in the lining that is buckled into a closed ring around the upper stomach. A reservoir port is Leptin placed under the skin for adjustments to the stoma size. Leptin, primarily produced in the adipocytes, acts on receptors in the Two procedures that use a more extreme intestinal bypass, hypothalamus where it inhibits appetite by counteracting the effects along with some modest gastric reduction, are the biliopancreatic of neuropeptide Y and anandamide and promoting the synthesis of diversion and the biliopancreatic diversion with duodenal switch α-MSH (Melanocyte-Stimulating Hormone). The initial studies of leptin in operations, which are often used for severely obese patients obese humans suggest that absolute leptin deficiency is an extremely (BMI ≥ 50). Biliopancreatic diversion combines a subtotal distal rare cause of obesity.35 Although leptin is a circulating appetite gastrectomy and a very long Roux-en-Y anastomosis with a short suppressing protein hormone, obese people have unusually high leptin common intestinal channel for nutrient absorption. Biliopancreatic concentrations – said to be resistant to leptin.36 Plasma leptin levels are diversion with duodenal switch combines a 70% greater curve elevated in obese patients, and correlate with their increased fat mass. gastrectomy with a long intestinal bypass, where the duodenal Messenger RNA levels for leptin are increased in their adipose cells stump is defunctionalised or ‘switched’ to a gastroileal anastomosis. and also correlate with fat mass. Human obesity is likely to result from The most recent major bariatric procedure to be introduced defects in the leptin receptor, in generation of its second messenger is the vertical sleeve gastrectomy, and its popularity is rapidly or effector mechanism within the leptin target cells or in other effector increasing.43 This technique consists of a 70% vertical gastric cells further downstream. Studies are currently underway to determine resection, which creates a long and narrow tubular gastric reservoir whether or not partial resistance to leptin can be overcome by sufficient with no intestinal bypass component.4 exogenous leptin therapy. For patients who are severely obese (BMI ≥ 38 kg/m2 for women, ≥ 34 for men) surgery remains more effective than a non-surgical Surgery approach in the longer term (measured up to 10 years after Bariatric surgery was first developed 50 years ago. However, in the surgery).45 However, bariatric surgery is not without risks. Despite past 20 years, a dramatic increase in the prevalence of severe obesity the lower mortality rate associated with newer laparoscopic combined with improvements in the efficacy and safety of bariatric techniques, the perioperative mortality for the average patient surgical techniques has led to a 20-fold increase in the numbers of varies across subgroups, ranging from 0.3% to 2% or even higher in procedures performed annually worldwide.37 Bariatric surgery has some patient populations.46 increased exponentially in UK over the past eight years with more than 46 10,000 bariatric surgical procedures performed in 2012.38 A prognostic risk score for bariatric surgery includes: In the UK, surgery is considered for people with severe obesity if:39 • BMI 50 or greater • They have a BMI of 40kg/m2 or more, or 35kg/m2 < BMI < 40kg/m2 • Male sex and other significant disease (e.g. type II diabetes, hypertension) • Hypertension that could be improved if they lost weight. • Known risk factor for PE

• All appropriate non-surgical measures have failed to achieve or • Aged 45 years or more maintain adequate clinically beneficial weight loss for at least six Patients with four to five of these characteristics are at higher risk months. of death (4.3%) during the first 90 days postoperatively. • They are receiving or will receive intensive specialist management. • They are generally fit for anaesthesia and surgery. In addition, evidence indicates that vitamin and mineral deficiencies, • They commit to the need for long-term follow-up. including deficiencies of calcium, vitamin D, iron, zinc and copper, are Surgery is considered as a first-line option for adults with a BMI of more common after bariatric surgery.48 Interestingly, some observational than 50kg/m2 in whom surgical intervention is considered appropriate. studies suggest that some bariatric procedures introduce a greater Orlistat and/or CAAS (off label) can be prescribed before surgery if the long-term risk of substance misuse disorders, suicide and increased waiting time is long. alcohol consumption.49 For instance, pharmacokinetic studies indicate

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015 @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

that the gastrointestinal anatomy after Roux-en-Y gastric bypass applied in the consideration of obesity — health professionals and vertical sleeve gastrectomy leads to more rapid absorption commonly recommend the same lifestyle-based interventions of alcohol. This may inadvertently increase the frequency of to those with overweight or mild obesity as to those with more physiological binges and subsequent alcohol misuse disorder.50 severe problems. I am of the belief that obesity should be treated in a much more protocol-driven manner. On the topic of obesity, Conclusions my colleague and aesthetic doctor Dr Richard Brighton-Knight said Obesity is a chronic disease and a risk factor for many other that if we were looking at cancer interventions we would be using medical conditions, affecting health and longevity. It is a hugely studies; entering everyone into follow-up studies and adapting complex condition, and environmental factors such as automation protocols to improve results. The way obesity is currently treated and change in working conditions has meant that calorie output is haphazard, without enough long-term population studies. Within has reduced significantly over the past decades. Combined with the NHS, the focus is too much on bariatric surgery and not the increased availability of cheap food and disposable income, enough on non-surgical interventions. Non-surgical interventions obesity rates continue to increase. Prevention is the best public can produce successful changes without the need for surgery, but health strategy, and continued work in communicating the benefits they do require support from practitioners and crucially, motivation of a healthy lifestyle is crucial for this. Doctors involved in the from the patient’s part. I strongly believe that the NHS should be management of overweight and obese patients must be familiar running non-surgical programmes with standardised protocols with NICE protocols and all modalities available in order to be able that are monitored and reviewed; these can then link into surgical to guide patients in the right direction, to ensure optimal long-term options when needed. The focus of treatment needs to be long- results and to minimise potential complications. Modest weight term weight loss, which often requires a change to eating habits loss is achievable and undoubtedly provides health benefits.1 and increased activity levels. The major challenge, though, is to improve patients’ ability to Dr Sotirios Foutsizoglou specialises in minor maintain whatever weight loss that has been achieved. In order cosmetic surgery and aesthetic medicine. He is the to be successful, anti-obesity treatments need to reflect the founder and medical director of SFMedica, based on Harley Street in London. In addition to his MBBS he also individual’s needs since methods of weight loss not only contain holds a BSc(Hons) in mathematics from the University physical elements, but also strong psychological and emotional of Athens and a MSc in Biostatistics and Epidemiology from the motivational factors. Unfortunately, clinical logic is not always Harvard School of Public Health.

REFERENCES 1. Goldstein D., ‘Beneficial effects of modest weight loss’,International Journal of Obesity, 16 26. Verrotti A et al, ‘Topiramate-induced weight loss: a review’, Epilep Res 95 (2011), p.189-99. (1992), pp. 397-415. 27. Bays HE, ‘Lorcaserin: drug profile and illustrative model of the regulatory challenges of weigh 2. Foutsizoglou, S., ‘Managing Obesity: An Introduction’, Aesthetics, 3 (2015), pp. 27-33. loss drug development’, Expert Rev Cardiovasc Ther, 9 (2011) 9 p.265-67. 3. National Institute for Health and Care Excellence, Obesity: Guidance on the prevention of 28. Kim GW et al., ‘Anti-Obesity Pharmacotherapy: New Drugs and Emerging Targets’, Clin overweight and obesity in adults and children (nice.org.uk, 2006) < https://www.nice.org.uk/ Pharmacol Ther, 95(1) (2014), pp. 53-56. guidance/cg43> 29. Smith SR, Weissman NJ, Anderson CM, et al., ‘Multicentre, placebo-controlled trial of lorcaserin 4. Goodman-Gruen D, Barrett-Connor E., ‘Sex differences in measures of body fat and body for weight management’, N Engl J Med 363 (2010), pp. 245-56. distribution in the elderly’, Am J Epidemiol, 143 (9) (1996), pp. 898-906. 30. Hess R, Cross LB, ‘The safety and efficacy of lorcaserin in the management of obesity’, 5. McKeigue PM, Shah B, Marmot MG., ‘Relation of central obesity and insulin resistance with high Postgrad Med, 125 (6) (2013), pp. 62-72 diabetes prevalence and cardiovascular risk in South Asians’, Lancet 337(1991), pp. 382-386. 31. Scacchi M, Pincelli AI, Cavagnini F., ‘Growth hormone in obesity’, Int J Obes Relat Metab 6. Myers, J., ‘Cardiology patient pages. Exercise and cardiovascular health’, Circulation, 107(1) Disord, 23 (3) (1999), pp. 260-71. (2003), e2-5. 32. Shadid S and Jenssen MD, ‘Effects of Growth Hormone Administration in Human Obesity’, 7. Flint E et al, ‘Associations between active commuting, body fat, and body mass index: Obesity Research, 11 (2) (2003), pp. 170–175. population based, cross sectional study in the United Kingdom’, BMJ, 349 (2014) p.10. 33. Münzer, T, Harman, SM, Hees P, et al, ‘Effects of GH and/or sex steroid administration on 8. Nick Cavill, Louisa Ells, Treating adult obesity through lifestyle change interventions. A briefing abdominal subcutaneous and visceral fat in healthy aged women and men’, J Clin Endocrinol paper for commissioners (National Obesity Observatory, www.noo.org.uk, 2010)< http://www. Metab, 86 (2001), p.3604-3610. noo.org.uk/uploads/doc/vid_5189_Adult_weight_management_Final_220210.pdf> 34. Scacchi M, Pincelli A I and Cavagnini F, ‘Growth hormone in obesity’, International Journal of 9. Connolly HM, et al., ‘Valvular heart disease associated with fenfluramine-phentermine’,N Engl Obesity, 23 (1999) p.260-271. J Med, 337 (1997), pp. 581-8. 35. Jeffrey M. Friedman, Jeffrey L. Halaas, eptin‘L and the regulation of body weight in mammals’, 10. Rueda-Clausen CF and Padwal RS., ‘Pharmacotherapy for weight loss’, BMJ 348 (2014), g3526. Nature 395 (1998), pp. 763-770. 11. Wolfe SM., ‘When EMA and FDA decisions conflict: differences in patients or in regulation?’, 36. Bisht S., ‘Leptin hormone: it’s association with obesity: a review’, International Journal of Drug BMJ, 347 (2013), f5140. Formulation & Research, 1 (1) 2010, pp. 204-220. 12. British Medical Association and Royal Pharmaceutical Society of Great Britain, British National 37. Buchwald H, Oien DM., ‘Metabolic/bariatric surgery worldwide 2008’, Obes Surg 19 (2009), pp. Formulary No. 40, (London: British Medical Association and the Royal Pharmaceutical Society 1605-11. of Great Britain, 2000) 38. Arterburn D and Courcoulas A, ‘Bariatric surgery for obesity and metabolic conditions in 13. European Agency for the Evaluation of Medicinal Products, Committee for proprietary adults’, BMJ, 349 (2014) p.28-32. medicinal products European Public Assessment Report (EPAR): xenical (London: EMEA, 1998), 39. National Institute for Health and Care Excellence, Obesity: identification, assessment and pp. 1-39. management of overweight and obesity in children, young people and adults, (www.nice.org. 14. National Institute for Health and Care Excellence, Evidence search: Methylcellulose (evidence. uk, 2014) nhs.uk) 40. Balsiger BM, Murr MM, Poggio JL, Sarr MG., ‘Bariatric surgery. Surgery for weight control in 15. Preuss, H. G., Echard, B., Perricone, N. V., Bagchi, D., Yasmin, T., Stohs, S. J., ‘Comparing patients with morbid obesity’, Med Clin N Am, 84 (2000), pp. 477- 89. metabolic effects of six different commercial trivalent chromium compounds’, Journal 41. Mason EE, Ito C., ‘Gastric bypass’, Ann Surg, 170 (1969), pp. 329-39. of Inorganic Biochemistry, 102 (11) (2008), pp. 1986–1990. 42. Favretti F, Cadiere GB, Segato G, Himpens J, De Luca M, Busetto L, et al. ‘Laparoscopic 16. Chaudhary S, Pinkston J, Rabile MM, Van Horn JD, ‘Unusual reactivity in a commercial banding: selection and technique in 830 patients’, Obes Surg 12 (2002), pp. 385-90. chromium supplement compared to baseline DNA cleavage with synthetic chromium 43. Nguyen NT, Nguyen B, Gebhart A, Hohmann S., ‘Changes in the makeup of bariatric surgery: a complexes’, Journal of Inorganic Biochemistry 3 (2005) p. 787-794. national increase in use of laparoscopic sleeve gastrectomy’, J Am Coll Surg 216 (2013), pp. 252-7. 17. Advisory Bodies, Statement on the mutagenicity of trivalent chromium and chromium 44. Welbourn R et al., National Bariatric Surgery Registry: first registry report to March 2010. picolinate, (COM/04/S3, 2004) (Dendrite Clinical Systems: www.e-dendrite.com, 2011) Good_Practice_in_Prescribing_Medicines.pdf_25416575.pdf> 45. Gloy VL, Briel M, Bhatt DL, Kashyap SR, Schauer PR, Mingrone G, et al. ‘Bariatric surgery versus 19. Bang WD, et al., ‘Pulmonary Hypertension associated with the use of Phentermine’, Yonsei non-surgical treatment for obesity: a systematic review and meta-analysis of randomised Med J, 56(6) (2010), pp. 971-73. controlled trials’, BMJ 347 (2013), f5934. 20. Nelson DL, Gehlert DR, ‘Central nervous system biogenic amine targets for control of appetite 46. Buchwald H, Estok R, Fahrbach K, Banel D, Sledge I. ‘Trends in mortality in bariatric surgery: a and energy expenditure’ Endocrine Feb, 29 (2006) p.49-60. systematic review and meta-analysis’, Surgery 142 (2007), pp. 621-32. 21. World Public Library, Phentermine (netlibrary.net) 47. Anterburn DE and Courcoulas AP., ‘Bariatric Surgery for Obesity and Metabolic Conditions in 22. Richards D and Aronson J, ‘Oxford Handbook of Practical Drug Therapy’, Oxford University Adults’, BMJ 349 (2014), g3961. Press, (2006). 48. Gletsu-Miller N, Wright BN, ‘Mineral malnutrition following bariatric surgery’, Adv Nutr, 4 (2013) 23. Caplan, J., ‘Habituation to Diethylpropion (Tenuate)’, Canadian Medical Association Journal, 88 p.506-17. (1963), pp. 943–944. 49. Svensson PA, Anveden A, Romeo S, Peltonen M, Ahlin S, Burza MA, et al, ‘Alcohol consumption 24. Caterson ID et al., ‘Maintained intentional weight loss reduces cardiovascular outcomes: and alcohol problems after bariatric surgery in the Swedish Obese Subjects study’, Obesity results from the Sibutramine Cardiovascular OUTcomes (SCOUT) trial’, Diabetes, Obesity and (Silver Spring) 21 (2013) p.2444-5. Metabolism, 14 (6) (2012), pp. 523–530. 50. Maluenda F, Csendes A, De Aretxabala X, Poniachik J, Salvo K, Delgado I, et al. ‘Alcohol 25. Williams G, ‘Withdrawal of Sibutramine in Europe: Another sign that there is no magic bullet to absorption modification after a laparoscopic sleeve gastrectomy due to obesity’, Obes Surg 20 treat obesity’, BMJ, 340 (2010). (2010), pp. 744-8.

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015 F

i o lipomed n Skin Tightening

A Powerful Three Dimensional Alternative to Liposuction

No other system offers this advanced combination of technologies designed to target fat removal, cellulite and skin tightening without the need to exercise

This NEW advanced device is dedicated

exclusively to the clinical market Cellulite

Why choose 3D-lipomed?

A complete approach Face and Body skin Cavitation (Overall Circumference Reduction) to the problem tightening Cavitation is a natural phenomenon based on low frequency ultrasound. The Ultrasound produces a strong wave of Prescriptive Highly profitable pressure to fat cell membranes. A fat cell membrane cannot withstand this pressure and therefore disintegrates into a Multi-functional No exercise required liquid state. The result is natural, permanent fat loss. Inch loss National PR support Duo Cryolipolysis (Superficial Targeted Fat Removal) Cellulite campaign Using the unique combination of electro and cryo therapy 20-40% of the fat cells in the treated area die in a natural Clinician use only 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 Treatment Equipment Supplier The Pinnell Award for Dermology RF with the stand alone benefits of the Year of the Year Product Innovation of automated vacuum skin rolling and radio 3D Lipomed 3D Lipo Limited 3D Lipomed frequency.

What the experts say... ‘As a Clinician I need to know that the treatments we offer are safe, effective, scientifically based and fit in with our ethos of holistic care for our clients. 3D-Lipo has delivered this to us’ Dr Mohamed Dewji – GP & Medical Director LasaDerm Ltd (Milton Keynes)

For further information or www.3d-lipo.co.uk a demonstration call: 01788 550 440 @3Dlipo 3D-lipo Aneva DermaTM Advanced Nutritional SKIN Beverage

Anti-Ageing from Within

Aneva Derma™ is a new, clinically proven, nutraceutical drink supplement. The ingredients in Aneva Derma™ Advanced Nutritional SKIN beverage are digested and distributed via the blood vessels into the deeper layer of the dermis, where they multiply and stimulate ﬁ broblast cells to produce more collagen and hyaluronic acid in the dermis.

• Boosts collagen production, HA and skin hydration. • Improves overall skin health and supports ageing skin. • Once daily, pleasant tasting, easy to digest. www.aneva.co.uk

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

A4 Aneva Derma.indd 1 12/12/2014 14:11 aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics The role of topical and oral antioxidants Surgeon Ms Rozina Ali and nutritional therapist Eva Escofet explore the benefits of topical and oral antioxidants in treating the signs of ageing Aneva DermaTM INTRODUCTION Advanced Nutritional SKIN Beverage The doctor-patient relationship is the keystone of their overall wellbeing, as are their recreational and relaxation of any therapeutic interaction, and I am a methods. Oral antioxidants are an essential component of a patient’s great believer in patient engagement and therapeutic regimen. Today’s busy lifestyles don’t always allow for responsibility. This makes for a more rewarding fresh organic green vegetables or a wholly raw food diet, so I hunt outcome for the patient, as they know just tirelessly for the pills or solutions that provide the richest possible how much they have contributed to their own source of absorbable, active nutrients. I recommend all kinds of age Anti-Ageing Ms Rozina Ali wellbeing. The true ‘transformation’ of aesthetic or hormone-appropriate supplements and am always keen to try surgery is not just a passive change in appearance, but is in fact the latest active ingredients. Oral antioxidants exert a generalised the end result of a process of reflection, consultation, absorption of benefit, usually slow, steady and subtle, but undoubtedly profound. from Within information and what we hope is a commencement of a therapeutic Crucially, they allow for uncomplicated, rapid and strong wound doctor/patient partnership, all of which takes places in order for the healing.1 Topical antioxidants are much more localised and specific, patient to arrive at their ‘best self’. As a matter of course, I discuss making them feel more like part of the treatment. They rely on skincare with all facial aesthetics patients that I see, regardless of patient compliance as, after all, no cream provides benefit if it the treatment, and my two therapeutic mainstays are corrective stays in its tube. I strongly encourage topical antioxidants with (antioxidants to neutralise free-radical damage) and protective any facial procedure, whether surgical or non-surgical, invasive or (the use of adequate physical or chemical sun protection). Every non-invasive, since, in my opinion, it allows for better results. Tauter, consultation includes a medications and social history – but the best tighter skin and a healthy glow2 can be felt and seen by patients and aesthetic consultations also include the documenting of a lifestyle others alike. The stability, ingredients, consistency, smell and cost and nutrition history. The patient’s diet, exercise regimen and over- of the products all have an effect on how easy they are to use and, the-counter (OTC) supplements are important components hence, their overall effectiveness.

BACKGROUND gut microorganisms, absorption rates of nutrients post 40 years An antioxidant is any substance that delays, of age onwards are certainly compromised.8,9,10 Plus, with adding prevents or removes oxidative damage to a everyday stress into the equation, which further reduces digestive target molecule.3 Oxidation reactions produce function and absorption,11 the need for dietary supplementation free radicals that can start multiple chain for all nutrients, especially antioxidants, is crucial. Whilst there Aneva Derma™ is a new, reactions that eventually can cause damage are several assays currently used to assess in vitro antioxidant clinically proven, nutraceutical Eva Escofet or death to the cell. Therefore, due to their activity, the following two are most common. The first is the oxygen action of inhibiting free radicals, antioxidants are crucial towards the radical absorbance capacity (ORAC) assay, which measures the drink supplement. prevention of ageing and disease.4 decrease in fluorescence decay caused by antioxidants. The The ingredients in Aneva Derma™ Advanced second is the total oxyradical scavenging capacity (TOSC) assay, Nutritional SKIN beverage are digested and Oral antioxidants which measures the decrease in ethylene gas production, caused distributed via the blood vessels into the deeper Oral antioxidants can come in the form of dietary supplements or by the inhibition of the thermal hydrolysis of ABAP (2,2-Azobis layer of the dermis, where they multiply and natural food substances. Although dietary supplements are not [2-methylpropionamidine] dihydrochloride) by KMBA (alpha- stimulate ﬁ broblast cells to produce more designed to replace a healthy balanced diet, the Food and Drugs keto-gamma-methiolbutyric acid) in the presence of antioxidant 12 collagen and hyaluronic acid in the dermis. Administration (FDA) explains that supplements help to ensure that compounds. There are various oral antioxidants with beneficial users get an adequate dietary intake of essential nutrients, such anti-ageing properties. For the purpose of this article, however, we as antioxidants.3 Although a healthy diet often provides a source will review those especially effective for dermal anti-ageing. • Boosts collagen production, HA and skin hydration. of vitamins and minerals, taking dietary supplements on top is, • Improves overall skin health and supports ageing skin. largely, essential in ensuring your body receives all the nutrients it L-Ascorbic Acid • Once daily, pleasant tasting, easy to digest. www.aneva.co.uk needs each day. With a consistent decline in nutrients within food L-ascorbic acid is a water-soluble antioxidant that the body is production over the past 70 years,4,5 combined with age-related unable to synthesize, therefore ingestion through supplements and decline in digestive enzymes6,7 and also a reduction in probiotic diet is essential.13 As an antioxidant, it scavenges free radicals and Meeting the needs of your business, delivering high satisfaction to your patients Call us on 01234 313130 [email protected] www.aestheticsource.com Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015

A4 Aneva Derma.indd 1 12/12/2014 14:11 LAG OL EN C

B R O O S T E

A touch of Ellansé™ for Nancy Sorrell

Model and actress

Stimulates collagen and corrects wrinkles for long-lasting, natural looking results

Sinclair IS Pharma. 1st Floor Whitfield Court, 30-32 Whitfield Street, London W1T 2RQ. United Kingdom. www.sinclairispharma.com Date of preparation: March 2015 UK/SIPPEL/15/003 aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics

reactive oxygen molecules, which are produced during metabolic chelate redox-active transition metals, regulate the detoxification of pathways of detoxification. It also prevents formation of carcinogens heavy metals and modulate various signal transduction pathways in LAG 14 29 OL EN from precursor compounds. Ascorbic acid (above other forms physiological and pathological conditions. ALA has a high TOSC C of vitamin C, such as ascorbates) has been shown to increase value of 3,380 µmol of trolox equivalents per mg, but a relatively collagen synthesis in cultured skin fibroblasts by approximately low ORAC figure of 23,200 µmol of trolox equivalents per mg. ALA B R 15 O O S T E eight-fold. It is also an essential cofactor for lysyl hydroxylase and research on human dermal fibroblasts in vitro in cell-culture systems prolyl hydroxylase, the enzymes needed for collagen biosynthesis.16 shows that ALA helps to prevent cellular damage via its antioxidant Supplementation doses of 250mg have been shown to be properties. It can protect fibroblasts, thus helping to slow down the sufficient and effective.17 ageing process in the dermis, whilst stimulating repair.30

A touch Grape Seed Extract (GSE) Topical antioxidants GSE is known as a powerful antioxidant that protects the body It has long been understood that the skin is able to produce ™ of Ellansé from premature ageing, disease and decay. Grape seeds contain antioxidants. As we age, however, not only does the skin’s ability mainly phenols such as proanthocyanidins. Studies have shown that to synthesise antioxidants (such as ascorbic acid glutathione, for oral administration of GSE lowers reactive oxygen species (ROS) alpha-tocopherol and superoxide dismutase) decrease, but our generation and plasma protein carbonyl groups, while enhancing susceptibility to reactive oxygen species (ROS) increases.31 In 2001 Nancy Sorrell the activity of the endogenous antioxidant systems.18,19,20,21 GSE has Dreher stated, “Regular application of skin care products containing an impressive ORAC figure of approximately 63,000 µmol of trolox antioxidants may be of the utmost benefit in efficiently protecting Model and actress equivalents per mg, and also a high TOSC value of 3,200 µmol of our skin against exogenous oxidative stressors occurring during trolox equivalents per mg. Research suggests that GSE is beneficial daily life. Furthermore, sunscreening agents may also benefit in many areas of skin health because of its antioxidant ability to from combination with antioxidants resulting in increased safety bond with collagen, promoting youthful skin, cell health, elasticity and efficacy of such photoprotective products.”32 A study also and flexibility. Other studies have also shown that GSE helps to showed topical application of antioxidants reduced UVA-induced protect the skin from sun damage.22 dermatoses, and an increased exposure to UVA is required to induce hyperpigmentation in skin exposed to topical antioxidants.32 Green Tea Simply placing an ingredient with antioxidant capacity on to the skin Green tea polyphenols (mainly catechins) have been shown to have will not necessarily protect against ROS. Antioxidants need to be cancer preventative effects in vivo.23,24 Catechins scavenge ROS by absorbed into the skin in their active form and remain stable for long generating more stable phenolic radicals. The ORAC assay scores enough to achieve the intended antioxidant functionality. Oxidation green tea as providing an extremely high figure of approximately could be described as a flaw in topical antioxidant therapy; for 120,000 µmol of trolox equivalents per mg of dried tea leaves.25 It example vitamin C is susceptible to damage from exposure to also has a high TOSC value of 3,780 µmol of trolox equivalents per light and oxygen. This has led to a search for intelligent delivery mg. Green tea has more than five times the amount of catechins mechanisms and packaging solutions, such as airtight metallicised as black tea.26 Oral green tea catechins are shown to protect skin containers.33 Topical antioxidants can be divided into two main against harmful UV radiation, improve overall skin quality and boost categories – water soluble (eg. glutathione, silymarin, vitamin C, oxygen flow to the skin.27 resveratrol, grape seed extract) and fat soluble (eg. curcumin, coenzyme Q10, idebenone). A few antixoidant ingredients are both Alpha Lipoic Acid (ALA) water and lipid souble, such as alpha lipoic acid.34 ALA is an organosulfur compound derived from octanoic acid, Many other additional ingredients used in anti-ageing skincare essential for aerobic metabolism in the body. Naturally occurring have dual or multiple actions. For example, polyhydroxy acids lipoic acid is always covalently bound and not readily available (PHAs) and bionic PHAs are recognised as powerful antioxidants. from dietary sources, and is also only present in very low doses Gluconolactone, a PHA, has been shown to inhibit elastin promoter within dietary foods.28 Dietary or drug supplementation is therefore gene by 50%, decreasing solar elastosis by reducing the over necessary for therapeutic doses. Both in vivo and in vitro studies production of elastin.35 The Bioinc PHAs lactobionic acid and demonstrate that ALA exhibits the ability to scavenge free radicals, maltobionic acid have both shown powerful metal chelating capacity. Lactobionic acid has been used VERBASCOSIDE for many years as a component of organ- Rosmarinic Acid preserving solutions, limiting reperfusion injury Quercetin in isolated ischaeimc organs.36 Maltobionic

Ascorbic Acid acid is also a powerful metal chelator, directly 37 Rutin reducing damage from free radicals. Maltobionic acid has also been shown to Alpha-tocopherol reduce the production of malondialdehyde and Trolox therefore reduce oxidative damage to lipids in Resveratrol the cell membrane and the mitochondria.38 An Stimulates collagen and corrects wrinkles 0 0,5 1 1,5 2 2,5 3 3,5 alpha hydroxyacid, citric acid is synergistic to TEAC Value (mM) the known antioxidant vitamin E. It enhances for long-lasting, natural looking results Figure 1: Relative Trolamine Equivalent Absorbance Capacity of selected potential antioxidants vitamin E’s antioxidant action towards radiation-

Sinclair IS Pharma. 1st Floor Whitfield Court, 30-32 Whitfield Street, London W1T 2RQ. United Kingdom. www.sinclairispharma.com Date of preparation: March 2015 UK/SIPPEL/15/003 Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015 @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

induced peroxidation and, as well as being an antioxidant in its own cells, with known antioxidant, anti-inflammatory and photoprotective right, it inhibits lipid peroxidation and scavenges superoxide anion actions.42 In comparison, using the trolamine equivalent absorbance free radicals, which can form peroxynitrite – a known detrimental capacity (TEAC) scale, verbascocide showed strong antioxidant oxidant.39,40,41 Resveratrol and verbascocide are both curently activity in comparison to ascorbic acid, alpha tocopherol and attracting attention for their potent antioxidant effects. Verbascoside, resveratrol; verbascocide induces a dose dependent decrease a phenylpropanoid glycoside is a natural plant agent, usually derived of expression of pro-inflammatory chemokines on human from phytostem lilac leaf cell culture or buddleia davidii meristematic keratinocytes, as demonstrated in Figure 1.43

CONCLUSION The effective use of oral antioxidants requires a lifestyle shift; it takes discipline and thought on the patient’s part. Using topical antioxidants can be a very enjoyable and constructive ritual every morning and night. In reality, each patient has to decide which regimen matches their personality, lifestyle or budget and is suitable to their everyday commitments. I advise all my patients that the maintenance and often even enhancemment of the results of any plastic surgery treatments requires their input. The plethora of data available regarding the effectiveness of key antioxidant ingredients Ms Rozina Ali in both skincare ingredients and supplements is indisputable. It is heartening to learn of the objective, scientific, biopsy- proven benefits of these various ingredients, as well as the clinical synergies within products. The current trend towards layering various products to effect the best outcome is proven in our own clinics. My erstwhile refrain of ‘yes, but, does it work’ has been answered with a resounding yes, so I strongly believe we should all be including both oral and topical antioxidants in our treatment recommendations for our aesthetic patients, to ensure the best possible outcome of any procedures we recommend.

Ms Rozina Ali is a highly trained and experienced consultant Eva Escofet is a highly established nutritional therapist with 12 reconstructive and aesthetic surgeon with an interest in facial years of clinical experience. She owns a busy multidisciplinary aesthetic surgery. clinic, where she mentors a team of nutritionists.

REFERENCES: 1. Blass SC, Goost H, Tolba RH, Stoffel-Wagner B, Kabir K, Burger C, Stehle P, Ellinger S. ’Time to 25. Cui Y, Morgenstern H, Greenland S, Tashkin DP, Mao JT, Cai L, Cozen W, Mack TM, Lu QY, Zhang wound closure in trauma patients with disorders in wound healing is shortened by supplements ZF, ‘Dietary flavonoid intake and lung cancer’,Cancer , 112 (2008), p.2241-2248. containing antioxidant micronutrients and glutamine: a PRCT, Clinical Nutrition 31(4)(2012) p.469-75 26. Uan JM, Koh WP, Sun CL, Lee HP, Yu MC, ‘Green Tea intake, ACE gene polymorphism and breast 2. Dreher F, Maibach H, ‘Protective effects of topical antioxidants in humans’,Curr Probl Dermatol, 29 cancer risk among Chinese women in Singapore’, Carcinogensis, 26 (2005), p.1389-1394. (2001) p.157-64. 27. Chandra S, de Mejia EG, ‘Polyphenolic compounds, antioxidant capacity, and quinone reductase 3. B Halliwell and JMC Gutteridge, ‘The Definition and Measurement of Antioxidants in Biological activity of an aqueous extract of Ardisia compressa in comparison to mate (Ilex paraguariensis) and Systems’, Free Radical Biology and Medicine, Vol. 18, No. 1 (1995), p.125-126. green (Camellia sinensis) teas’, J Agric Food Chem, 52 (2004) p.3583–3589. 4. B Halliwell, ‘Biochemistry of Oxidative Stress’, Biochemical Society Transactions, Vol. 35, No. 5 28. Lu QY, Jin YS, Pantuck A, Zhang ZF, Heber D, Belldegrun A, Brooks M, Figlin R, Rao J, ‘Green tea (2007), p.1147-1150. extract modulates actin remodeling via Rho activity in an in vitro multistep carcinogenic model’, Clin 5. Food and Drugs Administration. Dietary Supplements: What You Need to Know (USA: Food and Cancer Res, 11(4) (2005), p.1675-83. Drugs Administration, 2014) Available at: [Accessed 17 March 2015] photoprotection, increase microcirculation, and modulate skin properties of women’, J Nutr. 141(6) 6. Mayer, AM, ‘Historical changes in the mineral content of fruits and vegetables: a cause for (2011) p.1202-8. concern?’ in Agriculture Production and Nutrition: Proc, (USA: Tufts University, 1997). p 69-77 30. Reed, LJ, ‘A trail of research from lipoic acid to alpha-keto acid dehydrogenase complexes’, Journal 7. Long, C, ‘Is chemical farming making our food less nutritious?’ Org Gardening (1999) p.12. of Biological Chemistry, 276 (42) (2001) p.38329-36. 8. Laugier R, Bernard JP, Berthezene P, Dupuy P, ‘Changes in pancreatic exocrine secretion with age: 31. Salinthone S, Yadav V, Bourdette DN, Carr DW, ‘Lipoic acid: a novel therapeutic approach for pancreatic exocrine secretion does decrease in the elderly’, Digestion, 50(3-4) (1991), p.202-11. multiple sclerosis and other chronic inflammatory diseases of the CNS’, Endocr Metab Immune 9. Morley JE, ‘The aging gut: physiology’, Clin Geriatr Med,;23(4) (2007), p.757-7. Disord Drug Targets, 8(2) (2008), p.132-142. 10. Hurwitz A, Brady DA, Schaal SE, et al., ‘Gastric acidity in older adults’, JAMA, 27;278 (8) (2007), 32. Annals of the New York Academy of Sciences, (2002) p.133-166. p.659-62. 33. Fuchs J, Huflejt ME, ‘Acute effects of near ultraviolet and visible light on the cutaneous antioxidant 11. Guslandi M, Pellegrini A, Sorghi M, ‘Gastric mucosal defences in the elderly’, Gerontology, 45 (4) defense system’, Photochem Photobiol, 50:739 (1989). (1999), p.206-8. 34. Dreher F, Maibach H, ‘Protective effects of topical antioxidants in humans’,Curr Probl Dermatol, 29 12. Pirlich M, Lochs H, ‘Nutrition in the elderly’, Best Pract Res Clin Gastroenterol, 15(6) (2001), p.869-84. (2001) p.157-64. 13. Konturek PC, Brzozowski T, Konturek SJ, ‘Stress and the Gut: Pathophysiology, Clinical 35. Bauman L, Allemann IB, ‘Cosmetic Dermatology: Principles and Practice’, 2nd edn. McGraw, 34:298 consequences, diagnostic approach and treatment options’, Journal of Physiology & Pharm, 62, 6, (2008). (2011), p.591-599. 36. Cliff S,PRIME International Journal of Aesthetic and Anti-Ageing Medicine, December 2013. 14. Garrett AR, Murray BK, Robison RA, O’Neill KL, ‘Measuring antioxidant capacity using the ORAC and 37. Briden ME, Green BA, ‘The Next Generation Hydroxyacids’, Draelos Z, Dover J, Alam M, eds. TOSC assays’, Methods Mol Biol, 594 (2010), p.251-62. ‘Procedures in Cosmetic Dermatology: Cosmeceuticals’, Philadelphia, PA: Elsevier Saunders (2005) 15. Jialal I, Grundy SM, ‘Preservation of the endogenous antioxidants in low density lipoprotein by p.205-212. ascorbate but not probucol during oxidative modification’,Journal of Cl. Invest, 87 (2) (1991), p.597. 38. Charloux C, Paul M, Loisance D, Astier A, ‘Inhibition of Hydroxyl Radical Production By Lactobionate, 16. Block G, Menkes M, ‘Ascorbic Acid in cancer prevention, Nutrition and cancer Prevention, T.Moon Adenine and Tempol’, Free Radical Biology & Medicin, 19 (5) p.699-704 eds, (1998). 39. Brouda I, Edison BL, Weinkauf RL, Green BA, ‘Maltobionic acid, a powerful yet gentle skincare 17. S Murad, D Grove, K A Lindberg, G Reynolds, A Sivarajah and S R Pinnell, ‘Regulation of collagen ingredient with multiple benefits to protect and reverse the visible signs of agin’, Am Acad of synthesis by ascorbic acid’, Proc Natl Acad Sci, 78(5) (1978), p.2879-2882. Dermatol Poster Exhibit: Chicago, (2010). 18. Pinnell SR, ‘Regulation of collagen biosynthesis by ascorbic acid: a review’, Yale J Biol Med, 58(6) 40. Brouda I, Edison BL, Weinkauf RL, Green BA, ‘Maltobionic acid, a powerful yet gentle skincare (1985), p.553-9. ingredient with multiple benefits to protect and reverse the visible signs of aging’, Am Acad of 19. Woollard KJ, Loryman CJ, Meredith E, et al., ‘Effects of oral vitamin C on monocyte: endothelial cell Dermatol Poster Exhibit: Chicago, (2010). adhesion in healthy subjects’, Biochem Biophys Res Commun, 294(5) (2002), p.1161-8. 41. Wills ED, ‘Effects of antioxidants on lipid peroxide formation in irradiated synthetic diets’,Journal Int 20. M Balu, P Sangeetha, G Murali, and C Panneerselvam, ‘Age-related oxidative protein damages J Radiat Biol Relat Stud Phys Chem Med. 37(4) (1980) p.403-14. in central nervous system of rats: modulatory role of grape seed extract’, International Journal of 42. Van den Berg AJ, Halkes SB, van Ufford HC, Hoekstra MJ, Beukelman CJ, ‘A novel formulation of Developmental Neuroscience, 23, (6) (2005), p.501–507. metal ions and citric acid reduces reactive oxygen species in vitro’, J Wound Care, 12(10) (2003), 21. M Balu, P Sangeetha, D Haripriya, and C Panneerselvam, ‘Rejuvenation of antioxidant system in p.413-8. central nervous system of aged rats by grape seed extract’, Neuroscience Letters, 383, (3) (2005), 43. Higashi-Okai K, Ishikawa A, Yasumoto S, Okai Y, ‘Potent antioxidant and radical-scavenging activity p.295–300. of Chenpi – compensatory and cooperative actions of ascorbic acid and citric acid’, J UOEH 31(4) 22. A Devi, AB Jolitha, and N Ishii, ‘Grape seed proanthocyanidin extract (GSPE) and antioxidant (2009) p.311-24. defense in the brain of adult rats’, Medical Science Monitor, 12 (4) (2006). p.124-129. 44. Vertuani S, Beghelli E, Scalambra E, Malisardi G, Copetti S, Dal Toso R, Baldisserrotto A, Manfredini 23. Busserolles, E Gueux, B Balasińska et al., ‘In vivo antioxidant activity of procyanidin-rich extracts S, ‘Activity and stability studies of verbascocid, a novel antioxidant, in dermocosmetic and from grape seed and pine (Pinus maritima) bark in rats’, International Journal for Vitamin pharmaceutical topical formulations’, Moleculs, 16(8) (2011), p.7068-80. and Nutrition Research, 76, (1), (2006) p. 22-27. 45. Data on file:Resources Of Nature, 801 Montrose Avenue, South Plainfield, NJ 07080. 24. Shi J, Yu J, Pohorly JE, Kakuda Y, ‘Polyphenolics in grape seeds-biochemistry and functionality’, J Med Food, 6(4) (2004) p.291-9.

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015 Grow Your Practice by Offering Postpartum Treatments to Your Patients!

Give your patients the full Body After Baby treatment! • VelaShape® - Non Invasive Body Shaping, elōs® Based Technology* Cellulite reduction • Body shaping • Skin tightening • UltraShape® - Non Invasive Focused, Pulsed UltraSound Immediate fat cell destruction • Localized reduction of fat deposits • Sublative® - Fractionated Bi-polar Radio Frequency Technology Improvement of striae and textural irregularities • Smoother, rejuvenated appearance of the skin

*elōs technology combines bi-polar radio frequency and optical energies for deeper dermal penetration and a more safe, effective treatment than with optical energy alone.

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

*The VelaShape III is indicated for non-invasive treatment for body contouring via temporary cellulite and circumference reduction. This brochure is not intended for use in the U.S. market. ©2014. All rights reserved. Syneron, the Syneron logo, VelaShape, UltraShape, Sublative and elōs are registered trademarks of Syneron Medical Ltd. and may be registered in certain jurisdictions. Candela is a registered trademark of the Candela Corporation. PB85751EN Award-Winning Fractional Laser Device

ResurFACE A New Era for Aesthetic Rejuvenation

The award-winning ResurFACE fractional laser delivers dramatic results for complete skin resurfacing. Offering a whole range of treatments from congestion clearing, skin smoothing procedures through to scar revision and wrinkle reduction, not to mention stretch mark removal! Voted ‘Most Innovative Aesthetic Treatment of 2014’, ResurFACE offers a unique opportunity to widely expand your service offering with an award-winning treatment.

Work with the best... call Lynton today on 01477 536 977 or visit lynton.co.uk

The most sophisticated laser addition to my clinic yet! This laser is easy to use and it is brilliant for resurfacing, stretch marks, acne scars, wrinkles, pigmentation. Down time is minimal, it is very well tolerated and clients re-book because they love the results.’ Sally O’Donnell - Aesthetic Laser Clinic, 2015

Acne Scarring Fine Lines Rejuvenation 01477 536975 @lyntonlasers Stretch Marks Congestion Anti Ageingcall Lynton today on [email protected] Wrinkles Sun Damage Uneven Texture01477 536 977 fb.com/lyntonlasers www.lynton.co.uk/duetto Award-Winning Fractional Laser Device aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics

The latest ResurFACE advancements A New Era for in laser Aesthetic Rejuvenation Laser specialist Dr Elizabeth Raymond Brown gives an overview of the latest technological advancements in the field of aesthetic lasers Introduction The award-winning ResurFACE fractional laser delivers The concept of the laser traces back to the theory of stimulated emission register laser products, but it is a legal requirement proposed by Albert Einstein in 1917.1 The first experimental laser, using a synthetic to meet the ‘Essential Safety Requirements’ of the dramatic results for complete skin resurfacing. Offering ruby crystal, was demonstrated in 1960 by Theodore Maiman.1 According to applicable European Directives, ie. BS EN 60601-2- a whole range of treatments from congestion clearing, Hecht,2 the development of the laser was ‘neither simple nor easy’, but in the 22:2013.5 Laser products are classified according intervening 55 years, lasers impacted every aspect of life, including surgical and to the accessible laser emission, and if this exceeds skin smoothing procedures through to scar revision and non-surgical cosmetic interventions. The UK market for cosmetic interventions limits defined in BS EN 60825-1,6 the product wrinkle reduction, not to mention stretch mark removal! (consumer value) was worth £2.3bn in 2013, and it is estimated to rise to must be accurately labelled and must incorporate £3.6bn by 2015. Non-surgical procedures (injectables, laser/light therapies) are engineering features such as key switches and Voted ‘Most Innovative Aesthetic Treatment of 2014’, estimated to account for 90% of procedures and 75% of the market value.3 Rarely interlocks. Manufacturers must also provide adequate instructions for safe and appropriate ResurFACE offers a unique opportunity to widely expand can medical aesthetic clinics afford to invest in laser technology unless it offers a wide range of treatment modalities or unique features, with superior performance use. Laser eye protection has to be CE marked your service offering with an award-winning treatment. and benefits over other modalities and devices. What could be considered good and comply with BS EN 207:2009,7 the ‘European examples of customisable laser and intense light devices for multi-applications Directive on Personal Protective Equipment’. As include: the Alma Harmony XL, the Lumenis M22, Lynton Lumina and the Cutera a certified laser protection advisor (LPA), I would Xeo (Figure 1). These systems offer versatile and expandable ‘platforms’ with strongly advise those purchasing equipment Work with the best... as many as 24 different treatment modalities from a single platform, helping to directly from non-European websites, or pre-used grow practice treatments and revenue. Devices offering fewer, but more specific devices to seek independent advice on product call Lynton today on applications, such as body contouring or treatment of hyperhidrosis include; the safety compliance, output calibration and suitability 10600 nm output of the Syneron-Candela CO2RE for ablative rejuvenation or the of treatment protocols and protective eyewear. 01477 536 977 1565 nm fibre laser of the Lumenis ResurFX Figure( 2), offering fractional non- ablative skin rejuvenation. Extending treatment opportunities or visit lynton.co.uk All aesthetic laser and light-based therapies exploit the concept of selective absorption of incident radiation by a given chromophore or target, as described by the theory of Selective Photothermolysis.8 To achieve an efficacious and The most sophisticated laser addition to my clinic yet! This laser safe clinical outcome, specific device variables is easy to use and it is brilliant for resurfacing, stretch marks, acne must be selected and controlled according to the presenting condition to be treated and patient scars, wrinkles, pigmentation. Down time is minimal, it is very Figure 1. Cutera Xeo treatment hand-pieces Figure 2. Lumenis ResurFX factors such as skin type, hair colour etc. well tolerated and clients re-book because they love the results.’ An established marketplace These variables include: The economic downturn and subtle changes in customer demands resulted in Sally O’Donnell - Aesthetic Laser Clinic, 2015 some key mergers and acquisitions, which has brought benefits to companies, Wavelength (nm / µm) – determining absorption investors and consumers alike. With companies extending their product by a given chromophore, and depth of penetration portfolios, research and development (R&D) bases, and customer support into tissues. services, practitioners expect suppliers to offer reliable, high performance devices, limited or zero consumable costs, on-going clinical education and Pulse duration (ms / µs / ns / ps) – determining rate Acne Scarring Fine Lines Rejuvenation ‘on-call’ service support. Lasers are designated as ‘Medical Devices’, and thus of heating of target tissues and thus interaction 01477 536975 @lyntonlasers Stretch Marks Congestion Anti Ageingcall Lynton today on must be CE marked and comply with applicable European Medical Device mechanism, eg. photochemical, photothermal, [email protected] Directives (within the EU).4 Unlike the United States, the UK is not required to photomechanical. Wrinkles Sun Damage Uneven Texture01477 536 977 www.lynton.co.uk/duetto fb.com/lyntonlasers Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015 @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

Energy, power, fluence (J, W, J cm-2 according to output) · Simultaneous wavelength delivery – eg. The Quanta System – determining amount of energy/power delivered to the tissues. Duetto MT laser (Figure 3), distributed by Lynton Lasers, can emit Alexandrite (755 nm) and Nd:YAG (1064 nm) wavelengths Treatment area (mm, cm-2) – affecting depth of penetration into in a single emission in varying proportions. Mixing the efficacy tissues, thermal diffusion of heat and treatment time. of the Alexandrite with the safety of the Nd:YAG offers treatment for challenging conditions such as reducing fine hair in darker It is the subtle but significant refinement of these variables that skin types. offer further opportunities to improve clinical efficacy, reduce treatment times and enhance patient comfort. For example, the Pulse durations – ever shorter introduction of ‘fractional’ technology – delivering energy in micro- Some of the most recent product advances have come from the ability spots rather than over a full beam area – had a significant impact to produce reliable and repeatable ultra-short picosecond (ps, 10-15 s) on extending both ablative and non-ablative treatments.9 Other pulses of energy, previously the reserve of the research laboratories. innovative advances are outlined below: Picosecond pulses induce photodisruption – a physical effect associated with optical breakdown that results in plasma formation Wavelengths – adding more and ‘mixing’ them up and shock wave generation.10 Photodisruption is a well-known tool of A number of devices offer multiple wavelengths and interesting minimally invasive surgery such as posterior capsulotomy and laser- ways of delivering them: induced lithotripsy of urinary calculi. The nanosecond pulses (ns, 10-9 s) of Q-switched lasers are · Independent wavelength delivery – eg. Syneron-Candela successfully used for tattoo removal and treatment of pigmented GentleMax Pro, offers an Alexandrite (755 nm) and an Nd:YAG lesions. However, picosecond pulses can produce incredibly high (1064 nm) output for hair reduction, allowing treatment of all peak powers from lower pulse energies – still causing optical skin types and pigmented and vascular lesions. breakdown but with less disruptive effects to surrounding tissue.10 · Sequential wavelength delivery – eg. Cynosure Cynergy Devices exploiting this technology include: Multiplex technology emits a pulsed dye (585 nm) beam milliseconds before the Nd:YAG (1064 nm) output for increased · Cynosure PicoSure, dual wavelength (755 nm / 532 nm) laser: absorption by methemoglobin and enhanced treatment of Cynosure has exploited the laser-induced optical breakdown vascular lesions. in tissues via their FOCUS lens array to include treatment of acne scars and wrinkles. Brauer et al11 have shown new collagen and elastin production, similar to fractional ablative lasers, but without the side effects and downtime. Rarely can medical · Syneron-Candela PicoWay (Figure 4), dual wavelength (1064 nm / 532 nm) laser: claimed to remove multi-coloured tattoos, aesthetic clinics afford to recalcitrant tattoos and pigmented lesions. · Cutera enlighten: This is a dual wavelength (1064 nm / 532 invest in laser technology nm) laser offering both nanosecond and picosecond pulse durations (fixed), in one device, which with their variable spot unless it offers a wide range sizes claimed to offer removal of both epidermal and dermal of treatment modalities pigmented lesions. Treatment areas – bigger, faster, cooler Patients not only expect great results, but also want fast and comfortable treatments, especially with hair reduction. Increasing

Figure 3 Quanta Duetto Figure 4 Syneron- Figure 5 Alma Lasers Soprano Figure 6. GME Linscan 808 Diode laser MT Laser Candela PicoWay

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015 aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics

Whilst perhaps understandable, this can be risky and it is wiser To achieve an efficacious to focus on company pedigree, product portfolio and customer support. Reputable and trust-worthy companies offer information and safe clinical outcome, on compliance with safety and licensing requirements, advice on premises and room layouts, dedicated clinical trainers, specific device variables workshops and educational events, webinars and learning resources, ‘user’ groups, training and business development must be selected and support and rapid response to equipment service or break-down. Companies can also support their customers with contacts for controlled according to the finance companies, laser protection advisers (LPA) and expert presenting condition to be medical practitioners (EMP). Conclusion treated and patient factors From the first medical treatment of a retinal tumour with a ruby laser in 1961,12 to the surgical and non-surgical interventions such as skin type, hair available today, lasers have proven themselves as precision tools for an incredibly extensive range of treatments. Pushing colour etc. the boundaries with mid and far infrared wavelengths, beam delivery methods, faster treatments over bigger areas and treated area, scanned beams and comfort cooling are the enhanced comfort, will continue to raise expectations of both industry’s response to these demands. For example: patients and users. A word of caution however, advancing the technology without advancing practitioner education is · Soprano from Alma Lasers (Figure 5) is well known for its dangerous. Just because a laser can remove our wrinkles, SHR hair removal (high repetition of short pulses to achieve reduce our hair growth and banish our brown spots, it should not high average power) and their in-motion treatment technique. mean that the technology becomes so readily accessible that Extending this technology further is the Soprano Ice diode anyone can perform such treatments. In my opinion, this is where laser, with large spot size and ICE contact cooling designed manufacturers and distributors have a wider role to play than just to enhance patient comfort. selling the latest technology. But thanks to significant R&D and · A new device, recently available in the UK via Aster investment, it is now possible to deliver medical grade treatments International Ltd, is the German Medical Engineering Linscan from the most reliable, efficient and technically-advanced devices 808 diode laser (Figure 6). A novel method of linear scanning than ever before. across a treatment area of 50 x 15 mm offers high efficacy Dr Elizabeth Raymond Brown is an RPA2000 accredited and reduced treatment times. Combined with contact cooling, laser protection advisor and academic lead for the MSc. in Motion Control Technology (MCT) and menu driven pre- non-surgical facial aesthetics (NSFA) at the University of sets, this compact laser offers all the important features for Central Lancashire in Preston. She has previously worked safe treatment delivery. Interestingly it also offers treatment as a laser safety lecturer at Loughborough University and was head of lasers at Loughborough College. settings for Onychomycosis, as a less painful alternative to the Nd:YAG 1064 nm wavelength. · Building on the well established Lightsheer technology for hair reduction is the Lightsheer INFINITY, from Lumenis, offering diode wavelengths of 805 nm and 1060 nm, with REFERENCES nd a unique active pain reduction mechanism using vacuum 1. Hecht, J. (1992) The Laser Guidebook. 2 edn. USA: McGraw-Hill 2. Hecht, J. Beam: The Race to Make the Laser, (USA: Oxford University Press, 2005) assisted (HIT) technology and the ChillTip handpiece for 3. Department of Health (2013) Review of the Regulation of Cosmetic Interventions – Final Report (UK: Department of Health, 2013) Available at: example of the enhanced features that manufacturers [Accessed 17 March 2015] 4. British Standards Institute. European Medical Device Directives (UK: British Standards Institute, need to include for both patient and practitioner with an 2015) Available at: [Accessed 17 March 2015] 5. British Standard Institute. BS EN 60601-2-22:2013: Medical electrical equipment: Particular defaults, benefiting the users and reducing the likelihood of requirements for basic safety and essential performance of surgical, cosmetic, therapeutic and inappropriate treatment settings. diagnostic laser equipment (UK: British Standards Institute, 2013) 6. British Standards Institute. BS EN60825-1:2014: Safety of laser products - Part 1: Equipment classification & requirements (UK: British Standards Institute, 2014) Going the extra mile – customer support 7. British Standards Institute. BS EN 207:2009: Personal eye-protection equipment. Filters and eye- Aside from the technological advances and refinements, it is protectors against laser radiation (laser eye-protectors) (UK: British Standards Institute) 8. Anderson R, Parish J. (1983) ‘Selective photothermolysis: Precise Microsurgery by Selective notable that manufacturers now strive to enhance the customer Absorption of Pulsed Radiation’. Science 220 (1983). p 524-527. experience of buying and using a laser. It is no longer acceptable 9. Gold, M.H Ed. (2010) ‘Update on Fractional Laser Technology’ J Clin Aesth Dermatol, 3(1): pp.42-50 10. Niemz, M.H. Laser-Tissue Interactions: Fundamentals and Applications. (Berlin Heidelberg: to take delivery with a half day training session and being left to Springer-Verlag, 1996). 11. Brauer, J, Kazlouskaya, V, Alabdulrazzaq, H, Bae, Y, Bernstein, L, Anolik, R, Heller, P, and ‘get on with it’. With such a range of devices available from an Geronemus, R. ‘Use of a picosecond pulse duration laser with specialized optic for treatment of increasing number of suppliers, it can be hard to differentiate facial acne scarring’, JAMA Dermatology, 151(3) (2015) p 278-284 12. Institute of Medicine (US) Committee on Technological Innovation in Medicine; Rosenberg N, between them, and the decision on system purchase often comes Gelijns AC, Dawkins H, editors. Sources of Medical Technology: Universities and Industry. down to the rapport developed with an individual sales person. Washington (DC): National Academies Press (US); 1995. PART II, Medical Device Innovation. 3, pp 7.

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015 aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics

their skin is oily/acne-prone or dry/sensitive, and whether they have undertaken previous treatments, as well as their medical conditions and medications. In Ichibori R et al’s study of ageing in monozygotic twins, it was shown that facial texture ‘is influenced by environmental factors rather than solely by genetic factors’.1 In other words, extrinsic factors play a bigger role than intrinsic ones. This is great news for those of us not naturally blessed with flawless skin – it can be nurtured! The two factors that have been shown to have the greatest impact on skin texture over time are the use of sun protection and the avoidance of smoking.1,4 Therefore, it is imperative to advise the patient of the importance of these lifestyle choices. The importance Achieving good skin texture starts with a good skincare regime and diet. Numerous studies have demonstrated that Ultra Violet (UV) damage is of skin texture the single biggest factor in skin ageing.1,5 The ‘Sunscreen Fact Sheet’ published by the British Dr Sharon Crichlow analyses the role Association of Dermatologists in 20136 recommends and importance of skin texture in the use of a sunscreen of at least SPF 30 and with UVA rating of 4 or 5 stars as providing adequate treating the signs of ageing protection against UV damage. We would therefore advise the same. The use of creams containing the antioxidants vitamin C (at pH <4 and concentrations The Oxford English dictionary defines texture as ‘the feel, appearance or up to 20%) and the vitamin E isomer Tocopherol consistency of a surface or substance’. Is it dry, rough, smooth, grainy, irregular? potentiates the effect of a sun-block by scavenging Does it reflect light evenly? For practical purposes, Ichibori1 states that ‘skin free radicals generated both by body metabolism as texture represents the degree of uniformity of the surface of skin’. It can be well as by UV damage.1,4 Vitamin C levels are high in argued that, as it relates to the overall skin surface, anything which affects normal epidermis and dermis but the levels fall with the skin either directly or indirectly will affect skin texture. There are many natural ageing as well as environmental and sun factors involved in the perception of skin ageing; these include spots, uneven damage.7 Although both of these vitamins should pigmentation, wrinkles, loss of volume, pore size, erythema and texture.1 Skin feature in a healthy balanced diet, significant levels texture is hugely important in skin ageing and in fact, in one Japanese study, are often not reached in the epidermis and topical visible skin firmness and texture was found to be the first skin parameter to application of these vitamins may be a more efficient decline with age, occurring in participants’ 20s; whereas hyper-pigmented spots targeted method for supplying nutrients to the skin, appeared in the 30s and wrinkles in the 40s.2 Therefore if we wish to prevent the especially to the epidermis.7 earliest signs of ageing, we must focus on optimising skin texture first. Regular cleansing and exfoliation with fruit enzymes, Historically the focus has predominantly rested on treating wrinkles and volume alpha- or beta- hydroxy acids and the use of retinoic loss with muscle relaxing injections, fillers and surgery; treatments that provide acid (the active form of vitamin A in the skin), the instant wow-factor that patients crave. Patients, however, are no longer increase the turnover of new skin cells and keep the satisfied with having tightened, plumped-up faces free from wrinkles. In my skin looking luminous. Vitamin A preparations such experience, patients are now requesting the ‘no makeup, makeup’ look. The as retinol, retinaldehyde or retinyl-propionate, as rise of celebrities with flawless looking skin in popular culture, many of whom well as newer formulations of vitamin A, for example, now acknowledge the procedures that they have had, has fuelled the demand nano-particulate tretinoin, optimise topical retinoid for perfection. Skin resurfacing and rejuvenation techniques have experienced therapy while reducing the skin irritation that often significant advances in the last few decades and new devices are continuously limits its use.8 being introduced.3 This has been facilitated by developments in science and skin A well-hydrated skin ages more slowly.2 The regular culture laboratories, which have allowed us to test both the safety and efficacy use of moisturisers containing hyaluronic acid, of anti-ageing treatments on human skin equivalent culture models.4 As a result, glycerine and other compounds which help to retain we have been able to develop a wide range of both preventative and corrective water in the dermis and reduce trans-epidermal water products which are proven to improve skin texture.4 loss is therefore essential. Healthy skin texture should be smooth, evenly pigmented, well hydrated and Chronic inflammation leads to the production overlying a well supported dermis. Unfortunately there is no quick fix to achieving of free radicals which damage cell components optimal skin texture; a patient must be committed to an ongoing skincare regime and contribute to disease and ageing.4 The role tailored to their individual skin needs. This starts from the initial consultation. of inflammation in both skin and body ageing is Practitioners first and foremost need to know the patient’s desires, and assess becoming increasingly recognised and with it, the whether they are realistic or not. Factors influencing the choice of treatment for importance of a diet high in essential fatty acids, which each patient would include their age, skin colour and Fitzpatrick type, whether help to reduce skin inflammation.9

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015 @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

Specific treatments could include fractional laser devices, which If the skin texture is not can work to refine pores and improve skin texture, and can be used regularly as part of a prophylactic or maintenance regime. specifically addressed, the Dermarolling is another widely used rejuvenating treatment which also enhances the absorption of topical product. Carbon dioxide and patient will not get the fractional laser can also be used as resurfacing tools, and are usually reserved for deeper scarring or more intensive rejuvenation. A series best outcome from their of chemical peels using salicylic acid 20-30%, glycolic acid 40-70% or trichloroacetic acid 20-30% depending on skin type and indication treatment and their skin will will also enhance skin texture and tone.10 Complications of all of these treatments include scarring, infection and in darker skin types, the remain looking aged potential for pigmentary problems. Side effects are minimised by careful patient selection, adequate preparation as necessary (e.g. Other products which have been shown to deliver texture benefits to reduction of melanocyte activity) and the skill of the practitioner. The the skin include Panthenol (which increases skin hydration), N-acetyl patient will choose a treatment modality that suits their own personal glucosamine (NAG) and Niacinamide, a water soluble derivative of preference and skin needs, taking account of price, time commitment vitamin B3 which has been shown to reduce pore size. for the procedure and the ‘down-time’ required afterward. More recently interest has grown in investigating the role of In summary, changes in skin texture represent the first signs of ageing epidermal growth factors and peptides – synthetic or naturally and hence must be targeted at an early age, ideally whilst patients occurring dermal proteins which are involved in wound healing and are still in their 20s. Modern advances in bio-science are making have been proven to stimulate proliferation of collagen and elastin in it increasingly possible to study the ageing process and to keep skin cultures. The palmitoyl derivative of one such peptide (lysine- it at bay. A good everyday skincare regime, with regular specific threonine-threonine-lysine-serine (pal-KTTKS) has demonstrated treatments as per patient need, is the basis of achieving a healthy significant reductions in wrinkles and general skin appearance.4 texture in all types of skin. Once the patient’s skincare regime, diet and lifestyle are optimised, Dr. Sharon Crichlow works as a consultant more targeted treatments can be added. As mentioned earlier, all dermatologist at the Skin to Love Clinic in St. Albans, UK. cosmetic skin treatments will affect skin texture, whether directly or Her interests include the treatment of acne scarring and indirectly. Skin peels, wrinkle relaxing injections, fillers, dermarolling, the pigmentary disorders commonly seen in patients skin tightening devices and laser treatments will all influence the with skin of colour. skin texture. In general, most patients attending an aesthetic clinic REFERENCES: 1. Ichibori R, Fujiwara T, Taniqawa T et al., ‘Objective assessment of facial skin ageing and the are initially more concerned with volume loss and wrinkles and so associated environmental factors in Japanese monozygotic twins’, Journal of Cosmetic appreciate the instant gratification produced by fillers and toxins. Dermatology, 13 (2) (2014), pp. 158-63. 2. Kukizo Miyamoto, Yasuko Inoue, Kesyin Hsueh et al., 10 year longitudinal Japanese study tracking However, if the skin texture is not specifically addressed, the patient facial skin ageing for wrinkles, texture, hyperpigmented spots, radiance and firmness(UK: P&G Beauty and Grooming) remain looking aged. Sometimes the improvement in the wrinkles 3. Kirkland EB, Gladstone HB, Hantash BM, ‘What’s new in skin resurfacing and rejuvenation?’ Giornale Italiano Di Dermatologia e Venereologia, 145 (5) (2010), pp. 583-96. and facial profile paradoxically makes the abnormal skin texture even 4. P&G beauty and grooming, Innovations in Technology and Clinical testing (UK: P&G Beauty and Grooming)< http://pgbeautyscience.com/fine-lines-wrinkles-texture-influence-self-perception1.php> more conspicuous. I would therefore recommend offering a suitable 5. Maria Celia B, Gail M Williams, Peter Baker and Adele Green, ‘Sunscreen and prevention of skin skincare regime alongside toxins and fillers, with more targeted ageing’, Annals of Internal Medicine, 158 (11) (2013), pp. 781-790. 6. British Association of Dermatologists, Sunscreen Fact Sheet (www.bad.org.uk) 7. Alexander J Michels PhD. Vitamin C and skin health (US: Linus Pauling Institute, 2011) and therefore, they will hopefully be encouraged to continue with 8. Siddharth Mukherjee, Abhijit Date, Vandana Patravale et al., ‘Retinoids in the treatment of skin ageing: an overview of clinical efficacy and safety’, Clinical Interventions in Ageing, 1(4) (2006), pp. the valuable skincare regime you have recommended. It is worth 327-348. 9. Giana Angelo PhD., Essential fatty acids and skin health (US: Linus Pauling Institute, 2012) programme take longer to achieve, they are well worth the wait and 10. Marta I Rendon, Diane S Berson, Joel L Cohen et al., ‘Evidence and Considerations in the Application of Chemcial Peels in Skin Disorders and Aesthetic Resurfacing’, The Journal of Clinical the benefits accumulate over time. and Aesthetic Dermatology, 3(7) (2010), pp. 32-43.

Why are Doctors and Nurses switching

THE ART OF FACIAL REJUVENATION to VARIODERM HA Dermal Fillers?

• Made in Germany to the highest of standards • Clinical trials show that it outperforms other major brands for elasticity, longevity and performance • Dynamic product range for various indications • Very competitive pricing • Very high level of patient satisfaction Contact [email protected] for further info and pricing.

Adare Aesthetics Ltd, 26 Fitzwilliam Square South, Dublin 2, Ireland. Mob: +353 (0)85 711 7166 | Tel: +353 (0)1 676 9810 Email: [email protected] | Skype: ivanlawlor | Web: www.adareaesthetics.com Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015

...is a new generation • of highly concentrated & cross-linked hyaluronic acid ﬁller • for various indications in the dermis & subcutis • convincing with long-lasting clinical results • available in 70 countries worldwide • Made in Germany

Adare Aesthetics Ltd, 26 Fitzwilliam Square South, Dublin 2, Ireland.

Mob: +353 (0)85 711 7166 | Tel: +353 (0)1 676 9810 Email: [email protected] | Skype: ivanlawlor Web: www.adareaesthetics.com NEW PRODUCT LAUNCH

skinmed LTH A three dimensional alternative to surgery

1 . L I FT

2 . T IG H TEN

3 . H Y DR ATE

The Ultimate Multi technology clinical platform soon to be revealed as the NEXT TOP CELEBRITY SECRET to an uplifted and regenerated skin Here’s why 3D-skinmed is a must investment for 2015

Advanced multi-technology platform offering 1 the latest clinical treatments for facial lifting, 3D-HIFU skin tightening, acne scarring, scarring and High Intensity Focused Ultrasound is the latest clinically 1.5mm proven technology for face lifting and the improvement in the cosmeceutical product infusion. 3.0mm 4.5mm appearance of lines and wrinkles in one single session. Synonymous with the 3D-Brand this affordable cutting edge technology and consumables 2 3D-RF make this advanced treatment accessible to a Focus Fractional Radio Frequency is the 3rd generation wider consumer base. of RF technology. It utilises three or more pole/electrodes to deliver the RF energy under the skin providing more A highly profitable addition to any clinic’s menu. superficial skin tightening to compliment the deeper results achieved by HIFU. As expected of the 3D-Brand, backed by 3 one of the largest National PR awareness 3D-Impact 3D-Impact creates an intensive delivery of cosmetic campaigns that the industry will have ingredients to help fight the visible signs of aging and witnessed! maximising the skins hydration.

For further information or www.3d-lipo.co.uk a demonstration call: 01788 550 440 @3Dlipo 3D-lipo FACIAL ANATOMY TEACHING FOR REGISTERED MEDICAL PROFESSIONALS

Consultant Plastic, Reconstructive & Aesthetic Surgeon Mr Dalvi Humzah provides independent bespoke Facial Anatomy Teaching for registered medical professionals.

These sessions hold a strong practical component Teaching Initiative’ at The Aesthetic Awards 2013-14 and are entirely focused to meet the learning needs & 2014-15. In addition, Mr Humzah provides teaching of the individuals who attend and are tailored to to focus upon ‘The Management of Non-Surgical comprehensively explore facial anatomy in the Complications Through Anatomy’ to further explore context of safely performing injectable treatments. the concept of safe injecting and increase awareness The teaching holds CPD from The Royal College of surrounding complications encountered through Physicians & Surgeons of Glasgow and has won ‘Best botulinum toxin and dermal fillers. UPCOMING EVENTS 6th May 2015 3rd June 2015 ‘The Management of Non-Surgical ‘Facial Anatomy Teaching’ Complications Through Anatomy’ The Royal College of Surgeons Eng - 9am-5pm The Royal College of Surgeons Eng - 9am-5pm Call 07739 378 693 to book your place

W - facialanatomy.co.uk T - 07739 378 693 E - [email protected]

@facialanatomy aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics

and was much less noticeable with make-up Case Study: Treating (Figure 3 – no make-up). By September it had completely subsided but the patient was Filler Complications left with a deep line on hard expression in the glabella area (Figure 4). In November, the Frances Turner Traill shares her experience of area had completely recovered so I treated managing a filler complication, and advises it with botulinum toxin, which improved the appearance of the deep line – making the practitioners on how to handle adverse events patient, once again, a satisfied patient Figure( 5). As soon as the patient reported the As an independent nurse prescriber, I have in the injected area” and was becoming complication, I asked her to take good, clear been treating aesthetic patients since extremely distressed as a result (Figure 1). I photographs of her face and send them to me 2008. In June 2014, a long-standing 36-year- was acutely aware that I could be dealing with immediately. I also took my own photographs old patient visited my clinic for dermal filler a potentially delayed skin necrosis. I managed when she came to the clinic. Taking well-lit, treatment. The patient had been treated with the distress and psychological issues the well-positioned photographs regularly is botulinum toxin and dermal filler in my clinic patient was experiencing holistically, using essential for the successful management annually for the past four years. She had not my general nursing, diagnostic prescribing of complications. It allows practitioners to undergone any previous aesthetic treatments and psychiatric nursing skills. It is essential conduct thorough patient assessment and prior to this. I had injected less than 0.5ml of that, following a complication, patients receive enable accurate treatment of the complication hyaluronic acid filler into her glabella area four both verbal and written advice quickly and in a timely and visual manner. I ensured that times previously but with a lower viscosity clearly. I contacted the patient via telephone, the patient continued to take her medication HA filler, with no adverse reaction. During explained what an impending necrosis and kept in touch with her regularly. With new consultation I had followed usual protocol and was, and reassured her that I would do my research and innovation presented to us each outlined the risks associated with treatment, utmost to control this unexpected reaction. day, it is vital that we ensure our patients are which I checked were understood by my As an immediate treatment, I instructed her offered the very best levels of competence patient. A full medical history was also taken, to take 75mg of Aspirin for two weeks, as available. Reading journals, attending which indicated that the patient would be well as over the counter antihistamines. She conferences and communicating with fellow suitable for treatment on this day. was also instructed to use heat pads on aesthetic professionals will help ensure To begin treatment, I first identified the the affected area to encourage the blood you are confident to deal with and support supratrocheal artery by the medial crease on vessels to dilate, resulting in improved blood patients when faced with any complication contraction. I adopted an aseptic, standard flow. I explained to the patient how to test in your practice. To that end, I presented this technique in which I insert the needle, stop, her blood circulation, which we found was case study at the Edinburgh BACN meeting aspirate the needle and watch both the not compromised. She was then asked to in November 2014. The main question skin and patient’s reaction. I injected slowly, attend the clinic as soon as possible. After asked was why I didn’t use Hyaluronidase to performing retrograde linear threading whilst a face-to-face assessment (Figure 2), I degrade the HA dermal filler. My diagnosis continually observing for signs of vascular prescribed 500mg of Clarithromycin tablets was that the patient had post-injection occlusion. I injected 0.5ml medium viscosity BD for 14 days, and 400mg Moxifloxacin swelling, causing some compromise of her filler into the patient’s glabella area using the OD for 14 days as a precautionary measure supratrocheal artery, which had reduced manufacturer’s syringe and needle. against acute infection. My original plan was significantly following Aspirin, heat, massage As expected, the treatment went smoothly to use 1500iu of Hyaluronidase dissolved and antihistamine use. I would have – the patient did not complain of any with 2.5ml of normal saline for rapid injected Hyalronidase if there had been no unexpected discomfort and was happy degradation of the HA dermal filler. The improvement, a deterioration or if necrosis with the immediate outcome. There was patient, however, had reported a significant was impending. no analgesia used, the patient did not improvement since she had started taking Independent nurse prescriber experience any pain at the time of injection, the Aspirin and antihistamines. Taking this Frances Turner Traill runs her there was no evidence of bruising or into account, we decided to adopt a ‘watchful own medical aesthetic clinics blanching and the vascular return was waiting’ approach, during which she would in Glasgow and the Highlands. She is an active board member excellent. Three days post treatment, send me regular photographs of the skin’s of the British Association of Cosmetic Nurses however, the patient called the clinic to say developments. Fifteen days post injection, (BACN) and continues to lead the Scottish that she had developed a “significant bruise the complication had significantly improved Regional Group’s educational meetings.

Figure 1: Three days post injection Figure 2: Four days post injection Figure 3: 15 days post injection Figure 4: 106 days post injection Figure 5: 156 days post injection

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015 COMPOSED • CONFIDENT • MY CHOICE

INDICATION

PURIFIED1 • SATISFYING2,3,4 • CONVENIENT5

Now approved for crow’s feet lines

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

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

MZ052 ISOBEL A4 AJ 1180BOCOCT2014LD.indd 1 23/10/2014 15:48 aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics

Perioral Ageing Dr Souphiyeh Samizadeh outlines how to create an aesthetically pleasing smile through awareness of perioral ageing and dental structure

When we start our training to become aesthetic practitioners, the movement and sometimes require additional dental or surgical first things we learn are to fill the nasolabial folds and marionette treatment. Dentition and dental treatment play a significant role lines. But how much do we actually know about perioral ageing? in restoring the perioral complex. Conversely, rejuvenation of the The lips and the perioral soft tissues play a key role in facial perioral complex will further enhance the aesthetic outcome of attractiveness. Lips have physiological functions (protection, eating, cosmetic or restorative dentistry. When treating perioral ageing, it speaking and position of teeth) and are central to non-verbal and is important to bear in mind that facial characteristics are different psychological communication. Plump and well-defined lips represent in men and women. Men have larger philtrum widths, and total lip youth, attractiveness, sexuality and beauty.1,2 Teeth are an integral height, wider mouth width, and their pogonion (the most forward- part of a beautiful smile, and the dentition and smile are significant projecting point on the anterior surface of the chin) is located more features in determining facial attractiveness.3 Healthy and well- inferiorly than in women.10,11,12 aligned teeth have been shown to have a positive effect on an individual’s confidence and psychosocial wellbeing.3,4,5 From my own Figure 1 – The perioral region: Lower third of the face findings, as well as media reports, ageing of the perioral region (e.g. (indicated by dark blue line). thin lips, mouth furrows, and downward corners of mouth) seems to The width of oral commissures be amongst the main reasons people seek surgical or non-surgical is equal to the distance between the medial limbi (light 6 aesthetic treatments. Understanding the components of facial blue lines). The lips should be ageing will result in a better understanding of the patient’s individual parallel to interpupillary line (green lines). needs and therefore better-tailored treatment plans.

The perioral region is defined as the lower third of the face, extending from the subnasale to mentum Characteristics of ideal lips (Figure 1). The key perioral landmarks are: · The width of the lips: approximately 40% of width of the lower face16,17 · The philtrum · The ideal lip ratio on the frontal view is 1:1:6; 40% the upper lip and 60% the 18 · Cupid’s bow lower lip · The lips are parallel to the interpupillary line19 · Lips and vermillion border · The length of the upper lip from subnasale is approximately half the length of · Nasolabial folds the lower lip from the chin10,19 · Labiomental folds (Marionette lines) · The width of oral commissures is equal to the distance between the medial limbi17 Skeletal structure and relationships, soft tissue · Subnasale to the vermilion border of the lip is curved contours, the dentition and gingival contour, and · There are specific break points on the lips the lip framework determine a patient’s lower · There is an anterior projection of the central cutaneous lip10 face aesthetic. Skin ageing, subcutaneous fat · The upper lip: well-defined Cupid’s bow with the apexes at the inferior aspect 20,21 atrophy and skeletal remodelling are the key of the philtral columns · The lower lip: fuller than the upper lip, with factors that contribute to facial ageing. Other slight eversion and more vermillion border factors include smoking, stress, lifestyle, work show 7,8,9 habits and diet. Treatment and rejuvenation · On profile, the upper lip will extend beyond of this region without an in-depth understanding the lower lip by a couple of millimetres21 of the anatomy and the ageing process can Figure 2: Youthful lip, full volume, slight eversion of produce undesirable results. For example, as the lower lip, vertical rhytides are preserved and the we age lower facial volume increases, thus, ‘wet-dry junction’ of the lower lip is visible. the desired ‘inverted triangle’ facial aesthetic A: Cupid’s Bow B: anterior projection of the central cutaneous lip decreases. I also find patients lose fine lip

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015 @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

The lip framework aesthetic of a patient’s face. When discussing ideal aesthetics and treatment planning Studies have shown that with for patients, it is important to recognise the differences in ageing:9,16,26,29 races, genders, cultures and aesthetic ideas. The position of · The ramus height and lips is affected by the skeletal make up of an individual and mandibular body length 13,14,15 the underlying dental support. Abnormal dental-skeletal Figure 5 – Perioral ageing: Volume decreases significantly as both relationships should be recognised. loss, loss of skin elasticity, soft-tissue men and women get older, atrophy, loss of bony support and These patients may need orthognathic surgery or orthodontic projection. Loss of mandibular volume therefore decreasing chin treatment, which is beyond the scope of this article. Regardless of also means decreased support of the projection soft tissues and may contribute to laxity cultural and ethnic differences, youthful lips are characterised by of platysma. · The bigonial width does not fullness and well-defined curvatures. change significantly · The mandibular angle increases in both genders, this may result in Lip-teeth relationships blunting or the loss of jawline definition The position and alignment of the dentition influence position of · Loss of mandibular volume contributes towards laxity of platysma lips, smile, phonetics and functional balance. The maxillary incisal and soft tissues of the neck edge curvature would be parallel to the curvature of the lower lip in an ideal smile arc (Figure 4). At rest, there should be 2-4mm vertical The dentition exposure of the maxillary incisors in relation to the upper lip.21,22,23 Chronological tooth wear may result in flattening of the incisal Evaluation of anterior smile aesthetics must include both static and edges, and consequently adversely affect the smile arc. Tooth loss dynamic evaluations of profile, frontal and 45° views to optimise affects the thickness of cortical bone; edentulous patients suffer from both dental and facial appearance.23,24 Position of the upper and significant cortical bone loss and maxillary and mandibular alveolar lower teeth, crowding, lost dentition, discoloured teeth or different ridge resorption. This is more pronounced in the mandible than coloured restorations and tooth wear, all affect the aesthetic of a maxilla, and more in women than men, and results in reduced lower smile. During advanced facial and smile analysis, tooth proportions face height.30 Tooth loss from the lateral areas of the jaw can result and symmetry, the dental midline, gingival aesthetics, the smile arc, in narrowing of the face and hollowing of the cheeks, whilst loss of width of the smile, buccal corridors (the negative space between anterior teeth will produce a concave profile.31 Severe tooth wear buccal surface of upper first premolars and the commissure of lips can also reduce the vertical dimension of the lower face. Dentures when patients smile), contacts, embrasures, and incisal and gingival affect the position of soft tissues and lips, and have a direct effect on display should be taken into consideration.21,25 the lower face height.27,29

Figure 4: The ideal aesthetic smile arc has the maxillary incisal edge curvature parallel to the curvature of the lower lip Changes with ageing: the soft tissue structures Skin The most important environmental insult that contributes to the age- related clinical changes in skin (changes in colour, surface texture, and functional capacity) is chronic solar exposure. Photoageing Changes with ageing: the hard tissue structures is distinct from intrinsic or chronologic ageing. Chronologically The hard tissue structures that shape the perioral complex aged skin shows epidermal thinning, with flattening of the dermal- include the mandible, the maxillary bone and the dentition. epidermal junction and loss of collagen, which results in increased These bony components are central to the overall facial three- water loss and decreased elasticity of the skin. Drier skin is also dimensional contour of the face and suspension of the soft the result of reduced water binding capacity and sebaceous gland tissues. The ageing process affects all of these structures. activity.9 Loss of skin elasticity and volume, in addition to repeated Genetics, occlusal relationship (the relationship between upper perioral muscle activity, contributes to perioral rhytides.5 and lower teeth), dental integrity, midface development and skeletal maturity are some of the factors that influence skeletal Fat compartments and the perioral muscles ageing. Therefore, the rate of skeletal ageing varies in different Facial fat is divided into deep and superficial compartments individuals.7,26,27 and planes. With ageing, the perioral fat compartments become lipodystrophic and ptotic.8 There is a superficial fat compartment The maxilla characterising the philtrum, which has a particular vascular Studies have shown that ageing results in: anatomy.32 · Maxillary retrusion in both dentate and edentulous individuals, in With ageing, the malar fat pad descends and overlaps medially and both men and women16,28 inferiorly over the firmly attached retaining ligament and creates a · Changes in the bony contour of maxilla: The maxilla rotates fold.8 Ptosis of the chin pad, mandibular resorption and lip depressor clockwise26 muscle function, contribute to a prominent labiomental crease.9 Decrease in the maxillary angle and height may play a role in the The mandibular septum separates the jowl from the submental malar fat pad moving down and forward. This results in a posterior fat and is adherent to the body of the mandible. The recession of positioning of the upper lip and deepening of the nasolabial folds.28 this septum with the ageing mandible results in soft tissue rolling over the border of the mandible.23 Orbicularis oris atrophy, in The mandible combination with thinning of the overlying skin, results in formation of The mandible is the structural foundation of the lower face. Any vertical rhytides above the vermilion border. This is made worse by changes in the dimensions of the mandible will affect the overall smoking.18

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015 aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics

Ageing of the lip therefore less display of incisors framework · We see increased intercommissural width at rest Structural changes with · The buccal corridor increases

age Figure 7: The images depict how, with ageing, the smile becomes wider Changes in lip transversely and narrower vertically, showing less maxillary teeth. In addition, morphology during the buccal corridor space increases. Older individuals tend to smile with the lower lip covering the maxillary anterior incisal edges. ageing include the

Figure 6 – Perioral ageing: The upper lip position of the lip loses its volume, lengthens and inverts; the lines, a decrease in lip lower becomes thinner and rolls inward. The volume and thickness intercommissural width becomes longer and commissures droop. The vermilion border (degeneration of elastic Conclusion and philtral columns become thinner; there and collagen fibres), lip The focus of human communication is the face, thus it is key to is flattening of the vermillion border and partial loss of Cupid’s bow; perioral rhytids tonicity, changes in lip social interaction and the perception of attractiveness. The correct become apparent and the nasolabial folds and length and retraction soft-hard tissue balance is important for achieving and maintaining labiomental folds become more noticeable. of the lips. On average, a pleasing aesthetic appearance and function. there is 2-4mm increase in upper lip length with age.2 It has been Better understanding of facial ageing leads us towards a three- observed that the natural curves of the lips are lost through ageing fold facial rejuvenation technique: restoring volume (loss of and lip dryness is shown to be statistically more marked in aged bony volume), lifting and reducing the soft-tissues and skin women. The lower lip becomes dominant over the upper lip and rejuvenation. Advanced rejuvenation involves multidisciplinary is more noticeable in women. Vertical wrinkle lines start to appear treatment and may necessitate dental restorations or plastic during the fourth decade of life but become more visible during surgery. Overfilling and volumising where there is advanced bone the fifth decade (there have been some suggestions that this resorption or dental problems may lead to undesirable aesthetic corresponds to menopause).11 The commissures descend and results. Likewise, perioral rejuvenation without midface correction inter-commissural distance increases with age.11 is not recommended as this can result in an unnatural look.

Dr Souphiyeh Samizadeh is a dental surgeon with a Changes in dynamic of lip movement with age special interest in aesthetic medicine. She is an honorary In a youthful and harmonious smile, the maxillary incisors should clinical teacher at King’s College London and the clinical be visible and exposed by the upper lip by 2-4mm at rest. On director of the Revivify London clinic. She has presented smiling, the entire crown of the maxillary incisors and up to 2mm of at both national and international conferences, and is actively involved with research into aesthetic medicine. associated gingiva should be exposed.

As a result of ageing:11,32,33 · The smile gets narrower vertically and wider across · There is a decreased display of maxillary anterior teeth · Exposure of mandibular anterior teeth increases · There is a reduction in the muscles’ ability to raise the upper lip,

REFERENCES 1. Wollina, U., ‘Perioral rejuvenation: restoration of attractiveness in aging females by minimally 17. Prendergast, P., ‘Facial Proportions’, in Advanced Surgical Facial Rejuvenation, A. Erian and invasive procedures’. Clin Interv Aging, 2013. 8: p. 1149-55. M.A. Shiffman, Editors. 2012, Springer Berlin Heidelberg. .p 15-22. 2. Van der Geld, P., P. Oosterveld, and A.M. Kuijpers-Jagtman, ‘Age-related changes of the dental 18. Penna, V., et al., ‘The aging lip: a comparative histological analysis of age-related changes in aesthetic zone at rest and during spontaneous smiling and speech’. The European Journal of the upper lip complex’. Plastic and reconstructive surgery, 2009. 124(2): p. 624-628. Orthodontics, 2008. 30(4): p. 366-373. 19. Perkins, S.W. and H.D.t. Sandel, ‘Anatomic considerations, analysis, and the aging process of 3. Robinson, P.G., ‘Summary of: The influence of tooth colour on the perceptions of personal the perioral region’. Facial Plast Surg Clin North Am, 2007. 15(4): p. 403-7, v. characteristics among female dental patients: comparisons of unmodified, decayed 20. Klein, A.W., ‘In Search of the Perfect Lip: 2005’. Dermatologic Surgery, 2005. 31: p. 1599-1603. and ‘whitened’ teeth’. Br Dent J, 2008. 204(5): p. 256-257. 21. Naini, F.B. and D.S. Gill, ‘Facial aesthetics: 2. Clinical assessment’. Dent Update, 2008. 35(3): p. 4. AL-DREES, A.M., ‘Oral and perioral physiological changes with ageing’. Pakistan Oral & Dental 159-62, 164-6, 169-70. Journal, 2010. 30(1): p. 26-30. 22. Sarver, D.M., ‘The importance of incisor positioning in the esthetic smile: the smile arc’. Am J 5. Desai, S., M. Upadhyay, and R. Nanda, ‘Dynamic smile analysis: changes with age’. American Orthod Dentofacial Orthop, 2001. 120(2): p. 98-111. Journal of Orthodontics and Dentofacial Orthopedics, 2009. 136(3): p. 310. e1-310. e10. 23. Frese, C., H.J. Staehle, and D. Wolff, ‘The assessment of dentofacial esthetics in restorative 6. Ferrario, V.F., et al., ‘Sexual dimorphism in the human face assessed by euclidean distance dentistry: a review of the literature’. J Am Dent Assoc, 2012. 143(5): p. 461-6. matrix analysis’. Journal of Anatomy, 1993. 183(Pt 3): p. 593-600. 24. Sarver, D.M., ‘The importance of incisor positioning in the esthetic smile: The smile arc’. 7. Coleman, S.R. and R. Grover, ‘The anatomy of the aging face: volume loss and changes in American Journal of Orthodontics and Dentofacial Orthopedics, 2001. 120(2): p. 98-111. 3-dimensional topography’. Aesthet Surg J, 2006. 26(1s): p. S4-9. 25. Ahmad, I., ‘Anterior dental aesthetics: Facial perspective’. British dental journal, 2005. 199(1): p. 8. Rohrich, R.J. and J.E. Pessa, ‘The fat compartments of the face: anatomy and clinical 15-21. implications for cosmetic surgery’. Plastic and reconstructive surgery, 2007. 119(7): p. 26. Shaw, R.B., Jr., et al., ‘Aging of the mandible and its aesthetic implications’. Plast Reconstr Surg, 2219-2227. 2010. 125(1): p. 332-42. 9. Zimbler, M., M. Kokoska, and J. Thomas, ‘Anatomy and pathophysiology of facial aging’. Facial 27. Wulc, A.E., P. Sharma, and C.N. Czyz, ‘The anatomic basis of midfacial aging’, in Midfacial plastic surgery clinics of North America, 2001. 9(2): p. 179-87, vii. Rejuvenation. 2012, Springer. p. 15-28. 10. Klein, A.W., ‘In search of the perfect lip: 2005’. Dermatologic surgery, 2005. 31(s4): p. 1599- 28. Shaw Jr, R.B. and D.M. Kahn, ‘Aging of the midface bony elements: a three-dimensional 1603. computed tomographic study’. Plastic and reconstructive surgery, 2007. 119(2): p. 675-681. 11. Leveque, J.L. and E. Goubanova, ‘Influence of age on the lips and perioral skin’. Dermatology, 29. Bartlett, S.P., R. Grossman, and L.A. Whitaker, ‘Age-related changes of the craniofacial skeleton: 2004. 208(4): p. 307-13. an anthropometric and histologic analysis’. Plast Reconstr Surg, 1992. 90(4): p. 592-600. 12. Masood, Y., et al., ‘Impact of malocclusion on oral health related quality of life in young people’. 30. Bodic, F., et al., ‘Bone loss and teeth’. Joint Bone Spine, 2005. 72(3): p. 215-221. Health Qual Life Outcomes, 2013. 11: p. 25. 31. Sveikata, K., I. Balciuniene, and J. Tutkuviene, ‘Factors influencing face aging. Literature 13. Naini, F.B. and D. Gill, ‘Facial aesthetics: 2. Clinical assessment’. DENTAL UPDATE-LONDON-, review’. Stomatologija, 2011. 13(4): p. 113-6. 2008. 35(3): p. 159. 32. Garcia de Mitchell, C.A., et al., The philtrum: ‘anatomical observations from a new perspective’. 14. Ahmad, I., ‘Anterior dental aesthetics: Dental perspective’. Br Dent J, 2005. 199(3): p. 135-141. Plast Reconstr Surg, 2008. 122(6): p. 1756-60. 15. Ahmad, I., ‘Anterior dental aesthetics: Dentofacial perspective’. Br Dent J, 2005. 199(2): p. 81-88. 33. Van der Geld, P., P. Oosterveld, and A.M. Kuijpers-Jagtman, ‘Age-related changes of the dental 16. Mendelson, B. and C.H. Wong, ‘Changes in the facial skeleton with aging: implications and aesthetic zone at rest and during spontaneous smiling and speech’. Vol. 30. 2008. 366-373. clinical applications in facial rejuvenation’. Aesthetic Plast Surg, 2012. 36(4): p. 753-60.

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015 Advertorial NeoStrata @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

“Our research goes on in our labs for ingredients we plan to use for the next five, ten, fifteen years” NeoStrata’s Vice President of International Business Development Leigh Ann Catlin, and Executive Director of International Markets Catherine Mueller, explain why an evidence-based approach is central to the skincare company’s ethos Leigh Ann Catlin Catherine Mueller

What makes NeoStrata stand out as a skincare company? standard lab for ingredients we plan to use for the next five, ten, fifteen Leigh Ann Catlin (LC): NeoStrata is totally unique as a cosmetic plus years. company for a couple of reasons. One is that we have several LC: Research is really the heritage of NeoStrata. It’s really important laboratories in our offices. We have a cell culture lab where we to Dr Van Scott and Dr Yu (NeoStrata founders Dr Eugene J. Van screen for various ingredients to measure their efficacy in treating Scott and Dr Ruey J. Yu, who discovered AHAs back in the 1970s) to the conditions that we want them to treat – this is where we actually continue researching and to discover new ingredients that can help grow and foster cells. We also have a standard research lab, where people’s skin. we do research on ingredients that we’re interested in using. We also have our own formulation research and development laboratory, with Why does NeoStrata appeal to aesthetic professionals? a full team of scientists that carry out research on our formulations. LC: I think aesthetic professionals can see that NeoStrata has a base So although a small cosmetic company, we research the active of clinical studies and effective products that really work. We have a lot ingredients that we want to use and we also develop our own of doctors that say they use the products themselves, so they feel very formulations. NeoStrata is also unique in the way that we do extensive comfortable recommending them to their patients. testing on our products. A doctor recommending our product, or a CM: They embrace the science that’s behind it. When the doctors consumer using our product, can feel very confident that the claims ask the questions, we have the answers, and we can prove it. They that we make about our products and the things that we say that they also then feel confident that if they’re going to use our products and do, they do. And we have the clinical studies, the data, and the before recommend them to somebody, they fully understand them as well. and after pictures to back up and support the claims that we make. What’s the future for NeoStrata? How important is continuous research and development CM: Dr Van Scott always says that we have great formulations and for NeoStrata? they do great things, but he says the best is always yet to come. And Catherine Mueller (CM): That’s extremely important. Historically we he’s so excited about that! Helping people improve whatever condition are known worldwide as the AHA (Alpha Hydroxy Acid) brand, but they’re trying to improve in their skin, helping them feel more confident although we continue to use AHAs in our formulations, we have in themselves, that’s a great place to be in. What’s great is that our researched other new compounds. We’ve gone from AHAs to Poly brand really does cross all ages, all generations and all conditions, Hydroxy Acids, and, specifically, Gluconolactone. We then went from pigmentation, acne, fine lines and wrinkles, to dry skin, sensitive to Complex Poly Hydroxy Acids, later using Lactobionic Acid and skin and rosacea. now Maltobionic Acid. In the past five years, we’ve started to use LC: The one thing that’s for sure is that NeoStrata Company will NeoGlucosamine, which is a non-acid anti-ageing ingredient with great continue its research. There are many things in the pipeline; there plumping and pigment-evening properties. In our latest technologies, are lots of ingredients and substances that we are researching now we’ve used the amino acid Amino Fill, which is a non-acid technology that will be used in future products. NeoStrata Company is a really – we’ve used this in our latest Skin Active Line Lift for targeted exciting thing to be a part of. treatments to further enhance the plumping, the collagen building and the production of GAGs (Glycosaminoglycans) in the skin. And these are just the ingredients we’ve commercialised over the past 27 years NeoStrata is distributed in the UK by AestheticSource. as a company; our research goes on in our cell culture lab and our For more information contact [email protected] / 01234 313130

54 Aesthetics | April 2015 aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics

A summary of the latest clinical studies

Title: Evolving Perspectives on the Etiology and continues to advance, we are sure to see improvements Pathogenesis of Acne Vulgaris in current treatments, as well as development of new Authors: LF Eichenfield, JQ Del Rosso, AJ Mancini, F applications of cutaneous lasers. Cook-Bolden, L Stein Gold, S Desai, J Weiss, D Pariser, J Zeichner, N Bhatia, L Kircik Title: Fractionated carbon dioxide laser therapy as Published: Journal of Drugs in Dermatology, March 2015 treatment of mild rhinophyma: report of three cases Keywords: Acne, development, topical/oral antibiotics Authors: AA Meesters, MM van der Linden, MA De Rie, A Abstract: As the pathophysiology of acne is complex and Wolkerstorfer multifactorial, the continued influx of new basic science and Published: Dermatology and Therapy, March 2015 clinical information requires careful analysis before drawing Keywords: Rhinophyma, rosacea, laser therapy conclusions about what truly contributes to the development Abstract: Rhinophyma is a bothersome condition of the and progression of this chronic disease. Our objective is nose that is regarded as a manifestation of rosacea (subtype to review the latest evidence and highlight a number of 3). Whereas the efficacy of medical treatments, including important perspectives on the pathophysiology of acne. antibiotics and retinoids, is often dissatisfying, conventional An improved understanding of acne pathogenesis should invasive procedures are limited by their unfavorable side lead to more rational therapy and a better understanding effect profile. We present three patients who were treated of the role of P acnes opens new perspectives for the by a minimally invasive approach using fractionated carbon development of new treatments and management. Further dioxide (CO2 ) laser therapy, showing variable response. research may be directed at targeting receptors, adhesion We observed that fractionated CO2 laser therapy may molecules, cytokines, chemokines or other pro-inflammatory improve patient-reported outcome in some patients with targets implicated in the activation of immune detection mild rhinophyma and is associated with a relatively favorable and response (i.e., toll-like receptors [TLRs], protease- side effect profile compared with conventional surgical activated receptors [PARs]) that appear to contribute to the techniques. pathophysiology of acne. Therapeutic options that reduce the need for topical and/or oral antibiotic therapy for acne are Title: A randomized, controlled clinical study to investigate welcome as bacterial resistance to antibiotics is a clinically the safety and efficacy of acoustic wave therapy in body relevant concern both in the United States and globally. contouring Authors: AH Nassar, AS Dorizas, A Shafai, NS Sadick Title: Laser treatment of periocular skin conditions Published: Dermatologic Surgery, March 2015 Authors: B Yates, SK Que, L D’Souza, J Suchecki, JJ Finch Keywords: Body contouring, acoustic wave therapy, lateral Published: Clinics in Dermatology, March 2015 thigh Keywords: Lasers, lesions, periocular, resurfacing Abstract: There is an increased demand for the reduction Abstract: Advances in laser technology in recent of localized adipose tissue by noninvasive methods. The decades have increased the options for the treatment of objective of this study was to determine the safety and dermatologic conditions of the eye and eyelid. Benign efficacy of noninvasive lipolysis of excess adiposities tumors can be laser-ablated with relative ease, and vascular overlying the lateral thigh region using acoustic wave therapy and melanocytic lesions can be precisely targeted with (AWT). This study incorporates 2 mechanical waves with modern lasers. In this contribution, we review treatment of varying properties in the same session: radial and planar periocular pigmented lesions, including melanocytic nevi AWT. The treatment was performed using AWT on the and nevus of Ota; vascular lesions including telangiectasias, lateral thigh areas of 15 female patients. The study was port wine stains, and infantile hemangiomas; hair removal; performed using the planar and radial pulse handpieces, eyeliner tattoo removal; laser ablation of common benign with 8 sessions performed within 4 weeks. Follow-up visits periocular tumors, such as syringomas, xanthelasma, milia, were performed 1, 4, and 12 weeks after the last treatment. and seborrheic keratoses; and laser resurfacing. The recent Reduction in both thigh circumference and subcutaneous fat advent of fractionated laser technology has resulted in layer thickness, measured through ultrasound, was observed. dramatically decreased healing times for periocular skin This study demonstrates that AWT is safe and efficacious resurfacing and fewer adverse effects. Fractionated laser for the treatment of localized adiposities in the saddlebag resurfacing has now nearly supplanted traditional full-field area. However, the results obtained were not statistically laser resurfacing, and safe treatment of rhytides on the thin significant. Larger studies will be needed to further access skin of the eyelids is possible. Proper eye protection is, of the effects of AWT on thigh circumference reduction. course, essential when using lasers near the eye. Patient Furthermore, the authors also found an improvement in preparation, safety precautions, and risks-intraocular and the appearance of both cellulite and skin firmness after the extraocular-are discussed herein. As laser technology treatments.

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015 TEOSYAL®PEN manufactured by Juvaplus YOUR ART FOR THE FINE OFPRECISION ART SPEAK LET aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics

other clinics and capture the consumer’s attention. The simplest way to do this is through package names and creatively named treatments or treatment zones. For example, if you simply say, “Get in Shape for Summer with the Latest Body Contouring Treatments” it’s bland, but if you created a ‘Bikini Beach Body Menu’ of treatments, it engages readers and suddenly comes to life. For example:

The Bikini Bottom Treatment: Let us sculpt your derriere into the Creating a perfect beach peach with just six pain-free radio frequency treatments The Bikini Belly Treatment: Just two fat freezing treatments will have you ditching your swimming costume and dusting off your Summer favourite bikini The Beachy Bingo Wing treatment: Wave without the wobble in just six weeks LET Lovely Lasered Legs: Want to be smooth and fuzz free this summer? Marketing Ditch the razor and love the laser! Being creative with language does not undermine the seriousness of the treatments; it’s a way of capturing attention and enticing patients Campaign to enter your clinic, where they will then receive thorough consultation and can be provided with any relevant literature on the treatment in YOUR ART Charlotte Moreso explores the question. benefits of seasonal marketing Create a consistent campaign and shares practical tips on how Create the strap line for your summer treatment campaign and stick to to entice patients into your clinic it. Use this throughout all communication. A strap line is the title of the campaign that would be used in press releases and in all marketing during the summer months materials. This could be something like, ‘xx Clinic Beach Body Beautiful Treatments’. Public Relations (PR) and marketing tools could comprise: SPEAK Summer provides a huge opportunity to enhance your aesthetic • A window sticker for your clinic practice, but your marketing must be planned well in advance. Miss • Posters the season by a week or two and your competitor might just snatch • Leaflets that display the treatment menu up your potential business. Methods of marketing are boundless, and • Roll-up banners it’s often a minefield to decipher which of these might work best for • Press releases for journalists your business and within your budget. This guide aims to help you decide which avenues might be best for enticing new patients to How to reach new patients your clinic, whilst capturing the attention of your current patient base Post office mailings, a marketing service provided by the Royal Mail and extending their treatment preferences. Above all, though, your that sees your marketing materials delivered to the door of selected communication methods must be creative. Patients respond best to recipients, can offer a very good return on investment and are interesting tag lines, innovative treatments and eye-catching imagery straightforward to carry out. You are able to pick exact postal drop as much as if they were exploring the latest fashion. zones, targeting people in exactly the area you wish, for what is essentially a nominal amount of money. Once you have selected the Marketing preparation area it is critical that the promotional material looks good and stands Timing: Forward planning is critical in order to capture business. Reach out from other free post. Make it beautiful and something patients patients with your messaging and offers in the spring, when they are will want to pick up and not just throw away. An aesthetically pleasing starting to think about ‘bikini-body’ season, then consistently target image one side and treatment menu on the reverse with your clinic them with updated information and messaging. details is sufficient. Offer a free taster treatment and the phones will FOR THE FINE ART OF PRECISION The Science: You may respond to the intricacies of the latest aesthetic start ringing. You can send materials in envelopes or alone, but placing technology, but the average patient will not. They will want to know it in a good quality coloured envelope could become more enticing to how it works, how long until they see results, whether it will it hurt, the recipient, and is a unique idea if the budget allows. and prices – so don’t blind them with science. Think of those beauty adverts that proclaim, ‘The Science Bit’ at the end of the advert and aim Summer treatment open days for the same level of information when marketing to your patients. I have witnessed immense success from open days, with patients queueing to pay for bookings – but open days only work if you get The First Steps: Before you do anything, look at your treatments and them right. Here’s the magic formula for filling the diary with bookings: list what aspects of the body patients will be hoping to improve this What: Open your clinic for a day or afternoon and evening to all your summer. Your list will usually include laser hair removal, sun protection, patients and potential new patients, offering free taster treatments from body contouring, fat reduction, cellulite treatments, stretch mark your summer treatment menu. Also ensure you have a few ‘models’ PEN manufactured by Juvaplus PEN manufactured ® treatments and facial treatments to even out the complexion so that to perform demonstrations on in quieter spells, as this often attracts an they can ‘go bare-faced’ on the beach. Once you have your definitive audience. When conducting these tasters, leave treatment doors open treatment list, it’s time to get creative. You need to stand out from the so people can see what is going on inside. It soon draws a crowd. TEOSYAL

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015 Botulinum toxin and dermal fillers courses at the RSM

Cosmetic procedures are some of the most rapidly growing specialties of medicine and surgery today. The Royal Society of Medicine brings you bespoke CPD accredited courses that will effectively update and enhance your knowledge and skills within the field of cosmetic surgery.

The courses cover both theoretical learning and hands-on experience, with patient-models, under the supervision of expert trainers. A certificate of attendance will be provided at the end of the course to those who pass the assessment.

Botulinum toxin and its applications - a day course

Dates: Tuesday 19 May and Thursday 2 July Venue: Royal Society of Medicine, London CPD: 6 credits Rates: RSM members £599 Non members £669

Dermal fillers course

Dates: Tuesday 2 June and Wednesday 8 July Venue: Royal Society of Medicine, London CPD: 6 credits Rates: RSM members £699 Non members £799

Botulinum toxin and dermal fillers course – intermediate (Manchester) Dates: Saturday 13 - Sunday 14 June and Saturday 12 - Sunday 13 September Venue: Manchester (Venue TBC) CPD: 12 credits (6 per day) Rates: RSM members £599 - £1,199* Non members £649 - £1,399* *please note, one and two day rates available

For more information and to register online, visit www.rsm.ac.uk/courses

Contact details: Telephone: 0207 290 3928 Email: [email protected]

Aesthetic_Ad_amended.indd 1 05/03/2015 11:25 aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics

When: April or May is a good time, but avoid school holidays as Successful summer campaigns potential patients who are also busy parents may be unable to attend. A recent summer campaign I was involved with was for a world- Deals: Create good value package offerings, redeemable only if they leading aesthetic beauty company where we promoted all their book on the day. This ensures immediate booking without the risk of body devices, both existing and new, at a press event in London. losing their interest once they have walked away. Of course, it is vital The campaign, entitled ‘Body Beautiful’, was divided into two clear that you adhere to Keogh’s recommendations when marketing these areas: Skin Perfecting and Body Perfecting. Skin Perfecting included clinic ‘deals’. It was stated in the Keogh Review that, “advertising and treatments for stretch marks, veins, tattoo removal and body scars and marketing practices should not trivialise the seriousness of procedures Body Perfecting included treatments for fat, cellulite and skin laxity. My or encourage people to undergo them hastily.”1 Offering time-limited team enlisted leading UK aesthetic doctors and experts to present deals, financial inducements, cosmetic procedures as competition both the ‘Facts & Fix’ for each issue at the press event. A Little Black prizes and package deals such as ‘buy one get one free’ or ‘refer a Book of Body Beautiful was written, detailing each presenter’s topic, friend’ should be avoided. and this was given to the UK’s top 500 health and beauty writers as Goody Bag: Contact the suppliers of your brands and ask them to a resource for their articles. The event took place mid-January, when donate some mini-samples to the goody bag – everyone loves a editors and journalists were working on their early summer issues. freebie! To add theatre to the event we had a male and female model spray Adding Luxury: Serve canapés, sparkling wine when appropriate and painted gold and silver to signify the concept of ‘Body Beautiful’. healthy juices. This doubled up as a social media tool, where journalists tweeted How: Create a postcard-sized flyer with details of the event on the novelty shots of themselves with the models. The most successful front, and treatment menu on the reverse, that can be mailed out to summer-themed PR and marketing campaign we have created homes in your local area. Go online and buy a stock image (from a was for a leading laser hair removal device. Their Unique Selling stock photography website) of a good bikini body to capture attention, Point (USP) was that all skin colours and most hair colours could be and ensure your flyer contains the following information: treated. We therefore created a consumer-focused campaign called, • Invitation to preview/experience the Must-Have Summer Bikini ‘No Shades Barred’. Creative marketing materials were developed Body Menu at your clinic using a block of facial images illustrating all the different skin and hair • Menu of Taster Treatments colours on their laser spectrum. This eye-catching image was placed • Complimentary Taster Treatments onto roll-up banners, posters, leaflets and window stickers. A press • When and where pack was created and included in a marketing guide sent to all the • Special Offers clinics using the laser. This enabled the clinics to send the pre-written • Goody Bag for every attendee press releases to their local newspapers and magazines, and refer • RSVP to reserve your place to our guide on how to best communicate with journalists. The pack also detailed how to order the different marketing materials. The Press Reviews: Use the same menu of treatments to invite your local campaign materials were up-taken by many clinics and the campaign press to try out full-length versions for reviews in the local magazines images were used online as well. This campaign won Best Consumer and newspapers. If possible, avoid inviting them to the consumer open Campaign 2013 at the Aesthetic Awards. day, as they like to be treated on a one-on-one basis and expect the full treatment or a course of treatments in order to write a thorough And don’t forget… review. If you advertise with local magazines or newspapers you should Use any press coverage you receive to best effect. Consumers love to try and use this to your advantage in order to secure editorial reviews. see your name in the media, so scan it and post on Facebook, Twitter Depending on the publication, try and negotiate editorial reviews when and your website or if the piece is particularly good, produce an e-mail you book any advertising; alternatively, develop a good relationship flyer and send to your patient list. Many clinics also produce coverage with the editorial team at the publication and they will naturally be more books or create montages of their coverage as a poster or postcard, inclined to write about your event and the treatments you provide. which can be displayed in reception. Also see what support the PR agencies that represent the aesthetic device companies can offer you. What not to do They may provide you with press releases or ideas on how to market the treatment to patients. When creating your summer marketing campaign, don’t… The three C’s Sell too hard: We all know when we are being sold to, In summary, be creative, consistent and think consumer, consumer, so keep it subtle and targeted towards what patients consumer. Tell patients what they’d want to know, rather than what really need Do a press launch: Unless you have something 100% you’d want to know. unique to tell journalists about. They are time-poor and Charlotte Moreso is managing director of True Grace PR. getting them out of the office can be tricky. One-to-one Charlotte has worked as a PR and marketing consultant invites set at a time that is convenient for them often in the health and beauty industry for more than 20 work better years, running highly successful campaigns for global Devalue your clinic: Too many offers might actually commercial brands, smaller UK beauty brands and in more work against you. You want to be seen as the more recent years, creating news for the UK’s leading aesthetic treatments, advanced clinic, not necessarily the cheapest doctors and clinics. Her work has won several industry awards. Overwhelm patients with too much science: Just REFERENCES because it’s a technical device doesn’t mean they want 1. Department of Health, Review of the Regulation of Cosmetic Intervention (England: GOV.UK, 2013) to read all the techy information https://www.gov.uk/government/publications/regulation-of-cosmetic-interventions-government- response [accessed 23 March 2015].

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015 WORLD NOVELTY WITH DEPTH-EFFECT

With its innovative mode of action EVENSWISS oﬀers a worldwide unique approach in anti-aging care. The patented active ingredient Dermatopoietin® (a full equivalent of the human epidermal cytokine interleukin-1 alpha) aﬀects the dermal skin layer without penetrating skin by triggering a cascade of reactions which propagates from the surface to the depth of skin. This way it stimulates the natural production of collagen and elastin.

53- YEAR OLD SKIN

COLLAGEN LOSS

BEFORE AFTER TREATMENT The results are clinically proven and visible: skin rejuvenates in the most natural way.

www.evenswiss.ch aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics

went, but you can rectify the situation. Use marketing strategies to attract them back to your clinic: an exclusive, limited-time offer with free taster sessions that showcase treatments needing regular clinic visits for optimum results. Provide results-driven treatments that patients can see and feel instantly – this will keep them coming back for more, and encourage them to book a course of treatments. Provide these ‘taster treatments’ on a usually quieter day, give it an appealing name and encourage them to bring friends to your new, say, ‘Love Your Skin Days’.

Get all your basics right There’s a big difference between a ‘need’ and a ‘want’. A need is just what must be done, and your patient has very little emotional attachment to it. Meeting his or her needs won’t necessarily turn the individual into a long-term loyal patient. A want is different. There’s a reason why your patient desires something and this is often loaded with emotion. Explore their real reasons for seeking Maintaining aesthetic consultations and reflect their own use of emotional words when presenting their individualised treatment plan. This way, your patient will know that you have listened and are now offering a Patient Loyalty personalised answer and treatment tailored to their wants. Another way of providing an individualised solution that suits the patient’s needs is to offer an annual treatment plan with monthly affordable Pam Underdown extols the value payments, perhaps using a monthly online recurring direct debit system. Patients benefit in terms of spreading the cost of treatment, of offering VIP service to encourage but to use this type of system your business needs to already be patients back into your clinic profitable. You must decide if this is of real value to your particular patient base and makes business sense for your clinic. However, ensuring return business is not about doing one or two big things; it’s doing a hundred little things with care and “You are the best and I will recommend you to everyone!” consistency, with every single patient and every single visit. These are the words practitioners should want to hear from every Anything that is meaningful, memorable, fun, unusual or unexpected patient. To achieve such acclaim, it is vital that you put the time will influence how patients feel about you and your clinic. Train your and effort into making sure your patient experience is beyond team to give outstanding service. Don’t accept mediocre results compare from beginning to end. This patient has chosen you and from your team and before long you’ll be attracting the staff that your clinic because, in an increasingly busy, stressful world where don’t want mediocre results either. Motivate your team through time is precious, you are able to connect with them simply by regular meetings, training and team building sessions to keep listening and caring enough to give them what they really want – a morale high and reach your targets, thereby ensuring patients are treatment and service that makes them feel valued and special. The consistently satisfied. Training should not just cover the clinical aesthetic patient that feels a bond with you and your clinic is your aspects of an aesthetic practice, but also brush up on business and walking, talking testimonial. Retaining this bond is crucial. This can customer service skills; skills that guarantee your patients leave be done in a multitude of ways, primarily through rewarding existing your clinic in high spirits. patients for their continued loyalty, providing unparalleled service and reconnecting with past patients. The best way to maintain this relationship is by enhancing the patient experience; giving them the ‘wow’ factor that keeps them coming back for more. Ensuring return business Are you a one hit wonder? If you spend all of your time, money and effort attracting a new is not about doing one or patient and then never see them again, you are doing them and your business a disservice. If the patient felt confident enough in you to say two big things, it’s doing a yes initially, the hard part is done. The least you can do is reciprocate by staying in touch and following up with how they are. It’s always hundred little things with faster, cheaper and easier to reconnect with previous patients than it is to attract new patients, so do your best to maintain connections. care and consistency, with

You are never going to know why you lost patients, unless you every single patient and reach out to them Chances are you lost some patients last year. Perhaps you can’t every single visit say for sure how many you lost, why you lost them or where they

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015 @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

Communicate and live by your ‘Patient Promise’ 20% of your patients. It’s called the Pareto Principle (named after Your promise doesn’t need to be long; it just needs to explain what the Italian economist Vilfredo Pareto) and it works just as well today patients can consistently expect, why you’re different and how you as it did decades ago.1 The Pareto Principle is very simple, yet very keep your promises. Testimonials from existing, loyal patients that important, particularly in business. What was most important about relate to your promise can be used as marketing material for new Pareto’s finding was that this 80/20 distribution occurs extremely patients and reinforce your clinic’s positive image. For consistent frequently. In addition, the principle also suggests that 20% of results you need effective systems and processes in place, as well your time produces 80% of your results. Your top 20% of patients as the standards and measurements so you know whether your provide a consistent revenue stream, and because of their frequent patient promise is being delivered every single time – regardless custom, they require less set-up time. Look for those who have spent of which staff member your patients sees, what day they have more with you, visited most frequently, referred more patients than had or their mood. In order to implement effective systems and others or those who are very connected in the community. Then processes (aka protocols) you must first ask yourself what your put a ‘fence’ around them to keep them happy, loyal, returning and goal is with your new ‘Patient Promise’, the vision you are pursuing, referring. With these select number of patients, you should market your patients’ expectations, your team’s expectations, what you to them in a different way, enhance their experience and reward do (the system), why you do this and how you do it (the process). them so that they feel appreciated. Make them part of your exclusive Document each element of your ‘Patient Promise’ using a step- VIP Club so they receive extra perks that other patients don’t. Give by-step approach and decide which areas need monitoring and them value-added extras such as: same day appointments, regular improving (the standards) and how you are going to measure each VIP patient appreciation events, or a free makeover after every one. Will you measure based on emotional benchmarks (so you procedure so they can go right back to their everyday activities. know the impact your clinic has emotionally on every patient)? Or Another effective way of rewarding these patients could be by will you measure it by performance (i.e. how quickly your phone offering them a free monthly skin treatment, a free skin analysis or a is answered)? Will you measure by financial targets or by patient retail discount card. Be creative; you have many options, just ensure feedback? Once fully documented, you can train your team to that whatever you are offering is feasible and realistic; you don’t want to end up disappointing your best customers by failing to deliver on a promise. The best way to retain The end goal of this marketing activity is to make these patients feel special because they are part of your inner circle. The notion of a patient loyalty is not to cut ‘VIP club’ has a very similar feel to the airline frequent-flyer clubs. You have a very different flying experience as part of the club – back on costs when times you get on first, there’s plenty of room for your luggage and you get more leg-room. It’s a different industry, but the same concepts are tough, but to invest apply. People like to feel special and will invest in that feeling. When a patient feels like they have been rushed through a treatment to in the right areas of your make room for the next patient, they are less likely to feel special and will probably visit a clinic elsewhere. Capitalise on the idea of VIP business service to ensure your patients are more than satisfied when they leave your clinic. This will guarantee verbal recommendations and implement each standard and ensure that the appropriate team ensure their return for their future treatments. member is accountable for on-going measurements, improvements and feedback. You must also include each one in your operations If you look after your patients – they will look after your profits manual and staff handbook. A simple example of a standard is Return patients and referrals are what make a business successful. the measurement of incoming calls: perhaps your Patient Promise Your loyal patients are your brand advocates and should be treated states that all calls will be answered within two to three rings – in like gold. Don’t take them for granted. Acknowledge and appreciate order to measure that you must carry out the appropriate checks, them for what they are – your positive spokespeople who keep either manually or by using call handling software to ensure this coming back to you again and again, and bring their friends, family standard is met constantly. Remember, your job as the business and colleagues. In simple terms, the best way to retain patient loyalty owner is to ensure your team knows what’s expected of them. You is not to cut back on costs when times are tough, but to invest in the must provide the training, measurement and support to guarantee right areas of your business; your patients, staff, marketing, education each standard is consistently achieved. By sticking to your promise, and continuous improvements to your patient journey. Do this well your business will reap the benefits. Satisfied patients will not only and watch your loyal patient base grow. come back regularly, but will also be more open to giving back, Pam Underdown is a business growth specialist and the which may be in the form of providing consent for their treatment owner of Aesthetic Business Transformations. She works images to be used within your marketing, or offering honest exclusively to help medical aesthetic business owners feedback on your clinical services. improve their marketing, increase their profits, reduce their costs and build a long term sustainable business asset. Pam has more than 25 years of business development, sales and marketing Discovering your VIP patients experience, including nine years in the aesthetics marketplace. Divide your patient database into those who are loyal, those who visited and never booked, and those who you treated but never REFERENCES saw again. People can be inconsistent – things change and people 1. Lavinsky D, Pareto Principle: How to use it to dramatically grow your business, (Forbes, 2014) < http://www.forbes.com/sites/davelavinsky/2014/01/20/pareto-principle-how-to-use-it-to-dramatically- change. I’m sure you’ve heard that 80% of your profits come from grow-your-business/> Last accessed 19 February 2015.

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015

@aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

or prescriptions. In addition, it is less likely that you will have colleagues that you can call upon or refer to. I gave my patient lengthy advice over the phone and asked her to keep me informed of her progress. The next day things had not settled and were, perhaps, even worse. She visited her GP and was referred to a dermatologist who saw her twice in two days and prescribed oral antibiotics to treat the complication. During this time I tried to keep in touch by phone, text and email, however, after a few days, she stopped responding to me completely. Handling a Never before (or since) have I come across such a violent reaction to a light-based treatment from such a small change in Legal Complaint settings. It was especially unexpected as my patient had received several previous In the January issue of Aesthetics, Dr Askari treatments, at greater energies than the one that had caused her blister, with no Townshend argued the importance of a skilful significant problems. My patient was and thorough approach to handling potential adamant that there had been no recent sun exposure, changes in medical history or litigation. This month, he shares his personal medication that could have contributed to experience of managing a legal complaint the abnormal response. I immediately stopped using my IPL system and cancelled all booked treatments. The Hamilton Fraser, the UK’s largest cosmetic which she signed, took good photographs self-test used to diagnose any problems insurer, include ‘top tips on how to avoid a of her condition and performed a test with the device was uneventful and the potential claim’ in the knowledge centre1 patch. When she attended the clinic for company engineer found no faults after on its website: her rosacea treatments, photographs conducting a full service. I contacted the were taken on each occasion and a company’s trainer and two other national 1. Keep detailed patient notes questionnaire on change in medical history experts who used the same system but 2. Keep hold of your patient notes was completed. none could shed any light on why this had 3. Assess your clients carefully The first four treatments with incremental happened. Once my device received the all 4. Obtain a full medical history from the increases in energy produced excellent clear I started using it again, very cautiously patient results. A very small blister did appear to begin with, and found no problem with 5. Patient consent after the second treatment, but this any other treatments. 6. Follow product guidelines resolved without consequence. For the I informed the Health Care Commission 7. Record settings fifth treatment, I increased the energy by (as the Care Quality Commission (CQC) 8. Encourage patient to follow guidance one joule (the smallest increment) – this is was known then) and my insurer. With no 9. Patient literature normal practice as the target chromophore channels of communication, there was 10. Take before and after photos is reduced by the success of previous nothing more that I could do to help my treatments. The next day, my patient patient, which meant I could only wait and All of these are important to follow and will contacted me to report that, after treatment, hope that all was healing well. reduce your chance of facing a claim, but her face had felt hotter than usual and had I received a formal letter of complaint four bear in mind that they will not eliminate the developed blisters, also experiencing a months later, to which I replied expressing risk – as I have found out to my cost. significant amount of swelling. Without my my regret at what had happened and After opening my own clinic in 2008, knowledge, she had attended her local enquired what outcome she hoped for patients that I had previously treated A&E department where she was treated in order to resolve the complaint. The followed me. One lady was happy to with prednisolone and a topical antibiotic. patient had seen a dermatologist who travel a more than 100 mile-round trip for Treating patients that are not local is had recommended a course of laser injectable treatments, which I felt was a challenging when there are complications. treatment to correct minor scarring. She compliment to my skills. After a thorough Although using modern technology, such had also discussed the case with a solicitor consultation with this particular patient, as smart phones, to send and receive and asked for £9,000 in compensation. we agreed on Intense Pulsed Light (IPL) photographs or video calls are useful, Even if I had wanted to, I didn’t have the treatment for her mild rosacea. Before digital communication is no replacement money to pay this. Having discussed conducting the procedure I discussed each for face-to-face assessment, being able to this with my insurer I offered a fraction aspect of the consent form with the patient, support and provide necessary treatment of this amount, which was declined. The

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015 aestheticsjournal.com @aestheticsgroup Aesthetics Journal Aesthetics excess on my insurance was £1,500, so had been discussed at a British Medical do anything to weaken your case or offering significantly more than this wasn’t Laser Association (BMLA) meeting I had invalidate your cover. Solicitor letters are practical. After the first flurry of solicitor attended after the incident, which found often worrying and use language that may letters encouraging me to admit liability that the majority of members – if not all – overstate their position. Try not to take (something you must not do without did not routinely test patch before every the process as a personal or professional discussing with your insurer first as it may minor change of settings. Despite this, my attack – a successful claim from a patient be against the policy requirements) we solicitor felt that a judge may rule that a is not always a sign that you have acted didn’t hear anything for more than a year. test patch could have avoided the injuries improperly in any way. Treat within your skill I thought that perhaps the solicitors had caused – especially as judges are not set, with care and diligence, and document recognised the quality of my notes and always sympathetic towards our speciality. every treatment as if a complication is consent process and had decided not to This was a disappointment as I felt that I expected. Even if you do this, you may pursue the case. This was optimistic as had done all that I could to ensure a safe well find yourself having to go through the three years after the procedure had taken treatment, and had not been able to find claims process – but at least you will have place, her solicitors were in touch once any practitioner that felt otherwise. protected yourself as best as you can. again. The result of the process, drawn out across International trainer and UK My solicitors felt that there was a weakness four years, was a payout to my patient medical consultant for Sculptra in our case as I had increased the energy of £7,000, with an additional £16,000 of by Sinclair Pharma, Dr Askari of the treatment without a prior test patch. legal costs. The financial cost to me was a Townshend qualified as a Some practitioners advocate test patches £1,500 excess fee and an increase in my doctor in 2002 and was awarded MRCS in 2006. With extensive injectable at the end of each treatment, though, in premiums, which no doubt will take some experience, Dr Townshend opened his own reality, this is not a good verification of years to normalise. clinic in 2008. In 2010, he sold the clinic to treatment response. A single shot is not Legal complaints are a stressful time for become director of medical services at sk:n comparable to the heat generated from all concerned and can last many months, until 2013. a full treatment – of course this is not to if not years. During this time it is important REFERENCES: 1. Hamilton Fraser Cosmetic Insurance, ‘Our top tips on be confused with test patches before the to keep in close contact with your insurer, how to avoid a potential claim’, Resources & Guides (2015) first treatment, or after a significant change especially before communicating with in settings, which are vital. This issue your patient, to ensure that you do not Last accessed: 18 February 2015.

The New Epionce Essential Recovery Kit Provides a targeted boost of hydration while rapidly restoring healthy barrier function after deeper resurfacing procedures.

Kit contains: • NEW Epionce Priming Oil (25ml) • Epionce Medical Barrier Cream (30g) • Epionce Enriched Firming Mask (30g)

Highly Commended for Best Cosmeceutical Range 2014 Become an Epionce Stockist 01245 227 788 | www.epionce.co.uk | [email protected]

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015 @aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

with their results – it’s always on your mind.” “It’s fascinating to see how our Reflecting on her career, Campion says, “Managing to have an entwined career, specialty and the industry is where I am an analyst, a businesswoman and a nurse, has been really rewarding and interesting. From the perspectives of the developing across the globe” various threads I work in, it’s fascinating to see how our specialty and the industry is Consultant nurse practitioner Constance Campion developing across the globe.” Whilst Campion tells us about her varied career within aesthetics, acknowledges she is proud of her own success, she emphasises that her marriage and the values that come first and family hold more value than anything else. “My husband and my family have been Hailing from a family of aesthetic nurses, says Campion, is something pivotal in my make-up and shaped me as a medical professionals, that needs work. Whilst she is critical of the person,” she says. “I am very grateful and I becoming a nurse Keogh Review, she says the jury is out on the don’t deny that hard work and meaningful was a natural career work of Health Education England (HEE). She choices lead to achievements, but business path for Constance does, however, fully support the work that is and career success can never take away Campion. “The care of being done by nursing colleagues, who are from the values I am rooted in – my family and patients was something representing and piloting the re-validation care of my patients are what comes first.” I was often exposed to as a young child,” work being conducted by the Nursing she explains, “My grandmother and my Midwifery Council (NMC) and the British aunt and uncle’s professional standing and Association of Cosmetic Nurses (BACN). What treatment do you enjoy giving the benevolence was particularly noticeable and I Campion has recently become the BACN’s most? wanted to emulate this.” London regional leader, having, alongside Any treatment related to the skin. I enjoy In 1972, Campion began her nurse training colleagues, first introduced and formally set facial augmenting and re-contouring. But I at St. Vincent’s University Hospital in Dublin, out the aesthetic nursing specialism to The never cease to be amazed by what can be after which she studied midwifery at The Royal College of Nursing in the early 90s; achieved in the skin. Rotunda Hospital. After an early nursing subsequently supporting the establishment of career, she worked in the private medical the BACN that followed. What technological tool best sector and was later headhunted into private Education, specialist training and ethics are compliments your work? The skin is a very revealing organ and equity. This led to a role as an analyst, where vital to improving the standing and branding can be the most amazing tool if you she became associated with the birth of the of our mutual specialism and the aesthetics understand how to assess it. You can private medical sector in Denmark. industry, argues Campion. “There is a clear harass its cellular biological regenerative Since 1989, Campion has been a partner demarcation and distinction between training processes to repair itself. You become far at Plastic Surgery Associates – a plastic, and education,” she says. “There is still no less reliant on magic wands and devices if reconstructive and aesthetic surgery practice core specialist education available and you start first with educating and training in based at Bupa Cromwell Hospital – and went aesthetic practitioners have to rely on supply the cellular aspects of the skin. on to expand this service by founding The companies for professional development and London Wellness Age-Management Centre. information. There needs to be demarcation What’s the best piece of career advice you’ve been given? In this time she also founded Medico Beauty between what constitutes product-training “When you’ve reached the end of your Ltd. and The Medico Beauty Institute, an and what’s generic specialist education.” rope, tie a knot on it and hang on!” aesthetics distribution network and education Establishing competency standards in company, established in 1998. medical aesthetics has been pivotal to Do you have any industry ‘pet-hate’? Speaking to Campion, it is clear that she Campion’s work. She chaired the first steering I don’t like reliance on extrinsic is fiercely passionate about the nursing committee at the Royal College of Nurses rejuvenation alone, because it mimics and profession. “Regretfully, there’s a great (RCN) and joined her nursing colleagues to limits practitioners to the levels of a beauty misunderstanding and lack of knowledge help write registered competencies. menu. Almost every identifiable issue in about the specialist nursing role which has Aesthetic practice is, “A lot tougher than aesthetics that we deal with is also linked to an intrinsic issue. to a great extent undermined the central role people think”, she says. “You’re trying to of nurses,” she says. “Nurses are the experts enhance, rejuvenate, protect and heal – and What aspects of aesthetics do you enjoy in patient care and that is not definable or this equates to a huge scope of responsibility the most? negotiable in any setting where patients are to the patient and their family,” she explains. Comprehensive-integrated consultation placed. As competent nursing care underpins “You also carry the duty to hold yourself out and assessment, and skin analysis. That’s patient outcomes, it was regrettable that as a reliable and competent professional as one of the busiest processes for us in our Keogh did not explore, let alone critically a nurse. You really do worry about patients, practice, because it sets out the specialist’s analyse, the elements of nursing care that about the risks and possible complications, paradigm in patient consultation, which should have been strengthened in the sector.” whilst having to balance this against the leads to appropriate treatment choices and patient care. Voicing the sentiments and experiences of patient’s notion of expectation associated

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015

@aestheticsgroup Aesthetics Journal Aesthetics aestheticsjournal.com

take a selfie with the camera directly in front of their face notice a nose appearing bigger and inconsistent to what it is in real life; a discouraging reality to, say, the recent rhinoplasty patient, especially when they look in the mirror and are equally discontent but not sure why. A mirror is a reverse image of what is seen in a photograph. A bump on the left side of the nose now becomes a bump on the right side of the nose, and it can get confusing. Additionally, we tend to be most comfortable with our image in a mirror because this is the version of ourselves we see most frequently. But even the physics of a mirror misrepresents from what others see of us. In a mirror, our facial size is half of what it is in real life, regardless of the distance you stand from the mirror. Yet most people believe the dimension of their face is the same size in the mirror as it is in real life. So our brain compensates, overestimating facial features. The Last Word So we have a mirror and a phone photo that are opposite images of each other, and both are varied images from what an outside Dr Steven Dayan argues for observer perceives. Therefore when a patient is disappointed patient education in a world of with how they look in a picture, when they tell us that they desire a smaller nose, which version of the patient are we attempting to distorted images improve? Without clear communication on the shifting parameters of image taking, this puts us, and the patient, in an Alice in Wonderland “I’m not happy, look at my phone. My nose is too big.” Are scenario of questioning what is real and who are we treating. these words familiar to you? When consulting with a patient, do I believe that the best way to address this is to first educate we always know which version of the patient we are attempting our patients, pulling out a mirror and a camera phone and to treat – what they see in a mirror, their appearance as we see demonstrating the image differences. It’s important to let them it, or their appearance as they see it reflected in the screens of their phone? Over the last five years, the new craze for ‘selfies’ has exploded in popular culture, sometimes with no regard We tend to be most for boundaries or borders. It has without a doubt impacted our consultation process, and maybe even the way we practice comfortable with our image cosmetic medicine. When the president of the US is caught taking a ‘selfie’ with the prime ministers of Britain and Denmark at a in a mirror because this is gathering of global leaders, there is no denying this craze is cross- cultural, and adopted by people worldwide. the version of ourselves we Yet taking an effective photograph like this is no mean feat. A photo that is taken close to its object will often enlarge and see most frequently distort the portion of the object that is closest to the lens, as demonstrated when taking a picture with a concave, or ‘fish eye’ lens. So when the lens of the phone camera is only a few know that while we want to improve their appearance and meet centimeters away, or the distance of an arm, it makes whatever their expectations, we are also interested in maintaining a natural feature of the face that it is closest to look biggest. If the camera appearance, since if we treat only their ‘selfie’ image, we may is straight on, then the nose looks largest; if from above then the inadvertently make their nose too small. We certainly are in a eyes look greatest; if taken from below then the chin and the difficult position where we are tasked with making people look lower one third of the face predominates. better naturally, yet also meeting their demands. In my opinion, Recent advances in product technology has allowed for the part of being a practitioner is to be a teacher, and I think it is creation of a device known as a ‘selfie stick’ – a convenient our responsibility to educate our patients, the media and a new portrait-pleasing device that is attached to a smart phone to allow generation of selfie takers about the physics of distorted imagery. users to take photographs from a distance of one metre. The end In this evolving modern age, this kind of approach is integral to a result is a more proportional and flattering facial image. For this successful consultation, and a successful aesthetic treatment. same reason, professional photographs are taken from a distance, Dr Steven Dayan is a facial plastic surgeon who in such a way that all facial features are at a relatively similar has had more than 90 articles published in medical distance from the lens. journals and authored five books including Subliminally In our western society, the female face that is generally considered Exposed. His accolades include the AMA Foundation’s attractive is one with a large upper third, one highlighted by Leadership Award. He serves on the scientific and steering committees of multiple medical congresses, holding an prominent infantile eyes and coupled with a small chin. Our elected position within his facial plastic surgery society. culture also appreciates sumptuous lips. This is reflected in the myriad of ‘selfies’ we see, and that are brought to us, where the patient has taken the photograph from above and is consciously REFERENCES 1. Lawson R, Bertamini M. ‘Errors in judging information about reflections in mirrors’,Perception 35(9) making the lips seem more prominent. In contrast, patients that (2006) p 1265-88.

Reproduced from Aesthetics | Volume 2/Issue 5 - April 2015 ACE aesthetic ad_Layout 1 12/03/2015 15:49 Page 1

aesthetics

Silkann. A complete range of Sterimedix single-use needles and ﬂexible cannulas for the injection of dermal ﬁllers and other aesthetic procedures.

aesthetic cannula innovations

a unique, polycarbonate hub fully compatible with all types of ﬁller syringes • A new and unique screw type hub manufactured using polycarbonate to reduce the risk of cannula detachment. • Indicator on the hub to show orientation of the port during injection. • The best port quality and consistency of port position, to remove risks during procedures. • Ports designed to optimise the flow and performance of fillers whilst reducing injection forces. • The highest quality of packaging to maintain the integrity of the cannulas at all times.

single-use innovation for aesthetic surgery

For more information call: +44 (0)1527 501480 or visit: www.sterimedix.com For less than £35 per month, you can list your company details here. For more Directory information contact Aesthetics - 0203 096 1228 [email protected] a Carleton Medical Ltd ABC Laser Contact: Nick Fitrzyk Healthxchange Pharmacy Medico Beauty Contact: Guy Gouldsmit +44 01633 838 081 Contact: Steve Joyce Contact Name: Andy Millward +44 08451 707 788 [email protected] +44 01481 736837 / 01481 736677 +44 (0) 844 855 2499 [email protected] www.carletonmedical.co.uk [email protected] [email protected] www.abclasers.co.uk Services: Asclepion Lasers www.healthxchange.com www.medicobeauty.com & www.obagi.uk.com www.medicobeautyblog.com

d j Dermagenica AestheticSource MedivaPharma Contact: Sharon Morris Contact: Greg [email protected] 01908 617328 +44 01234 313 130 John Bannon - Www.dermagenica.co.uk [email protected] [email protected] Pharma and Reconstructive Division. 020 3515 0105 www.medivapharma.co.uk Services: NeoStrata and Exuviance [email protected] Service: Facial Aesthetic Supplies (00353) 874188859 Skype: Geoffduffydublin

l Aesthetox Academy DermaLUX Memento Skin Clinic Limited Contact: Lisa Tyrer Contact: Louise Taylor +44 0870 0801746 Laser Physics 0121 661 4416 +44 0845 689 1789 [email protected] +44 01829773155 [email protected] [email protected] www.aesthetox.co.uk [email protected] www.mementoskin.co.uk www.dermaluxled.com Service: Training www.laserphysics.co.uk Service: Manufacturer of LED Phototherapy Systems Merz Aesthetics +44 0333 200 4140 Allergan e Lawrence Grant [email protected] +44 0808 2381500 Contact: Alan Rajah www.juvedermultra.co.uk +44 0208 861 7575 [email protected] Eden Aesthetics www.lawrencegrant.co.uk/ WELLNESS TRADING LTD – Contact: Tania Smith specialist-services/doctors.htm Mesoestetic UK +44 01245 227 752 Contact: Adam Birtwistle AZTEC Services [email protected] +44 01625 529 540 Contact: Anthony Zacharek www.edenaesthetics.com [email protected] +44 07747 865600 www.epionce.co.uk www.mesoestetic.co.uk [email protected] Services: Cosmeceutical Skincare www.aztecservices.uk.com Lifestyle Aesthetics Treatment Solutions, Cosmelan, Service: exclusive UK distributor for the f Contact: Sue Wales Antiagaing, Depigmentation, Lutronic and Viora product ranges +44 0845 0701 782 Anti Acne, Dermamelan [email protected] www.lifestyleaesthetics.com n b Flawless Aesthetics and Beauty Mineral Makeup and Skincare FlawlessLuxury 100% Natural Mineral Makeup,Aesthetics & Beauty Bausch + Lomb UK Ltd Hypoallergenic, Vegan, Halal, Made in the UK Training Accredited by Leading Aesthetic Insurance Companies 01400 CPD Points 281902 Neocosmedix Europe 0845 600 5212 [email protected] Tel: 01400 281902 [email protected] [email protected] www.ﬂawlessaestheticsandbeauty.co.uk Contact: Vernon Otto Flawless Mineral Bronzer is just an invitation for www.solta.com www.flawlessaestheticsandbeauty.co.ukachieving a seductive and show-stopping look. Lumenis UK Ltd +44 07940 374001

Services:The sheer and Mineral soft texture will Makeup add that touch andof Skincare Contact: Nigel Matthews or www.neocosmedixeurope.co.uk colour that will leave skin healthy and radiant. Mark Stevens [email protected] Soft luminous powder blends effortlessly Youthful sun kissed glow +44 020 8736 4110 Works for all skintones [email protected] p www.lumenis.com Boston Medical Group Ltd Contact: Iveta Vinklerova PolarisMedical Lasers +44 0207 727 1110 Lynton Microdermabrasion 4T Medical Contact:From Neil Calder [email protected] MATTIOLI ENGINEERING 01223 440285 +44 01477 536975 +44 01234841536 www.boston-medical-group.co.uk As featured on [email protected] [email protected] [email protected] www.4tmedical.com www.lynton.co.uk www.polaris-laser.com

s m blowmedia needle free Creative and Digital Design agency Fusion GT Mesotherapy Contact name: Tracey Prior Silhouettefor the delivery of activeSoft 0207 481 1656 MACOM substances. [email protected] Tel. 020 7467 6920 [email protected] Contact: James Haldane 0845 2600 207 Contact:Tel: 01234 841536Emma Rothery www.fusiongt.co.uk +44 02073510488 www.polarismedicallasers.co.uk www.blowmedia.co.uk www.silhouette-soft.com [email protected] [email protected] www.macom-medical.com g c Med-fx Contact: Faye Price Candela UK Ltd Galderma Aesthetic & Corrective +44 01376 532800 Contact: Michaela Barker Division Sinclair Pharmaceuticals [email protected] +44 0845 521 0698 +44 01923 208950 [email protected] www.medfx.co.uk [email protected] [email protected] 0207 467 6920 www.syneron-candela.co.uk www.galderma-alliance.co.uk www.sinclairispharma.com Services: Adviser (LPA) Services z

Cosmetic Insure h Hamilton Fraser Medical Aesthetic Group Zanco Models Contact: Sarah Jayne Senior Contact: Stephen Law Contact: David Gower Contact: Ricky Zanco www.cosmeticinsure.com 0800 63 43 881 +44 02380 676733 +44 08453076191 0845 6008288 [email protected] [email protected] [email protected] [email protected] www.cosmetic-insurance.com www.magroup.co.uk www.zancomodels.co.uk

70 Aesthetics | April 2015 RESTYLANE SKINBOOSTERS – SHOW YOUR SKIN AT ITS BEST

Restylane Skinboosters are a brand new approach to nourishing your skin, especially designed to deliver lasting moisturisation and improvements in the skin. Restylane Skinboosters are clinically proven for treating the face, neck, hands, and décolletage3. Visible improvements to the skin can be seen after a course of treatments resulting in skin with a radiant glow. A series of tiny injections, made more comfortable with anaesthetic lidocaine, improves skin elasticity1, firmness2 and radiance.3 What you and everyone else will notice is fresh and wonderful skin.

IMPROVE YOUR SKIN QUALITY

FOREHEAD AREA

PERIORBITAL AREA

FACE REJUVENATION*

ACNE SCARS

PERIORAL AREA

NECK AREA

HANDS

DÉCOLLETAGE

1. Kerscher M et al. Dermatol Surg 2008;34:1–7 2. Williams S et al. J Cosmetic Derm 2009;8:216–225 3. Streker M et al. J Drugs Dermatol 2013; 12(9):990–994

RES/039/1214 Date of preparation December 2014 Experience all the benefits of VYCROSS™ technology. Treat various areas of the face using only 3 products. It’s that versatile.

Instructions and directions for use are available on request.

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

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