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Non-surgical Botox and Revalidation Anatomy of the lower face lift wellbeing for doctors Experts discuss Dr Ravi Jandhyala and nurses lower face - CPD treatments, on how treatment Dr Paul Myers Dr Raj Acquilla on the anatomical basis techniques and with botulinum toxin and Emma Davies and aetiology of lower facial ageing. trends for lower type A can improve summarise the CPD accredited article face rejuvenation patient quality of life new rules Introducing the NEW

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www.syneron-candela.co.uk | [email protected] Tel. 0845 5210698 This is not intended for the U.S. market. ©2013. All rights reserved. Syneron and the Syneron logo are trademarks of Syneron Medical Ltd. and may be registered in certain jurisdictions. Candela is a registered trademark of the Candela Corporation. UltraSculpt and UltraShape are registered trademarks of UltraShape. PB82801EN Contents • February 2014

INSIDER 05 The Word Dr Mike Comins on developments in the aesthetics industry in 2014 06 News The latest product and industry news CLINICAL PRACTICE 12 On the Scene Lower face Anatomy Page 17 Dr Leah Totton’s highly anticipated clinic launch 14 News Special: Aesthetics Online Investigating new adjudications surrounding advertising in aesthetics CLINICAL PRACTICE 17 CPD Clinical Article IN PRACTICE Dr Raj Acquilla on the anatomy of the lower face Revalidation Page 49 22 SPECIAL FOCUS: Non-surgical lower face lift Leading clinicians explain their treatments and techniques 26 Techniques Dr Linda Eve on delivering Sculptra using cannulas Clinical contributors 28 Clinical Study Dr Mike Comins is president and fellow of BCAM. He is part of the cosmetic interventions A study on use of radio frequency to treat primary axillary hyperhidrosis group and is an accredited trainer for advanced 34 Spotlight On Vaser liposuction. Dr Raj Acquilla is a cosmetic dermatologist The benefits of the new egenliteR Transform by Dr Donna Freeman with over 11 years experience in facial aesthetic 36 Clinical Focus medicine. He is a UK ambassador and masterclass trainer in botulinum toxin and dermal fillers. Dr Elisabeth Dancey explores the treatment of labia majora Dr Elisabeth Dancey has been practising cosmetic hypotrophy with Desirial Plus medicine since 1993. She introduced mesotherapy 38 Clinical Study to the UK having studied at Liege, Belgium. She now owns Bijoux Medi Spa in central London. Dr Ravi Jandhyala investigates the relationship between botulinum Dr Linda Eve is founder and medical director toxin type A and wellbeing of the EvenLines Clinics. She won the National 42 Treatment Focus Aesthetics Award for the Best UK Small Clinic for 2013-2014. Lisa Littlehales on the use of BTL’s Vanquish for uniform fat loss Dr Donna Freeman is director of clinical re- 43 Abstracts search and education at Chromogenex, focusing on the development of new devices and technol- The latest clinical studies ogies and construction of technical articles. 45 Aesthetics Conference and Exhibition Special Focus Dr Ravi Jandhyala has over nine years The latest news and reasons to attend ACE 2014 experience in aesthetics. He is a member of the Royal College of Surgeons of Glasgow and a IN PRACTICE leading voice on botulinum toxin. Lisa Littlehales is a registered nurse with 15 years 49 Revalidation for doctors and nurses experience in aesthetics. She is general manager of Harvey Nichol Knightsbridge and Beyond MediSpa Dr Paul Myers and Emma Davies share advice on how to be prepared Edinburgh, specialising in non-surgical treatments. 52 Taxing Times Accountant Ben Korklin on getting ready for tax year end NEXT MONTH 54 Learning from spas • IN FOCUS: Injectables • PRP investigation • Treating lips and perioral with Emervel Wendy Lewis suggests taking inspiration from spas for a better • Clinical study: Precision TX Neck Lift patient experience 56 Dealing with Negative Reviews Tingy Simoes explains how to handle unfavourable feedback online 58 In Profile Places for We speak to BACN vice-chair Sharon Bennett The Aesthetics Conference 60 The Last Word and Exhibition 2014 Dr Sarah Tonks shares her views on the culture of secrecy in are filling up fast! cosmetic interventions

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

Welcome to the February issue of Aesthetics. This month I’m delighted to welcome four new committee Despite dreary weather, Aesthetics this month members onto the board of the British College of Aesthetic is positively uplifting, with lower face smile Medicine (BCAM). Dr Beatriz Molina, Dr Ruth Harker, Dr Kathleen rejuvenation the focus of our CPD-accredited Long and Dr Paul Charleston join Dr Kam Singh and myself to feature: non-surgical lower face lift (p. 17), and our continue BCAM’s vital work in providing not only a professional Leah Hardy support network for aesthetic doctors, but also training and Editor round table discussion on lower face rejuvenation techniques (p. 22). education. As a body, we hope that 2014 will be the year when In his study, Dr Ravi Jandhyala adds to the growing body of evidence we will see implementation of improved standards, education for the positive psychological affects of treatments with botulinum toxin and regulation in aesthetic medicine. BCAM continues to work on p. 38. with the Department of Health, The British Standard Institute and Our contributors this month include Dr Linda Eve and Dr Elisabeth now Health Education England to help ensure that this happens. As such, 2014 will also see the launch of BCAM approved Dancey, who share their experiences of using Sculptra with cannulas courses, workshops and online learning platforms catering for (p. 26) and the new hyaluronic acid product Desirial (p. 36). Plus all levels and competencies of aesthetic doctors. Aesthetic there is information about new devices, including a study on the medicine is moving forward at a fast pace, and I am pleased effectiveness of radiofrequency as a treatment for hyperhidrosis, and to see revamped older products, such as collagen stimulating how Regenlite’s new Transform device boosts growth factors for better injections and thread lifts, making a well-deserved comeback. skin health. We also offer vital advice on managing reputation attacks The use of volumising fillers is now more or less standard online and improving your patients’ in-clinic experience. practice, as is the advanced use of botulinum toxin injections in On p. 60 Dr Sarah Tonks says it’s time for celebrities to admit the help the mid and lower facial muscles. Minor surgical body sculpting the aesthetics industry gives them. What do you think? treatments are producing results unmatched previously. I am I’m also proud to bring you our guide to the Aesthetics Conference also very encouraged to find more and more cross referrals. Not and Exhibition (ACE) in London, 8-9 March. In your supplement, you’ll just between colleagues, but also with groups such as personal find a complete programme with a comprehensive list of speakers trainers, nutritionists and psychologists/therapists. As medical and contributors. The exhibition is free to enter and registration is still professionals, it is crucial that we work together to provide the open for the conference, which is fully CPD accredited with 59 points best care for our patients’ wellbeing, in all aspects of their health. available. I very much hope to see you there. Dr Mike Comins (BCAM) Editorial advisory board

We are honoured that a number of leading figures from the medical aesthetic community have joined Aesthetics’ journal’s editorial advisory board to help steer the direction of educational, clinical and business content.

Dr Mike Comins is president and fellow of the British College Amanda Cameron is a sales and marketing professional, of Aesthetic Medicine. He is part of the cosmetic interventions and was one of the first nurse injector trainers in the UK for working group, and is on the faculty for the European College of dermal fillers. With over 20 years experience in the industry Aesthetic Medicine. Dr Comins is also an accredited trainer for in both the UK and Europe, Amanda has extensive knowledge advanced Vaser liposuction, having performed over 3000 Vaser of medical aesthetics and business development. liposuction treatments.

Mr Adrian Richards is a plastic and cosmetic surgeon with Dr Sarah Tonks is an aesthetic doctor and previous 12 years of specialism in plastic surgery at both NHS and private maxillofacial surgery trainee with dual qualifications in both clinics. He is a member of the British Association of Plastic and medicine and dentistry, who fell in love with the results Reconstructive Surgeons (BAPRAS) and the British Association possible through minimally invasive methods. Now based of Aesthetic Plastic Surgeons (BAAPS). He has won numerous at Beyond Medispa in Harvey Nichols, she practises cosmetic awards and has written a best-selling textbook. injectables and hormonal based therapies.

Sharon Bennett is currently vice chair of the British Dr Nick Lowe is president of the BCDG and a consultant Association of Cosmetic Nurses (BACN) and also the UK lead on dermatologist with over 30 years of experience and practises the BSI committee for aesthetic non-surgical medical standard. in London and California. Dr Lowe is clinical professor of Sharon has been developing her practice in aesthetics for 25 dermatology at the UCLA School of Medicine in Los Angeles, years and has recently taken up a board position with the UK as well as director of a clinical research company specialising Academy of Aesthetic Practitioners (UKAAP). in skin ageing.

PUBLISHED BY EDITORIAL Chris Edmonds • Managing Director T: 01268 754 897 | M: 07867 974 121 | [email protected] Suzy Allinson • Associate Publisher T: 01268 754 897 | M: 07500 007 013 | [email protected] Leah Hardy • Editor T: 01268 754 897 | M: 07880 812 582 | [email protected] Sarah Dawood • Journalist T: 01268 754 897 | M: 07788 712 615 | [email protected] Betsan Jones • Journalist T: 01268 754 897 | M: 07741 312 463 | [email protected] ADVERTISING Hollie Dunwell • Sales Manager T: 01268 754 897 | M: 07557 359 257 | [email protected] Craig Christie • Administration and Production T: 01268 754 897 | [email protected] MARKETING Jenna Earl • Marketing Manager T: 01268 754 897 | M: 07710 947 842 | [email protected] Claire Simpson • Events Manager T: 01268 754 897 | [email protected] DESIGN Peter Johnson • Senior Designer T: 01268 754 897 | [email protected] Chiara Mariani • Designer T: 01268 754 897 | [email protected] ARTICLE PDFs AND REPRO FOLLOW US Material may not be reproduced in any form without the publisher’s written permission. For PDF file support please contact Craig Christie; [email protected] @aestheticsgroup Aesthetics Journal Aesthetics

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© Copyright 2013 Aesthetics. All rights reserved. Aesthetics Journal is published by Synaptiq Ltd, which is registered as a limited company in England; No 3766240 Insider News aestheticsjournal.com Allergan’s Botox receives Call for Evidence licence for treatment of crow’s issued for review feet lines into non-surgical procedures

Health Education England (HEE) has issued a Call for Evidence to take forward a review of the qualifications required to perform non-surgical cosmetic procedures. Led by Charles Bruce, managing director for Health Education North West London Allergan’s Botox has received national marketing authorisation for treatment (HENWL), the purpose of the review is to aid the of lateral canthal lines, commonly known as crow’s feet. development of a minimum standard for education The multi-specialty health care company announced in January that Botox has and training within the field of non-surgical medical received the licence from the Medicines and Healthcare products Regulatory aesthetics. The review also looks at the qualifica- Agency (MHRA). The botulinum toxin type A treatment addresses moderate to tions required to be responsible prescribers. severe lateral canthal lines resulting in temporary improvement. The marketing The project was established in September 2013 as authorisation, specific to Allergan’s Botox, is based on the company’s a result of Sir Bruce Keogh’s ‘Review of the Reg- successful global Phase III clinical trial programme in crow’s feet lines. ulation of Cosmetic Interventions’ report. The Call President of Allergan Europe, Africa and Middle East, Paul Navarre said, for Action aims to garner feedback from regulators, “We are proud to deliver this important innovation to medical aesthetics royal colleges and other stakeholders on what they practitioners in the UK, allowing them for the first time to treat the glabellar and believe should be the minimum standard required crow’s feet areas either alone or simultaneously.” to perform these procedures. HEE are asking all Dr Imran Lodhi, medical director of Allergan UK and Ireland, said, “We are interested parties to reply to the Call for Evidence, delighted to be the first and only manufacturer licensed to treat crow’s feet from professional associations, course providers to lines with Botox either alone or in combination with glabellar (frown) lines.” insurers, as well as medical aesthetic practitioners “Through hands-on training and support, our goal is to give practitioners currently carrying out non-surgical procedures. the confidence to deliver optimal treatment results for their patients, whilst The project has been gathering evidence since maintaining natural expression and movement,” he said. “As the eye area is one September of existing frameworks and standards of the most important treatment zones, we hope this new indication will enable applicable to all practitioners administering non-sur- healthcare professionals to treat it even more effectively.” gical procedures. Through this work the project has summarised common issues that exist between different groups practising within the field, from plastic Study shows men more likely surgeons, dermatologists, dentists, aesthetic nurses, other health care practitioners and beauty thera- to receive treatments from pists. Factors include patient consent and health and safety. However, the challenge lies in establishing a untrained individuals minimum standard applicable to all. “The starting points of the various professionals de- Research conducted by Transform Cosmetic Surgery has found that men livering the treatments are very different,” said Jollie. are twice as likely as women to have botulinum toxin or dermal fillers “So whatever we come up with will take account administered by somebody untrained. The study found that one in four male of the fact that people have very different levels of patients seeking non-surgical treatments received it from untrained friends, experience and backgrounds.” compared to one in 10 women. It also found that 17% of men would allow These qualifications also need to be future-proofed, themselves to be administered botulinum toxin from an unqualified person, as HEE is keen to ensure any qualifications es- compared to 10% of women. 16% of men would allow somebody unqualified tablished need to encompass the rapid change in to administer dermal fillers, compared to 11% of women, and 19% of men would technology in the industry. Following the Call for allow them to perform non-invasive body sculpting compared to 9% of women. Evidence, HEE will conduct workshops that will take 15% of men surveyed also admitted to having been treated by a third party place on February 24 and 28. These workshops will when they were unaware of whether they had been appropriately trained to be followed by further events in March/April 2014 to perform the procedure. discuss the outcome of the review. Anne-Marie Gillett, non-surgical director at Transform Cosmetic Surgery, “It’s in the public interest to do whatever we can to said, “Men are seemingly looking for a ‘quick fix’. This risk-taking and blasé make sure that the treatments are safe and that the attitude where their health is concerned, needs to be addressed, and quickly. people delivering those treatments have met the We absolutely urge anyone thinking of undergoing non-surgical procedures minimum standards,” said Jollie. Details of the call to conduct thorough research so that they are armed with information that for evidence can be found at www.nwl.hee.nhs.uk ensures they are making the right decisions when it comes to deciding who and responses can be sent to [email protected]. should administer their treatments and where.” nhs.uk, no later than Sunday February 9 2014.

6 Aesthetics | February 2014 Insider aestheticsjournal.com News Free Expert Clinic added to News in Brief

ACE 2014 programme Dr Askari Townshend appointed Sinclair Pharma medical consultant The Aesthetics Conference and Exhibition (ACE) 2014 will be hosting a free Dr Askari Townshend has been appointed new Expert Clinic, new for this year. medical consultant for Sculptra, Sinclair IS Pharma, The clinic will provide delegates with the opportunity to meet with leading as previous medical consultant Dr David Evans medical experts, who will answer questions and demonstrate how to retires. Dr Askari, medical director at Northampton deliver precise treatment techniques. Confirmed for the clinic so far are sk:n clinic, said, “Sinclair IS Pharma share my Dr Tapan Patel and Dr Raj Acquilla, who will be demonstrating periorbi- passion for top quality and small group training, tal beautification and a non-surgical lower face lift in the session. Also which is so important for aesthetic treatments.” confirmed are Dr Sarah Tonks, Lorna Bowes, Dr Gabriela Mercik, Dr Leah Totton and Dr Martyn King. Murad launch Rapid Collagen Dr Acquilla, cosmetic dermatologist at the Dr Raj Acquilla Clinic, said, “The Murad has launched its first first topical product Expert Clinics at ACE are about giving the delegates what they want to that contains pure collagen. Murad Rapid Collagen learn; expert tips and tricks in key anatomical regions, which will impact Infusion deploys the use of broken down collagen positively on patients. It is my pleasure to share the latest knowledge and protein to hydrate and plump the skin with amino techniques from around the world to help my colleagues optimise results acids small enough to penetrate it. Developed by Dr in their practices.” Howard Murad and Jeff Murad the topical product To find out more about ACE and to book your place, visit www.ace2014. targets wrinkles and fine lines. co.uk or call 01268 754 897. Dermadart launch Precision Skin Needling British brand Dermadart has launched a new Sinclair IS Pharma buys microneedling device that uses an electromagnetic drive system to avoid potential risks of skin tearing. global rights to Perfectha Precision Skin Needling has an electromagnetic linear drive allowing for a millisecond speed of dermal fillers operation and minimal pain. The skin rejuvenating treatment treats generalised and acne scars, wrin- Sinclair IS Pharma has bought kles, stretch marks, and sun damage. global rights to Perfectha dermal fillers.The international speciality Theradome Laser Helmet is FDA cleared pharmaceutical company has Over-the-counter laser hair restoration treatment acquired global rights to dermal Theradome Laser Helmet LH80 PRO has acquired gel brand Perfectha through FDA clearance. The technology is clinically tested and the acquisition of Obvieline is intended for use by patients suffering from thinning Laboratories SA. The Perfectha hair and androgenetic alopecia. The helmet uses laser brand includes five gel products light therapy, which the manufacturers claim will limit to treat different facial areas hair loss and double follicle size of existing hair. to reduce folds, lines and wrinkles. The company has also entered into agreements to acquire distribution rights from Obvieline’s parent New map showing cellular response to UV company, Pharmavital SA. The total consideration of both acquisitions Researchers have unveiled a new map showing is €32.2 million (£26.7 million). The acquisition from Pharmavital is the network of genetic interactions underlying the expected to close within six months. It is likely that the Perfectha range cellular response to UV radiation. Researchers at will be extended to include a pre-mixed lidocaine product towards the University of California, San Diego School of the end of 2014. Global rights to Perfectha will see Sinclair IS Pharma Medicine, along with colleagues in the UK and The establish a global facial aesthetics presence. Sinclair IS Pharma CEO Netherlands, have established this resource to better Chris Spooner said, “The acquisition of Perfectha is a significant strategic understand how cells are damaged by UV radiation, step enabling us to create a global presence in facial aesthetics. and how they repair themselves. The findings can be We expect to benefit in the near term from accelerating growth and found in the December 26 issue of Cell Reports. significant operating leverage.’’ As a result of the company’s expansion plans, Sinclair IS Pharma is Over 1,000 registered for ACE 2014 currently advertising for an additional member to the team. Places are fast filling up for the Aesthetics Confer- Greg Parker, national sales manager at Sinclair IS Pharma said, “We ence and Exhibition (ACE) 2014. With over 1,000 are currently looking for an experienced product specialist to join our already registered to attend, the two-day confer- Aesthetic Account Manager team covering the North West.“This is an ence and exhibition is already proving to be an exciting opportunity to join a rapidly expanding and fast moving company, industry event not to be missed. ACE will take place with its sights clearly set on developing an incredible aesthetic portfolio.” on March 8 and 9 at the Business Design Centre in To find out more about this role contact London. [email protected] www.ace2014.co.uk

Aesthetics | February 2014 7 Insider News aestheticsjournal.com Question Time now free LPG launch new award- with ACE conference pass winning Endermolift

Entry to the Aesthetics Conference and Exhibition (ACE) LPG Systems have launched the new Endermolift, a cellular Question Time evening is now free when purchasing a one or stimulation solution for the effects of ageing. two-day conference pass. The technology was recently awarded the Innovation Award 2013 New for 2014, the Question Time evening session in March, for Aesthetic Medicine at Face2Face Cannes, and the Anti-Aging sponsored by 3D-LipoLite, is facilitated by former BBC News & Beauty Trophy 2013 at AMEC, Paris. The manufacturers claim Broadcaster Peter Sissons, and brings together a panel of leading that Endermolift is the only technology to increase the natural industry professionals to discuss the latest topics influencing the synthesis of hyaluronic acid by 80%. The mechanical stimulation industry. The latest member to join the panel is Mr Dalvi Humzah, device stimulates fibroblasts and fat cells in a non-aggressive consultant plastic, reconstructive and aesthetic surgeon based way, treating lines, puffiness and dark circles. Endermolift uses at the Plastic Dermatological Surgery. A former NHS consultant motorised pulsating flaps to carry out the anti-ageing treatment. plastic surgeon, Mr Humzah currently maintains a plastic surgery LPG International Trainer Pernelle Hourcade said, “This technique private practice and is a key opinion leader for several aesthetic has scientifically been proven to have a large impact on fibroblast companies. Other panel members include Dr Andrew Vallance- function - production of collagen, elastin (+46%) and hyaluronic Owen, member of Sir Bruce Keogh’s Cosmetic Interventions acid (+80%) – and to naturally rejuvenate skin from within. The Review team, and Apprentice winner Dr Leah Totton. results are the increase of the skin firmness (+23%), elasticity and To find out more about ACE and to book your place, visit the hydration, as well as a clear improvement of glowing complexion, website at www.ace2014.co.uk or call 01268 754 897. wrinkles and fine lines (21%).” 3D-Aesthetics set for an Talk Aesthetics #dangersofsocialmedia exciting 2014 LiniaCosmeticSurgery / @LiniaCosSurg @Bea_John enjoyed your piece in this month’s @ 3D-Lipo has celebrated a successful start to 2014, following a aestheticsgroup. Really informative. year that saw them reach distribution in over 10 countries. Now, with the help of Dr Leah Totton, they are to launch their new duo #advertising cryolipolysis device, 3D-LipoMed, which is able to treat patients Bernadette John / @Bea_John who want both body contouring and skin tightening. @LeahFHardy Sites promoting voucher discounts Dr Totton’s new clinic is the first in the UK to feature 3D-LipoMed. do nothing to enhance the professional reputation She explains she wanted to offer a medical-grade treatment that of a clinician. catered to her patient demographic. “Many will be professional #facingthefuture women in their late 30s and 40s, for whom cellulite is a big sharonbennettskin @sharonbennettuk problem,” said Dr Totton. “I tried various machines and 3D-LipoMed @aestheticsgroup Looking forward to editorial provides great results.” Managing director of 3D Aesthetics, board meeting dinner tomo eve with @ Roydon Cowley, says, “Affordable technology with extensive aestheticsgroup @DrNickLowe Lots to discuss. clinical trial data, full CE certification and excellent clinical results provides a total solution for practitioners”. The company has Remember to follow us at Twitter also seen more than 20 clinics sign up for the new 3D-LipoLite @aestheticsgroup and include #talkaesthetics programme, in which the treatment is combined with a diet and in your comments. exercise plan. Says Cowley, “After changing body shapes for two years, we can now tackle obesity and change lives.”

Practitioners & their patients feel the difference... “The favourable safety profile has lead to high patient satisfaction and subsequent recommendations from one patient to another, increasing our practice1” n Not® palpable2 No ® Tyndall Effect1 Comfortable® on injection2

1. Kuhne, U et al. Five-year retrospective review of safety, injected volumes, and longevity of the hyaluronic acid Belotero Basic for facial treatments in 317 patients. J Drugs Dermatol. 2012 Sep; 11(9):1032-5 2. Data on File: BEL-DOF2_001 Belotero Juvederm Study MRZ 90028_4007

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BEL065/0813/LD Date of Preparation: December 2013 Email: [email protected] Insider aestheticsjournal.com News

First swallowable weight loss

balloon launched in UK The fi eld of cosmetic £3.6 billion intervention in the Obalon, the first swallowable weight loss UK is estimated to balloon has been launched in the UK. rise to the value of Obalon is distributed exclusively by Purple 2015 £3.6 billion by 2015. Surgical and is a non-surgical procedure, (WhatClinic.com) simply placed by swallowing a capsule the size of a large vitamin pill. The capsule, which has a dissolvable outer MYA Cosmetic Surgery found that layer, is attached to a micro-catheter that the average breast implant size inflates the balloon to the size of an apple. requested reduced last year, from The balloon, as with gastric band treatments, < 410cc in 2012 to 385cc in 2013 > works to decrease feelings of hunger, and (Make Yourself Amazing cosmetic surgery) sits at the top of the stomach. The treatment costs £2,000 and is intended for people whose body mass index is 27 or over. Obalon can only be administered One in six beauty by a physician who has received specialist clinics surveyed were Obalon training, and clinics are required to happy to consider treating offer lifestyle and dietary advice along with teenagers aged 16 and 17 with botulinum toxin. the treatment. Obalon is currently offered in the UK at Spire Healthcare (The Mail on Sunday) hospital locations, and at Parkside Hospital and Highgate Hospital in London. Spire clinics consultant Sally Norton said, “I’ve been monitoring Oba- lon’s progress over the last few years as I was very excited about the SPF 5-8 SPF 2-3 potential it could offer those patients who do not qualify for weight loss Darker skin has an inbuilt surgery but are struggling to lose weight and improve their health on SPF of 5-8 compared to fair skin’s 2-3. their own. (Dr Nick Lowe) “It has minimal side effects, is quick and easy to place and is really well tolerated. It gives patients an initial weight-loss boost but also helps to change their eating behaviour that is needed for long-term weight loss,” Children she said. as young as six are undergoing cosmetic surgery, often because of bullying. Dermamelan repackaged to (American Society of Plastic Surgeons) deter imitations It’s predicted that there will be a big Skin whitening solution Dermamelan demand for plasma facials in 2014. by Mesoestetic has been repacked Five UK clinics currently use plasma in order to make the solution harder energy instead of laser. to copy. (WhatClinic.com) Adam Birtwistle, managing director of Mesoestetic UK said, “Mesoestetic The dermal ﬁ ller market is currently operates in a fragmented expected to grow in Western market with many other, less Europe by around 8% pa to 2017, consolidated companies. One of the main challenges of the company with HA ﬁ llers accounting for is to fight against counterfeit products that offer cheaper alternatives over 90% of procedures. to consumers. The financial crisis has worsened the problem. People (Millennium Research Group) are looking to save money by buying products or copies via unofficial channels. Dermamelan now features a seal to authenticate the product, along with a country code, agent code and sealed code. These codes 87% of people voted yes are kept on customer order records so that members of the public buying in a recent Guardian poll the products may call for confirmation that it is genuine. “Counterfeit asking whether there products are potentially very dangerous and put the consumer at risk,” should be a ban on cos- said Birtwistle. “Mesoestetic has gone some way to deal with this with metic surgery for minors. changes to some of the line’s packaging and traceability.” (theguardian.com)

Aesthetics | February 2014 9 Insider News aestheticsjournal.com Events diary Antioxidant Tiron found to

8th - 9th March 2014 protect skin from UVA rays Aesthetics Conference and Exhibition - An antioxidant has been ACE 2014, London found to protect the skin www.ace2014.co.uk from sun damage, helping to keep it looking younger rd th 3 - 5 April 2014 for longer. The antioxidant, Anti-Ageing Medicine World Congress - created by scientists at AMWC 2014, Monaco Newcastle University, provides www.euromedicom.com/amwc-2014 complete protection from UVA rays, which make up 95% 20th September 2014 of UV radiation in sunlight. British College of Aesthetic Medicine Laboratory tests demonstrated BCAM Conference 2014, RIBA, that Tiron provides 100% UVA protection. Dr Anne 66 Portland Place, London Oyewole, research associate www.bcam.ac.uk of Dermatological Sciences at Newcastle University, said, 25th - 26th September 2014 “Tiron is an antioxidant and The British Association of Aesthetic Plastic is able to mop up reactive Surgeons - BAAPS Meeting 2014, London oxygen species (ROS), which at high levels can damage DNA within our www.baaps.meetings.org.uk skin cells and destroy the supportive fibres within our skin, collagen and elastin, which are responsible for stretching our skin. Tiron is also able to rd 3 October 2014 reduce the level of free iron in our skin cells, which is released as a result British Association of Cosmetic Nurses - of sun exposure.” BACN Meeting 2014, London Professor Mark Birch-Machin, professor of molecular dermatology at the www.cosmeticnurses.org university, has said that more tests are needed to ensure the product is not toxic, but the results of the study, published in the FASEB Journal, are “exciting and promising”. He adds that a commercial product could be More men receiving available within five years. It has been suggested that the product will be administered via food or cosmetics. treatment on veins “Tiron is a synthetic compound and although further assessment of this compound is still required, it is most likely to be included in a cosmetic More men between the ages of 40 and 50 are receiving product or sunscreen which could be applied to the skin,” Dr Oyewole treatments for veins according to statistics gathered said. Medical professionals have said that results from the study should from the Dr Newmans Clinic chain. The UK network of be treated with caution. Dr Indi Ghangrekar, health information officer at clinics has seen an overall rise in the number of male Cancer Research UK, said, “This research was done on cells in the lab, patients over the past 10 years, from 5% to 40%, with a rather than on people, and only looked at UVA radiation, not UVB – both doubling of patients from this age range. of which are linked to skin cancer. This rise has taken place predominantly in London, but “We also don’t know if this man-made antioxidant might be toxic in is also evident in their clinics across the UK. The Dr humans, as the authors point out,” Dr Ghangrekar said. “So this research Newmans Clinic chain specialise in the treatment of veins, is a long way off telling us whether it could be useful in any way in skin using thermocoagulation as developed by Dr Newman. cancer prevention.” This involves the use of microwaves to destroy the thread Clinicians have also said that there is anti-ageing potential in antioxidants veins without scarring, hyper or hypo pigmentation. but thorough research is required to determine this. “Antioxidants, which Dr Peter Finigan, medical director at Dr Newmans Clinic, reduce free radical damage and oxidative stress by protecting the said, “Based on observations of our patients, it tends to mitochondria, can be highly effective in skin anti-ageing,” said cosmetic be more common for men to develop chunky veins on dermatologist Raj Acquilla. “Any new product must demonstrate efficacy in their noses. So we are largely treating men’s faces and vivo through robust clinical study.” in particular their noses, though we have also seen an increase in treating thread veins on men’s legs.” The reason for the rise is thought to be down to a Contribute combination of factors, including; partners prompting men to have the treatment, comments by work colleagues, and Are you interested in submitting an article, study or letter men becoming more aware of their appearance. to Aesthetics.? We are interested in helping you share your Dr Finigan added, “Thread veins can be caused by a knowledge and expertise. myriad of factors. It’s a common misconception that they Contact the editor [email protected] can only be caused by alcohol.

10 Aesthetics | February 2014 The Award Winning Laser

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Dr Leah Clinic Launch, London

The launch for Apprentice-winner Dr Leah Totton’s much anticipated first clinic took place on January 22 The clinic, designed by interior designer Rolfe Judd and based at 24 Chiswell Street, Moorgate, has four treatment rooms and nine qualified staff, ranging from doctors to nurse prescribers and aesthetic therapists. “We have a full clinical team that is quite doctor-heavy,” Dr Totton said. “But I was also keen to make it multidisciplinary. That’s key in this industry, and was important for us in terms of setting a standard.” The clinic offers a range of aesthetic treatments, including advanced facials, chemical peels, dermaroller therapy, microdermabrasion, enhancement treatments such as botulinum toxin injections, facial filler, cheek enhancement, lip augmentation and nose-reshaping. “I’m not just offering Botox,” Dr Totton said. “I want to cater for younger ladies too, with facials and non-invasive microdermabrasion.” The Dr Leah Clinic will also offer multi-platform fat loss technology 3D-LipoMed by 3D Aesthetics, which offers fat freezing, cavitation therapy, skin tightening and reduction of cellulite. Dr Totton’s clinic is the only one in the UK to own the medical-grade version of 3D-Lipo. The launch was attended by a host of medical professionals, including medical director of the clinic, Dr Martyn King. Karren Brady, “Leah approached us about becoming a member of BCAM. I esteemed judge of The Apprentice also attended. came along to explain how the organisation could help her: she Karren Brady said, “Leah is a determined and remarkable young already has an interest in industry regulation, and it will aid her woman. She has worked incredibly hard and it has been a pleasure in terms of revalidation and appraisal. She has a lot of publicity to see her build her business and brand. surrounding her, so it will be good for her to do everything “This is a difficult business, which doesn’t always operate with perfectly and be accredited by the body. Her involvement will integrity when it should,” she said. “And it’s a business that has been also help BCAM and the industry as a whole; having somebody male dominated. The hard work starts now.” Dr Totton has confirmed high profile involved will raise awareness to industry safety.” she will not provide Botox treatments for those under 18. She said, Dr Totton, who is part of the Aesthetics Conference and “The key thing we want to champion is safety in this industry. We Exhibition (ACE) 2014 Question Time panel and is presenting will not be administering anti-ageing botulinum toxin treatments for a demonstration on a 3D-LipoMed treatment, explains the teenagers; it’s not importance of conferences. “I think sometimes the aesthetics good practice. Our industry can be isolating,” she said. “Key things for professional clinic will provide development include understanding what’s new in the industry, a safe haven for having a clinical excellence board, and discussing new men and women to treatments with other aesthetic professionals. “Being part of undergo treatments.” conferences and having practical demonstrations is essential, Dr Beatriz Molina, as we all need to be continually learning and embracing other director of practices,” she said. For the immediate future, Dr Totton plans conferences at the launch of the Dr Leah skincare range. “I’m really looking BCAM, also attended forward to introducing that into the clinic, and hopefully the the launch. She said, marketplace,” she said.

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Contact us on Tel: 0845 1707788 [email protected] | www.abclasers.co.uk Insider News Special Report aestheticsjournal.com Aesthetics Online In the post-Keogh era, two new adjudications from the Advertising Standards Authority indicate clinics must work harder than ever to ensure their websites follow the rules

In December 2013, health minister and to “ensure that references to Botox price list should not include product claims Dr Dan Poulter announced that the were only presented in the context of a or actively encourage viewers to choose government would be, “Outlining potential outcome of a consultation with a product based on the price.” In 2012 the rigorous plans to clamp down on the clinic.” ASA ruled against a clinic whose website irresponsible cosmetics advertising.” • Provide information on Botox which referred to Line Relaxing Treatment (Botox) This statement made clear that could be navigated to directly, without and whose price list included ‘Line Relaxing the government would uphold consumers also viewing information Treatment’ saying, “Consumers would recommendations made in response to Sir about the consultation process. understand the reference to ‘Line Relaxing’ Bruce Keogh’s ‘Review of the Regulation • To suggest Botox be used off licence, so treatment in the price list was a reference to of Cosmetic Interventions’ report, only treatment to the glabella lines could Botox and therefore promoted a POM.” regarding the advertisement of cosmetic be referred to (and now crow’s feet) but There is clearly still a huge amount of interventions. It certainly appears that even not forehead lines or peri-oral lines. confusion as to what is allowed when it before the response is published, in this • To show any before or after photographs comes to clinic websites. When HB Health post-Keogh era, clinics whose advertising showing the potential outcome of treat- told the ASA that, “References to Botox is in breach of regulations can expect to ment, as these “would be understood as were extremely common within the beauty face swift sanctions. And these could have an efficacy claim and therefore constitut- industry and that many websites for clinics implications for almost every non-surgical ed a promotion for Botox.” contained similar content,” they were clinic in the UK. entirely accurate. Last month, the Advertising Standards Au- In addition, the ASA said information on The best source of help is probably the thority (ASA) took action against two clinics Botox can only be, “Presented in a bal- help note published by Committee of Ad- whose websites mentioned Botox. As a anced and factual way and for such factual vertising Practice (CAP) in October last year. prescription-only medicine, the advertising references to reflect the content of the For the first time this addressed non-surgi- of Botox to the public is prohibited. The Summary of Product Characteristics (SPC) cal advertising. original complaints against HB Health of document.” This means that any claims, “We know that it’s important that we are London and Dermaskin chain came directly such as HB Health’s statement that “Botox able to reflect the changing market,” says from one source, The Independent Health- dramatically softens facial lines and wrin- ASA spokesperson Matt Wilson, “Particular- care Advisory Service (IHAS). In both cases kles leaving you looking younger,” are not ly the huge growth in non-surgical pro- the websites made claims about Botox, and permitted, but statements such as “Botox cedures and the increasing use of digital discussed its use for facial lines and wrin- is the brand name for a form of Botulinum marketing.” kles. HB Health listed Botox as a treatment type A, which is produced by the bacteria The note covers advice on areas such as on its home page, and this mention linked clostridium Botulinum. Botox is an injection before and after photos, endorsements, to another page which described Botox in of minute doses into certain facial muscles testimonials, prescription-only medicines more detail as a beauty treatment. Der- …”, “Botox is injected using a disposable and sales promotions. It sets the limits of maskin’s website included claims such as syringe with a very fine needle. A very small advertising botulinum toxins, stating that “this revolutionary treatment … .is the most amount of the botox powder is diluted with clinics, “Should do so in a non-specific popular such treatment in the world” and saline …” and “Once you have been treated way without a reference to Botox,” “thousands of these treatments are per- it usually takes two to five days before wrin- specifying instead a description such as, formed every year with astonishing results”. kle softening treatment actually takes effect ”A consultation for the treatment of lines Both clinics defended their wording, but and sometimes even a little longer to notice and wrinkles.” This note should be required the ASA said, “ It was felt that these went the full effect” were all permitted as factual reading for anyone working in digital beyond factual references to Botox and claims. The Committee of Advertising marketing in aesthetics, and for doctors constituted a direct promotion of a POM.” Practice write and maintain the UK Adver- themselves. Clearly, in the post Keogh era, Both clinics changed their home pages, tising Codes which are administered by the simply doing what everyone else does, HB Health referring to ‘wrinkle softening Advertising Standards Authority. Its guide- even if you aren’t making outrageous, treatment’ and Dermaskin to ‘anti-wrinkle lines state that “Other than referring to a unethical or even inaccurate claims, will not treatment,’ but the ASA did not consider this consultation for lines and wrinkles, market- protect you from being reported to the ASA, adequate and demanded further changes. ers should take care not to refer to Botox having to face embarrassing publicity and at all on the home page of their website or needing to amend your website. In its adjudications, the ASA said it was a place where casual browsers can come For more help and advice on advertising not acceptable to: across information relating to Botox with cosmetic interventions visit www.cap.org. • Promote Botox except as a possible ease. An advertiser may include a price list uk, and view the Help notes section in the treatment option after a consultation, with a range of treatments available but the Advice and Training tab.

14 Aesthetics | February 2014 8th -9th MARCH 2014 THE BUSINESS DESIGN CENTRE, LONDON

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6433.1•eDS Trade Ad Jan 14.indd 1 15/01/2014 12:42 one point Clinical Practice aestheticsjournal.com CPD Clinical Article Non-surgical lower face lift

Dr Raj Acquilla MBChB MRCGP MBCAM ANATOMY - MUSCLES Cosmetic dermatologist with over 11 years The elevators of the mid and lower face from experience in facial aesthetic medicine. UK medial to lateral [3] Ambassador, global key opinion leader and masterclass trainer 1. Levator labii superioris alequae nasi – oral snarl in the cosmetic use of botulinum toxin & dermal fillers. Speaker of the Year 2012 at the UK Aesthetic Awards. Faculty lecturer at 2. Levator labii superioris – vertical lift of upper lip IMCAS, AMWC, FACE, ECAMS and AAAM. Clinic and Academy 3. Zygomaticus minor – oral smile in Cheshire and London. www.the-masterclass.co.uk 4. Zygomaticus major – oral smile 5. Risorius – lateral lift of oral commissure during ABSTRACT laughter Lower face lift has historically been the preserve of the surgical specialty. However, 6. Buccinator – retraction of the oral commisure owing to the increasing anatomical knowledge of facial ageing through cadaveric 7. Mentalis – lower lip elevator study and non-surgical lifting techniques we are now able to achieve excellent The depressors of the lower face from medial to outcomes with injectables. The ongoing advancements in filler science, technology lateral [4] and development of sophisticated injection techniques also contribute to the 8. Depressor septi nasi – nasal tip descent success of the injection facelift. 9. Depressor labii inferioris – lower lip depressor 10. Depressor anguli oris – oral commissure INTRODUCTION depressor In this paper I will explore the anatomical basis and aetiology of lower facial ageing. 11. Platysma – powerful lower facial descent during In particular we shall highlight the changes occurring in the facial skeleton, fat grimace compartments, musculature and skin. Understanding the pathology allows us to generate a treatment protocol in keeping with the most effective sequence of Figure 4 [8 & 9] The modiolus [5] treatments at the correct injection sites in order to generate tissue lift and support. is an important In my experience, effective treatment of this area tends to produce impactful fibromuscular results associated with high levels of patient satisfaction. junction [6] adjacent to the oral LOWER FACIAL AGEING corner, which is During ageing of the lower two thirds of the face we observe the following the insertion point changes when considering the tissue layers from superficial to deep [1]: for the orbicularis oris and seven Figure 1 Figure 2 1. Skin – laxity, sagging and excess other lower facial due to photo damage related loss of muscles. Its vertical collagen and elastin position can be 2. Fat – mid and lower facial lipo- influenced by atrophy resulting in deflation and strategic weakening of lower facial depressors with subsequent inferior migration of the botulinum toxin. This has a strengthening effect on fat compartments the reciprocal elevators of the mid face, generating a 3. Muscle – lower facial depressor lifting effect. [7] Fig 1 and 2 display the ageing process hypertonicity and hypertrophy which of the lower two thirds of the face exacerbates soft tissue descent VASCULAR SUPPLY Figure 5 [8 & 9] 4. Bone – facial skeletal resorption and remodelling which compromises soft The facial artery enters the tissue support in the anterior, lateral and vertical planes face at the anterior border Overall there is gradual age related change in face shape from the aesthetic ideal of the masseter muscle oval or heart shape towards a square or inverted triangle described as the Erosion and travels in a supero- of Beauty by Carruthers et al in 2006 shown below [2]. medial direction towards the modiolus then upwards Figure 3 [2] just lateral to the nasolabial fold to the alar fossa [9]. As it runs up the lateral border of the nasal bones it becomes the Angular artery before giving rise to the terminal branches

Aesthetics | February 2014 17 Clinical Practice one point CPD Clinical Article aestheticsjournal.com

(supratrochlear, supraorbital and the intraorbital arteries). These The sequence that we observe age Figure 7 [14] branches share an anastamotic relationship with the ophthalmic related volume loss and dehiscence artery, thus explaining the risk of visual acuity compromise following between facial fat compartments can be intravascular embolisation [10]. summarised as follows [14]: The proximal branches of the facial artery in the lower face from inferior to superior: 1. Anterior herniation of the infraorbital fat 1. Marginal mandibular artery – running medially in the mandibular leading to ‘eye bags’ and deterioration groove of the tear trough deformity 2. Inferior labial artery – running medially in the lower lip 2. Atrophy of the lateral malar fat 3. Superior labial artery – supplies the upper lip and nasal compartment without ptosis associated collumellar branch with reduced projection at the Ogee The branches have a midline anastomosis with collateral supply, curve which can reduce the risk of necrosis following vascular injury [5]. 3. Deflation of the lateral temporal cheek fat with mild descent The external carotid artery runs lateral to the mandible and gives rise 4. Deflation and descent of the medial malar fat compartment to the Transverse facial artery at the level of the tragus. This travels exacerbating the depth of the naso-labial fold medially behind the zygomatic arch and supplies the mid face and 5. Antero-medial herniation of the buccal fat compartment (Figure 8) buccal regions [11]. It is important to note that the corresponding resulting in fat accumulation and sagging at the jawline venous structures lie lateral to the facial arteries, which must also be avoided to minimise bruising [12]. Figure 8 [9]

NERVE SUPPLY Figure 6 [8 & 9] The motor supply to the muscles of facial expression comes from the facial (seventh cranial) nerve. It enters the face just below the tragus embedded within the body of the parotid gland where it emerges at its medial border and divides into five main branches It therefore confers that following a sequential technical strategy to from superior to inferior (temporal restore volume and lift soft tissue in keeping with the order of these / zygomatic / buccal / mandibular age related changes will produce more effective correction of this / cervical) [3]. Disruption to these process [4]. branches may result in a motor palsy therefore extreme care must be taken when injecting this area [13]. Figure 9 [6] The sensory innervation to the face is supplied by the trigeminal (5th cranial) nerve through its three branches (opthalmic / maxillary / mandibular). The branches of relevance to the mid and lower face from superior to inferior are [3]: 1. Zygomaticotemporal nerve – lateral cheek and lower eyelid sensation 2. Infraorbital nerve – entering the malar region via the infraorbital foramen (1cm below the infraorbital rim in the mid pupillary line) medial cheek and lower eyelid, lateral nasal wall and upper lip sensation FACIAL SKELETON 3. Mental nerve – entering the chin/jaw via the mental foramen During ageing there is a significant effect on bone density and supplying sensation to the chin, jawline and lower lip remodelling. In the facial skeleton we can observe these changes in Sensory branches allow patient feedback but injections around the transverse, vertical and anterior projection of the bony landmarks these nerves can be exquisitely painful and should be avoided as follows: unless performing a regional block with local anaesthetic [10]. 1. Loss of the youthful convexity of the frontal skull 2. Temporal hollowing and narrowing of the bi-temporal width FAT COMPARTMENTS 3. Orbital remodelling, flattening and lateral extension of the orbital In 2007, Rohrich and Pessa assessed 30 hemifacial dissections floor following injection of methylene blue dye into facial fat. The findings 4. Reduced projection of the zygomatic arch and maxilla concluded that the subcutaneous fat is divided into discrete fat 5. Increased diameter of the pyriform aperture resulting in nasal compartments separated by septi [14] or ‘retaining ligaments’ [15]. descent The sequence in which these compartments change in volume and 6. Retrusion of the dentition due to maxillary and mandibular position with age was found to be an important factor in assessing resorption and treating facial deflation and subsequent descent [14]. We have 7. Loss of mandibular height, width and anterior projection since used this information to develop accurate treatment strategies, which lift and project specific fat compartments to achieve a These combined changes result in less effective soft tissue support, desirable aesthetic effect [4]. dehiscence, descent, deterioration and sagging at the jawline [9].

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HCP_obagi_A4.indd 1 17/12/2013 17:02 Clinical Practice one point CPD Clinical Article aestheticsjournal.com

TECHNICAL STRATEGY CASE STUDY STEP 1 - BOTULINUM TOXIN 64-year old female before and after injection lower face lift using: Given that a significant component • Botox – Mentalis 5U, (DAO 2U, Platysma 10U, Masseter 18U) of lower facial descent is each side Figure 10 [8&9] exacerbated by the hyperactivity • Juvederm Voluma® – 2cc each side divided into 0.1-0.2cc and hypertrophy of lower facial aliquots as above depressors, we can effectively use botulinum toxin in specific Before After doses to selectively weaken these depressors. This allows the antagonistic mid facial elevators to facilitate lift and equilibrium in the lower face. This technique was described by Dr Phillip Levy in 2007 as the Nefertiti lift where 130 patients were studied and reported high satisfaction levels for jawline Risks & Complications tightening and lift [16]. Botulinum toxin [11] Hyaluronic acid [16] Following injection of botulinum toxin into the mentalis (4-5U deep), depressor anguli oris (1-2U SC) and platysma (5 x 2U SC) in the pattern Facial asymmetry Bruising / swelling Asymmetric smile Lumps / nodules / granuloma above, the patient should be reviewed at two weeks for HA filler. Salivary incontinence Infection / abcess

Dysphasia Allergy / hypersensitivity STEP 2 – HYALURONIC ACID Figure 11 [8 & 9] Dysphagia Vascular compromise FILLER Anterior neck weakness Necrosis / tissue loss We can volumise and lift lower facial soft Ptosis Bio-film and delayed reactions tissue in keeping with the sequential changes in facial skeletal projection and Adverse events can be minimised by selecting the correct fat compartment atrophy and migration patient, product, dosage, placement and administration by the during ageing as described above. The appropriate person in a suitable environment using an aseptic eight-point injection lift was described technique. Effective treatment planning and executing a robust by Dr Mauricio De Maio in 2010 which I protocol can help to reduce risks and complications. have modified below [4]. CONCLUSIONS 1. Lateral malar fat compartment – to Recent advancements through rigorous scientific study promote superolateral lift and development have culminated in a deeper and more 2. Beautification point (intersection of upper alar / tragus line with cultivated understanding of the injection face lift. We now lateral brow line) to optimise convexity and projection at oblique have the knowledge and tools to deliver exceptional products Ogee curve using the most sophisticated techniques. These non-surgical 3. Malar groove – to correct depression and promote anterior interventions have never been more effective in influencing projection and vertical lift of the medial cheek muscle, fat compartments, retaining ligaments, surface tension 4. Alar fossa – supports the upper 1/3 of the nasolabial fold and genuine tissue lift. 5. Oral commissure – oral corner lift and marionette line correction Through ongoing refinement of the art and science of facial 6. Menton – promote anterior / inferior chin projection to Steiners line aesthetics, our results can only improve and surpass the 7. Pre-jowl sulcus – uniform chin / jowl transition and jawline continuity expectations of our patients, raising the bar in our industry and 8. Angle of mandible – superolateral lift and contouring of the jawline promoting excellence as a pre-requisite standard.

REFERENCES 1. Hunter JS, J; Dahl, M. . Clinical Dermatology. 3rd ed. Massachusetts: 11. Hartstein, ME. et al. Midfacial Rejuvenation. Springer, 2012 Blackwell Science ltd; 2002 12. Coleman, SR et al; Aesthet Surg J. 2006 Jan-Feb;26(1S):S4-9. 2. Carruthers et al, Derm Therapy, Vol. 19, 2006, 177-188 13. Cohen J. Dermatol Surg 2008 ;34(Suppl 1):S92-9. 3. Drake RL et al. Gray’s Anatomy for Students. Churchill Livingstone; 2005. 14. Rohrich; Pessa, JE (2007). “The fat compartments of the face: anatomy 4. Injectable Fillers in Aesthetic Medicine, Mauricio de Maio, Berthold and clinical implications for cosmetic surgery”. Plastic and reconstructive Rzany, Springer, 2nd Edition 2014 surgery 119 (7): 2219–27; discussion 2228–31. 5. Weinberg MJ et al. Facial Plast Surg 2009 ;25(5):324-8. 15. Furnas, DW (January 1989). “The retaining ligaments of the cheek.”. 6. Mendelson, B. & Wong , CH.Aesthetic Plast Surg. 2012 Aug;36(4):753-60 Plastic and reconstructive surgery 83 (1): 11–6. 7. Cohen AJ et al. Mid face facelift. Medscape, 2012. 16. Levy PM. “Nefertiti lift” J Cosmet Laser Ther. 2007 Dec;9(4):249-52. 8. Endoscopic Plastic Surgery, Bostwick, Eaves & Nahai, 1st Edition 9. Clemente Anatomy – A regional Atlas of the Human Body, 4th Edition FURTHER READING: 10. Draelos ZD, Editor. Cosmetic Dermatology: Products and Procedures, 1st Papageorgiou, KI et al Aesthet Sur J. 32(1) 46 –57 2012 edn, Chichester, West Sussex: Wiley-Blackwell; 2010. Lowe NJ et al. Dermatol Surg 2005;31:1616-25

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For further information or a demonstration www.3d-lipo.com call: 01788 550 440 www.3d-skintech.com Clinical Practice Special Focus aestheticsjournal.com The Low Down. Rejuvenating the Lower Face Practitioners discuss the importance of a cocktail approach to lower face ageing, sharing their tips and techniques

Studies have shown that while younger women are mostly concerned about the look of their bodies, older women tend to be more dissatisfied with changes related to facial ageing, particularly in the lower face.[1] As discussed in the previous feature, multiple, interacting changes to the soft tissues and skeleton cause the visible signs of ageing in the lower face. Dr Nick Lowe says contributing factors including smoking, acne and genetic factors. “Smokers have been found to appear five to ten years older than non-smokers of the same age, with increased sagging and more lower facial lines. Previous inflamed acne on the lower face increases collagen and elastin damage and contributes to sagging around the chin and mouth. Orbicularis oris Before Ulthera movements such as lip puckering and pursing create wrinkles. Familial thin lips create a higher risk of barcode lines as they have less resistance to the folding of skin around the lips, and an inherited small or posterior chin (micrognathia) will also add to sagging of the jawline. Cosmetic dentistry, if done well, can considerably improve perioral ageing.” As the causes of visible ageing in the lower face are complex, reversing age-related changes using non-surgical methods may require a ‘cocktail’ approach, involving topical treatments, toxins, dermal fillers and skin tightening. For patients whose primary problem is superficial damage, such as wrinkling from smoking or UV exposure, Dr Lowe suggests encouraging use of a cream with both UVA and UVB protection plus a After Ulthera minimally inflammatory retinol. “My favourite is Isotrex gel,” he says. “If there is relatively superficial sun damage I may also use the Fraxel laser at 1550 nanometres. This penetrates into the mid-dermis, producing tightening and stimulating of collagen. For deeper folds and wrinkles I may suggest Intracel RF - Intracel. The insulated needles deliver radio frequency and resultant tightening to the collagen and Mono & Bipolar X 4 elastin tissues. Both Fraxel and Intracel produce minimal inflammation which is very important.” For ageing around the mouth due to loss of volume, fillers are the treatment of choice. Says Dr Lowe, “In my opinion, only hyaluronic acid fillers are safe to use in the lips and perioral area. I prefer to use a product which includes a local anaesthetic. This means choosing from the Juvederm, Restylane or Emervel families. I use a very fine, 30G cannula for the vermillion border then use the needle to deposit a small amount of dermal filler into the body of the lip and massage it smooth. I like Volbella as it is soft and produces little swelling at the injection site. However it may not last as long as other fillers. “I use approximately 1cc in the lower lip and a third of this in the upper to maintain good proportions. For patients with thinner lips, I’ll consider refining the effect with a maximum of one Before further syringe four to six weeks later. A slower improvement is more discreet for the patient, is less likely to cause bruising and increases the persistence of the filler, probably due to less inflammation, swelling and oedema in the area.” If a patient presents with significant ‘barcode’ lines above the lip, look at the patient’s dynamic movements to see how the lines change with muscle activity. Says Dr Lowe, “If this is significant I may consider botulinum toxin as an additional treatment. I use a total of about four units of Botox, or 12 units of Dysport or five units of Xeomin, deposited in two to four tiny amounts spaced out along the upper lip, depending where the maximum muscle activity is.” Dr Rita Rakus, who also likes to use Volbella for lip enhancement, says that many patients are concerned about the risk of a ‘trout-pout’. “For these patients discussion of the role of Hyalase in After dissolving hyaluronic acid fillers can allay their fears.“ she says. “It is part of sensible counselling that includes warning of possible bruising and swelling that may occur. It is important to remember that lip enhancement is never totally predictable. As they age, some patients develop a thin, compressed look to the lateral border of the lips, and ask for volumisation in that area. However, on injecting I sometimes discover that only the central portion of the lip will become fuller, with the edges

22 Aesthetics | February 2014 Clinical Practice aestheticsjournal.com Special Focus

remaining flat. In these cases I add more product to the centre of the lip at the top and bottom, and add a very small amount, around 0.5mls, to the area around the mouth, halfway between the centre of the border and the lateral edge, with more emphasis on the bottom lip, to lift the lip line. For patients with thin, ‘letterbox’ lips it can be difficult to get volume while the mouth is closed. For those patients it can be helpful to show them in a mirror how their lips look fuller when they are in motion.” For barcode lines, Dr Rakus says, “Fillers still achieve good results, but lasers such as Fraxel and Total FX can be highly effective in minimising fine lines and are often used in a combination treatment plan.” Ageing is often associated with a downturned, ‘sad’ mouth, which develops due to descent of surrounding tissue, habitual expressions and loss of volume. The use of botulinum toxin in the lower face, in particular to relax the depressor anguli oris muscles to create lift at the oral commissures is increasingly popular. However, Dr Mervyn Patterson warns that special care must be taken when treating the lower face. “If treatment of the depressor anguli oris is unequal on both sides the smile will be asymmetrical and difficult to correct. Slight diffusion laterally of toxin in the mentalis will affect the depressor labia inferioris which leads to a very unusual looking movement of the lower lip.” Aesthetic nurse Sharon Bennett says, “To avoid asymmetry, when targetting the perioral area and the depressor anguli oris it is important to avoid the orbicularis oris, which would affect the sphincter and EndyMed 3DEEP closure of the mouth with reduction in ability to pucker, while injections given too medially will affect the depressor labii inferioris between the DAO and the mentalis. This will cause a flattening of the contour of the lower lip, an asymmetric smile and reduction in the ability to purse the lips. You can I use the tower technique when injecting in the zygomatic arch, placing little towers of one of the thicker fillers, Dr Nick Lowe normally palpate the DAO by getting the patient to contract the muscle for example asking them to pronounce the letter ‘e’.” Dr Mervyn Patterson warns that, “Over zealous orbicularis oris injections impair the ability to pronounce ‘p’s and ’b’s. The correct procedure only lasts about 6 weeks.” Surgeon Adrian Richards adds that excessive relaxation of the depressor anguli oris muscle (DAO) may lead to the elevation of the corners of the mouth. This occurs because of the action of their antagonist levator anguli oris muscles, which elevate the corners of the lip. With less resistance to the levator muscle, the lips can curl up in an unnatural ‘joker smile’. This may be a particular risk with older patients because the philtrum area tends to lengthen with age, which lowers the central part of the upper lip. Says Richards, “The key is to be very conservative and very superficial. I would use 2 to 2.5 units of Botox, and inject just into the skin, allowing the toxin to diffuse into the muscle.” If a patient has a strong platysmal muscle pulling down the angle of the mouth giving jowls and marionette lines, Dr Lowe says, “I inject a maximum of ten units of Botox or equivalent into the muscle, divided equally between the right and left sides of the platysmal bands.” Lower facial ageing may also be caused by volume loss in the mid-face, so don’t ignore the use of lifting fillers injected into the lateral cheek and over the zygomatic bone to lift the lower face and mouth area. Dr Lowe says, “I use the tower technique when injecting in the zygomatic arch, placing little towers of one of the thicker fillers, injected vertically right on the periapical of the zygomatic arch with either SubQ or Voluma. Sculptra treatments can lift the mid-face but it is important to avoid the area around the mouth as it appears that the action of the muscles in this area concentrate Sculptra into small areas, which may result in nodules.” However, Dr Patterson says, “There is only so much lift one can be achieved with fillers, and lifting becomes more difficult with more aged faces without creating an over-inflated look to the cheek. Early intervention is best and patients should be informed when surgery is the best answer to their concerns.” For early signs of jowling, Dr Lowe says a more youthful jawline appearance can be achieved using a hyaluronic dermal filler injected into the indentation just below Dr Ariel Haus using the chin and before the jowl. “Used in combination with a thicker filler to lift the the Sublime skin tightening system cheek skin this can be extremely effective, In addition, Nefertiti injections of Botox along the jawline can be effective in cases where the platysmal bands are pulling

Aesthetics | February 2014 23 Clinical Practice Special Focus aestheticsjournal.com

downwards and Thermage can be used above the jawline and to the lateral and mid cheeks to tighten.” The growing desire of patients for non-surgical skin lifting has led to the development of more skin tightening treatments. One of the newest to the market is 3D-skintech used by Dr Martyn King, which uses tri-polar radio frequency for painless skin tightening. Dr Lowe says, “I would consider radio frequency lifting and tightening lateral to the marionette and nasolabial lines. I use Thermage or Intracel using both monopolar and bipolar frequencies.” Dr Rakus advises, “Combining volumising with radio frequency treatments such as Thermage or Pelleve, or controlled skin electrodes. Surgeon Chris Inglefield describes it as ultrasound therapy such as Ulthera can be very effective in helping “safe and effective.” For ‘pebbly’ or puckered chins, Adrian Richards to rejuvenate the lower face and oral commissures.” Dr Lowe also recommends injecting either the central area or both lateral sides of recommends the Venus Freeze (a combined radio frequency the mentalis muscle with 2-2.5 units of Botox or equivalent. magnetic resonance system) to tighten skin sagging in this area. Dr Lowe adds, “Injections of Voluma or SubQ can do a lot to improve “Studies conducted by US dermatologist Dr Neil Sadik and presented the appearance of a receding chin. When injected under the mentalis at the 5-continent Congress of Dermatology in Cannes in 2013 are muscle, these fillers can last two years or more, as the anterior very compelling. The treatment is painless but patients need at least mandible does not move much.” five or six sessions a week or so apart to see long lasting results, plus For submental fat and fat around the jawline, the best treatment in a top up treatment three to six months later.” future may be injectable fat dissolving injections. Ones currently in Dermatologist Dr Ariel Haus uses the Sublime skin tightening system use include the deoxycholate-based treatments Lipodissolve or on lower face folds, sagging jowls, neck and crepey skin. Sublime Aqualyx, while Kythera’s ATX-101 drug, after successful phase 3 trials, is uses bipolar radio frequency and infrared light and requires three to expected to receive approval for use in the US this year. five sessions spaced three to four weeks apart for best results. He Dr Lowe says, “The lower face usually changes because the whole says, “It is a comfortable treatment with zero downtime, making it a face is changing. It is extremely important to examine the patient good choice for those who prefer a non-surgical option. It also gives carefully to assess the causes of ageing before treating the area, and a temporary instant lift, and I normally show patients half the face a combination approach normally works best for global rejuvenation.” done before completing the treatment and they are very positive about the change.” Endymed 3DEEP is another pain-free option REFERENCES for skin tightening, with the energy delivered via multiple phase – 1. Clin Interv Ageing. 2006 June; 1(2): 115–119

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Using Sculptra with cannulas Dr Linda Eve describes the advantages for patients and clinicians of using cannulas to deliver Sculptra

I have been using Sculptra for over fluxing before injecting is easy and accidental as those with extensive sun damage, thin seven years, and have carried out around intravascular deposition can be avoided. dermis, leathered skin, or scarring from acne 1,200 individual treatments. It is a unique, or chicken pox. For best results, a course of long-lasting collagen stimulator called poly PATIENT COMFORT Sculptra treatments is normally required over L-lactic acid (PLLA), which stimulates the The flexibility of the fine cannula makes a two to three month period using on average fibroblasts to create new collagen cells. It is the technique more challenging, but also a total of two to seven vials. The number of the ideal treatment for patients who require makes the procedure far more comfort- vials used depends on patient age, present- general volume increase in the face such as able for the patient. I begin all Sculptra ing volume loss, and whether just the cheeks in the temples, cheeks, lower face and chin treatments by numbing the needle entry are being treated or the whole face. The areas. It is not advisable to use it in or above point using a Coolsense for a few seconds. gradual growth of collagen gives optimum the lips nor across the forehead, eyelids or No topical anaesthetic cream is therefore results after about six to ten months following nose. Sculptra is suitable for patients who required. I insert a flexible 27G x 37-40mm the last set of injections but early changes have suffered volume loss from as young cannula through the entry point, which has show at around two to three months. The as the mid-20s, to even the over 80s. It is been made with a 25G needle. The rest of effects of Sculptra last on average around two particularly useful for giving soft volume the procedure is relatively painless due to years when a smaller re-stimulation treatment and lift to patients with thin skin and volume the fast acting lidocaine mixed in with the is required to maintain the collagen lift. If no loss where a surgical face-lift could leave Sculptra. I only need to make 11 to 13 entry further treatments are given then the results them looking gaunt and dermal fillers might points for a full face treatment compared to achieved will be lost after about three years. end up visible. Sculptra is mixed with sterile between 30 and 50 if using a 26G needle, A similar treatment using HA fillers could water and lidocaine 2% several days prior because the long cannula allows me to cov- cost the patient around £4000 and only last to treatment. Injections are placed in the er a much wider area with each entry point. approximately one year. A full face Sculptra sub dermal or supra-periosteum areas to The cannula leaves minimal or no marks treatment for the average 50-year-old costs stimulate the fibroblasts and injections must on the skin and dramatically reduces the around £2000, and a top up treatment costs not be injected superficially in order to avoid discomfort of post-procedure massage. An around £1200 every two years. This afforda- the risk of nodules. While good results can additional advantage is that fewer than 10% bility combined with the speed and painless- be achieved with different techniques, my of my patients experience minor bruising ness of treatment creates enormous loyalty preference is to use a cannula rather than a when I use cannulas. in patients. My Sculptra patients stay with me needle when treating patients with Sculptra. for years for their repeat treatments. It is not a I find that although the technique is more REDUCED RISK OF NODULES treatment that patients ‘shop around’ for be- demanding, it has numerous advantages. In over 250 Sculptra treatments using cannu- cause once they see the results they always las, I have not had a single case where a pa- trust you. It is an amazing product that can be SAFETY tient has developed nodules. This is possibly successfully used by itself or in combination With needles, there is little or no sensory mainly because with the cannula there is min- with other dermal treatments to provide the feedback from the sharp tip, so it is easy imal risk of accidentally depositing droplets of most wonderful natural looking results. to puncture a vessel or accidentally place Sculptra superficially into the dermis. product in areas such as the parotid gland. Dr Linda Eve MBBS A cannula enters the subcutaneous plane IMMEDIATE DRAMATIC FACIAL is founder and Med- quite easily, and, with sufficient experience, VOLUMISATION ical Director of the EvenLines Clinics resistance to the blunt tip ensures you can A full face treatment takes around 45 based in Bourne- feel exactly where it is. However, cannulas minutes and my patients can immediately mouth and Spain do need to be used gently otherwise it is still return to non-strenuous activities, and they since 2007. She won possible to enter a vessel if forced: I always look as if they’ve had a temporary liquid the National Aesthet- advise aspirating before injecting. Unlike most facelift for a few days until the dilutant fluid ics Award for the Best UK Small Clinic for dermal fillers, Sculptra is not viscous so re- has been absorbed. With such a low risk of 2013-2014 and the Dorset Venus Award bruising, my patients feel 2013 for most successful female owned Before After confident in having treat- small business in Dorset. She regularly ments even on the day of speaks at conferences and workshops on Sculptra treatments. a special event. Disclosure: Dr Eve is the UK’s key opinion leader TREATMENTS FOR for Sinclair IS Pharma, chairman of the UK Sculptra A WIDE RANGE OF Advisory Board and member of the European PATIENTS Sculptra Expert Board. She recently launched the CanuSCULPT technique for treating patients with I use the cannula method Sculptra and has been carrying out regular training very successfully even courses in CanuSCULPT for Sinclair IS Pharma in difficult patients such since early 2013.

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Prof. Igor Pinson, MD, PhD, Prof. Olga Olisova, MD, PhD, Prof. Irena Verkhogliad, MD, PhD. First Moscow State Medical University, Skin & Venereal Diseases Department, Moscow Russia.

INTRODUCTION ics salts, largely sodium chloride, and organic substances which include lactic acid and Radiofrequency (RF) electromagnetic energy traces of urea. Eccrine glands are distributed throughout the skin in a common anatomic applicator comprises a monopolar or bipolar pattern of 3-6mm depth (Fig 1). electrode configuration and is applied in a stationary mode for deep skin heating, with- The apocrine gland is relatively bigger than the eccrine. It is situated in the deep der- out being absorbed in the skin’s biological mis or sub-cutaneous tissue at 6-8mm depth (Fig 1). The apocrine gland secretion is a chromophores and without causing ablation of thick, milky, odourless fluid rich in proteins, ammonia, lipids and carbohydrates. Their the epidermis and dermis. Since pathological secretion, which fluoresces is a turbid fluid (pH 5.0-6.5) containing proteins, sugars, and histological analysis in these indications re- ferric iron, and ammonia. vealed no irreversible damage to the upper skin layers or structures below the subcutaneous fat, TECHNOLOGY RF technology may be an attractive non-invasive The SweatX system (Alma Lasers Ltd., Caesarea, modality for sweat gland hyperthermia-induced Israel) is a high power, short-wave electromagnetic thermolysis and thus compromising the sweat energy device operating at 40.68 MHz. It employs glands electro-chemical activity in primary axil- two types of RF-induced heating of biological tissue: lary hyperhidrosis. (1) Unipolar Pro handpiece – single electrode characterised by high RF-energy penetration depth and (2) SWEAT GLAND NEURO-PHYSIOLOGY Coaxipolar Pro handpiece – coaxial electrodes op- Hyperhidrosis is a disorder of excessive timised for shallow treatment. The dominant heating Figure 1. Anatomical view of the sweating by the eccrine sweat glands, due to mechanism in both is rotational movement of water eccrine and apocrine glands. overactive cholinergic innervation, beyond what molecules in the alternating electromagnetic fields is physiologically necessary for thermoregula- (dielectric heating). The handpiece is operated by dynamic phase control of the RF elec- tion. Primary hyperhidrosis is a disorder in which tromagnetic field intensity and depth of penetration to accommodate the different depths there is excess sweating of the hands, feet, face, and physical size of the eccrine and apocrine sweat glands, and impedance matching and the axilla. Found in greatest density in the network, which provides compensation of the reactance of the attached piece of the skin. axillae, palms, and soles of the foot, the eccrine Figure 2 depicts thermographs of the Unipolar Pro and Coaxipolar Pro handpieces with glands produce sweat to help maintain body multi-level depths of tissue penetration: Unipolar-Pro: shallow (5-8mm), medium (10-12mm) temperature in response to exercise or expo- and deep (15-18mm), and Coaxipolar Pro: shallow (1-2mm), medium (3-5mm) and deep sure to heat. Axillary hyperhidrosis is believed to (6-8mm), respectively. arise from overstimulation of the eccrine glands by cholinergic nerve fibres of the sympathetic MECHANISM OF ACTION nervous system. When radiant RF electromagnetic energy is absorbed in tissue, it provokes oscillation of Sweat glands are classified according to mor- the dipole water molecules, which leads to frictional heating. Sweat gland water content phology and function as eccrine and apocrine is 99-99.5% whereas that of sweat glands. Eccrine sweat glands are innervat- surrounding skin appendag- ed by postganglionic sympathetic fibres of un- es (hair follicle, sebaceous myelinated class C type via acetylcholine. When gland) is significantly less. acetylcholine binds to muscarinic receptors on the sweat gland, intracellular Ca2++ concen- The rapidly oscillating elec- trations increase. This results in an increase in tromagnetic RF field (40.68 the permeability of K+ and Cl- channels, which MHz) emitted by the RF Un- initiates the release of an isotonic precursor fluid ipolar Pro causes rapid ro- from the secretory cells. Eccrine secretion is a Figure 2. Unipolar-Pro (Upper) and Coaxipolar-Pro (Lower) tation of the dielectric water clear fluid (pH 4.0-6.0) consisting of 99.0- 99.5% thermographs of dynamic phase control - shallow (left), molecules in the saturated water and 0.5-1.0% solids, a mixture of inorgan- medium, and deep (right). hyperactive sweat glands

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and consequently greater friction and heat production in the glands Figure 4(A) Figure 4(B) in comparison with that induced in lower water-content adjacent skin structures, such as hair follicles. The Coaxipolar handpiece greater power density targets the more superficial eccrine glands and traps the caloric reservoir of the Unipolar-Pro volumetric deep heating to increase glands thermolysis. Thus, the RF heating by the Unipolar Pro and Coaxipolar handpieces is to induce irreversible thermal damage to the hyperactive water-targeted and to both eccrine and Figure 4. Positive axillary iodine-starch test (A); laser beam axillary apocrine glands which are significantly different in their physical size skin temperature monitoring during SweatX treatment (B). and anatomical depths. Each treatment comprised 2 treatment steps: Initially, the Unipo- CLINICAL STUDY lar-Pro was employed over the entire axilla area to increase the axilla Between December 2012 and March 2013, 20 patients (17 women temperature under 45°C to the therapeutic level by depositing 25kJ and three men; age range 16-51 years old) diagnosed with primary of dielectric RF energy at 70-80 watts. axillary hyperhidrosis were randomly recruited to the study con- Immediately upon conclusion of the first step, the Coaxial Pro hand- ducted at a major dermatology clinic in Moscow. Study objectives, piece is applied to the same, now heated, axilla area. The purpose of protocol (number of treatments and intervals), benefits and possible the second step is to maintain the axilla deep tissue temperature at risks were delegated to the patient by the clinic medical staff. Patient a therapeutic level of 48-50°C by depositing and maintaining thermal screening for the study was based on those routinely seeking load primarily at the eccrine gland level (4-6mm in depth) by deposit- dermatology services at the clinic. Each patient signed an informed ing 10kJ of dielectric RF energy at 50-60 Watts. consent. The following Inclusion/Exclusion criteria were applied. Treatment time for each axilla was 8-10 minutes (~20 minutes for Inclusion criteria were: hyperhidrosis disease severity scale (HDSS) both axillae). Clinical endpoints were transient tissue erythema and questionnaire between three and four (Fig. 3) skin tenderness, which lasted up to one hour. No pre-treatment local anesthesia or pain medications were used and downtime is minimal. 1 - My underarm sweating is never noticeable and Post treatment care was cleaning and drying both axillae. Each patient underwent four consecutive treatments spaced one week never interferes with my daily activities apart. Baseline photography of each patient’s axilla iodine-starch test 2 - My underarm sweating is tolerable but sometimes was captured at baseline, one, three and six months after the last interferes with my daily activities treatment. Adverse side effect log was recorded for each patient and 3 - My underarm sweating is barely tolerable and after each treatment and during each follow-up visit. frequently interferes with my daily activities 4 - My underarm sweating is intolerable and always RESULTS 19 All 20 patients completed the interferes with my daily activities 1 study protocol. Expectedly, 15 Figure 3. Hyperhidrosis Disease Severity Scale (HDSS) during the treatment the 2 axillae become erythemous 11 In the iodine-starch test, a 10% povidone iodine antiseptic solution and tender which resolved 3 7 was applied to both axillae and allowed to dry for five minutes. up to three to four hours after 4 Cornstarch powder was then spread on the area and any excess the treatment. No adverse 4 starch brushed away. After 15 minutes, the regions were photo- side effects were noted or graphed (Fig 4A). Exclusion criteria: iodine allergic reaction, active recorded between the study 0 BL 1M FU 3M FU 6M FU infection, pregnancy planning, pregnancy or lactation, prior surgery treatments and the follow- Figure 5. Patients HDSS (1-4) at for axillary hyperhidrosis in the past 12 months, axillary injections of up visits. Before starting the baseline (BL), 1, 3 and 6 months (M) botulinum toxin A in the last 12 months, history of cancer, pacemaker treatment protocol, eight follow-up (FU) or other electronic implant. At baseline eight patients had HDSS level patients (40%) reported sweating severity (HDSS) equal to HDSS 4, and 12 patients had HDSS level 3. Forty-eight hours prior to the 3, and 12 patients (60%) HDSS level 4. In the control group eight iodine-starch test male patients were asked to shave both axillas and patients (80%) evaluated their sweating severity as HDSS 1 and all patients to avoid any use of deodorants. All qualified patients ex- two patients (20%) reported HDSS level 2. At the three month hibited positive iodine-starch test (Minor’s test) on both axillas. Each follow-up visit, patient improvement (by iodine-starch and HDSS) patient underwent four consecutive treatments spaced one week was almost unchanged (with one patient exception) in comparison apart. Baseline photography of each patient’s axilla iodine – starch with one month follow-up visit. At the 6 month follow-up, 11 patients test and HDSS were captured at baseline, one, three and six months (55%) were evaluated for sweat intensity of HDSS level 2, and nine after the last treatment. patients (45%) reported sweat intensity of HDSS level 1 (Fig. 5). At During each treatment, room ambient conditions – temperature and six month follow-up visit, the control group patients showed no relative humidity were monitored and recorded. Prior to the appli- changes from baseline in their HDSS questionnaires. cation of the RF handpieces, each axilla was coated with water-free Figure 6 depicts the number of patients shifted from baseline HDSS aromatic oil for lubrication to ease handpiece engagement with the (4 and 3) one month after the last treatment. From patient HDSS axilla area. Both handpieces were applied in overlapping strokes 4 group (n=8), five patients (63%) converted to HDSS 2 and three across the treatment area. Axillary skin temperature was monitored patients (37%) to HDSS 1. From patient HDSS 3 group (n=12), nine by laser thermometer (Fig 4B) to keep the epidermis below 45°C. patients (75%) converted to HDSS 2 and 3 patients (25%) to HDSS 1.

30 Aesthetics | February 2014 aestheticsjournal.com

14 Figure 6. Patients HDSS Are you easily LED? 12 4 (white bar) and 3 (blue 12 bar) at baseline and at one month (M) follow-up (FU). 10 9

8 8

6 5

4 3 3 Number of Patients Best New 2 Product or Treatment 2013-2014

0 Baseline 1M FU 1M FU HDSS 4 & 3 HDSS 2 HDSS 1 THE LEADING LIGHT IN DISCUSSION LED PHOTOTHERAPY This is the first study demonstrating the safety and long term efficacy (up to six months) of non-invasive short-wave guided dielectric radiofrequency technology for sweat reduction in patients Over 100 Clinics across the UK now have our Systems. Using with primary axillary hyperhidrosis. Interestingly, one month after a range of clinically proven the last treatment, all patients with HDSS 3 or 4 shifted to HDSS wavelengths Dermalux™ 1 or 2. This observation corresponded with an improvement in LED Phototherapy is a iodine-starch test results. non-invasive and Although a significant and similar improvement pattern was affordable treatment established one month after the last treatment in patients with delivering exceptional HDSS 4 & 3 (Fig. 6), patients reported significant improvement results for a wide range of skin in their daily sweat sensation already after their third and fourth conditions including: treatment. The clinical results remained unchanged in most patients up to six months where patients demonstrated significant • Skin Rejuvenation sweat reduction (Fig. 7). In the absence of histological evidence, it • Acne (all grades) • Pigmentation • Psoriasis COME AND SEE US AT STAND 22 • Rosacea • Accelerated Healing

Before & After Dermalux™ LED

Rosacea Psoriasis Acne Figure 7. Right (upper) and left (lower) axillae before, one, three and six months after four treatments. is speculated that the sustained high power RF dielectric heating of the highly saturated eccrine glands at different levels in the dermis and hypodermis may deactivate the gland electrophysiol- ogy function (i.e., thermal shock) and/or damage the hyperactive water-targeted secretory ducts of the eccrine glands by shutting BEFORE BEFORE BEFORE down the electro-conductivity pathway of the glands and pre- sumably deactivation or decay of pre-synaptic and post-synaptic excitation/activation of the gland cholanergic receptors. The current concept about axillary sweat glands differentiates between eccrine sweat glands producing abundant clear, non-odorous sweat and apocrine sweat glands excreting small amounts of AFTER AFTER AFTER turbid, odorous milky sweat. Since axillary hyperhidrosis is known 8 Dermalux treatments 8 Dermalux treatments 9 Dermalux treatments to coexist with malodor, the SweatX technology may potentially in 3 weeks in 2 weeks in 3 weeks be effective for the reduction in axillary osmidrosis (malodor).

Aesthetic Technology Limited REFRENCES Park View House, Worrall Street 1. Atkins JL, Butler PE. Hyperhidrosis: a review of current management. Congleton, Cheshire CW12 1DT Plast Reconstr Surg. 2002;110:222-228. t: 0845 689 1789 | e: [email protected] 2. Emilia del Pino M, Rosado RH, Azuela A, Graciela w: www.dermaluxled.com Guzman M. Effect of controlled volumetric tissue heating with Before and after images courtesy of; Rosacea – Blushers Clinic, Coventry; radio frequency on cellulite and the subcutaneous tissue of the Psoriasis – Miss Zahida Butt, The Cosmetic Clinic, Kings Lynn; Acne – Dr Steve McGurk – Ilkley buttocks and thighs. J Drugs Dermatol. 2006;5:714-722. Bocouture® 50 Abbreviated Prescribing Information Please refer to the Summary of Product Characteristics (SmPC). Presentation 50

LD50 units of Botulinum toxin type A (150 kD), free from complexing proteins as a powder for solution for injection. Indications Temporary improvement in the appearance of moderate to severe vertical lines between the eyebrows seen at frown (glabellar frown lines) in adults under 65 years of age when the severity of these lines has an important psychological impact for the patient. Dosage and administration Unit doses recommended for Bocouture are not interchangeable with those for other preparations of Botulinum toxin. Reconstitute with 0.9% sodium chloride. Intramuscular injection (50 units/1.25 ml). Standard READY • AUTHENTIC • MY BUSINESS dosing is 20 units; 0.1 ml (4 units): 2 injections in each corrugator muscle and 1x procerus muscle. May be increased to up to 30 units. Not recommended for use in patients over 65 years or under 18 years. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. Contraindications Hypersensitivity to Botulinum neurotoxin type A or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, Lambert-Eaton syndrome). Presence of infection or inflammation at the proposed injection site. Special warnings and precautions Should not be injected into a blood vessel. Not recommended for patients with a history of dysphagia and aspiration. Adrenaline and other medical aids for treating anaphylaxis should be available. Caution in patients receiving anticoagulant therapy or taking other substances in anticoagulant doses. Caution in patients suffering from amyotrophic lateral sclerosis or other diseases which result in peripheral neuromuscular dysfunction. Too frequent or too high dosing of Botulinum toxin type A may increase the risk of antibodies forming. Should not be used during pregnancy unless clearly necessary. Interactions Concomitant use with aminoglycosides or spectinomycin requires special care. Peripheral muscle relaxants should be used with caution. 4-aminoquinolines may reduce the effect. Undesirable effects Usually observed within the first week after treatment. Localised muscle weakness, blepharoptosis, localised pain, tenderness, itching, swelling and/or haematoma can occur in conjunction with the injection. Temporary vasovagal reactions associated with pre-injection anxiety, such as syncope, circulatory problems, nausea or tinnitus, may occur. Frequency defined as follows: very common (≥ 1/10); common (≥ 1/100, < 1/10); uncommon (≥ 1/1000, < 1/100); rare (≥ 1/10,000, < 1/1000); very rare (< 1/10,000). Infections and infestations; Uncommon: bronchitis, nasopharyngitis, influenza infection. Psychiatric disorders; Uncommon: depression, insomnia Nervous system disorders; Common: headache. Uncommon: facial paresis (brow ptosis), vasovagal syncope, paraesthesia, dizziness. Eye disorders; Uncommon: eyelid oedema, eyelid ptosis, blurred vision, eye disorder, blepharitis, eye pain. Ear and Labyrinth disorders; Uncommon: tinnitus. Gastrointestinal disorders; Uncommon: nausea, dry mouth. Skin and subcutaneous tissue disorders; Uncommon: pruritus, skin nodule, photosensitivity, dry skin. Musculoskeletal and connective tissue disorders; Common: muscle disorders (elevation of eyebrow), sensation of heaviness; Uncommon: muscle twitching, muscle cramps. General disorders and administration site conditions Uncommon: injection site reactions (bruising, pruritis), tenderness, Influenza like illness, fatigue (tiredness). General; In rare cases, localised allergic reactions; such as swelling, oedema, erythema, pruritus or rash, have been reported after treating vertical lines between the eyebrows (glabellar frown lines) and other indications. Overdose May result in pronounced neuromuscular paralysis distant from the injection site. Symptoms are not immediately apparent post-injection. Bocouture® may only be used by physicians with suitable qualifications and proven experience in the application of Botulinum toxin. Legal Category: POM. List Price 50 U/vial £72.00 Product Licence Number: PL 29978/0002 Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer Landstraße 100, 60318 Frankfurt/Main, Germany. Date of revision of text: FEB 2012. Full prescribing information and further information is available from Merz Pharma UK Ltd., 260 Centennial Park, Elstree Hill South, Elstree, Hertfordshire WD6 3SR. Tel: +44 (0) 333 200 4143

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard Adverse events should also be reported to Merz Pharma UK Ltd at the address above or by email to [email protected] or on +44 (0) 333 200 4143.

1. Frevert J. Content in BoNT in Vistabel, Azzalure and Bocouture. Drugs in R&D 2010-10(2), 67-73 2. Prager, W et al. Onset, longevity, and patient satisfaction with incobotulinumtoxinA for the treatment of glabellar frown lines: a single-arm prospective clinical study. Clin. Interventions in Aging 2013; 8: 449-456. 3. Sattler, G et al. Noninferiority of IncobotulinumtoxinA, free from complexing proteins, compared with another botulinum toxin type A in the treatment of glabelllar frown lines. Dermatol Surg 2010; 36: 2146-2154. 4. Prager W, et al. Botulinum toxin type A treatment to the upper face: retrospective analysis of daily practice. Clin. Cosmetic Invest Dermatol 2012; 4: 53-58. 5. Data on File: BOC-DOF-11-001_01

Bocouture® is a registered trademark of Merz Pharma GmbH & Co, KGaA. 1131/BOC/NOV/2013/LD Date of preparation: November 2013 Bocouture® 50 Abbreviated Prescribing Information Please refer to the Summary of Product Characteristics (SmPC). Presentation 50

Bocouture® is a registered trademark of Merz Pharma GmbH & Co, KGaA. 1131/BOC/NOV/2013/LD Date of preparation: November 2013 Clinical Practice Spotlight On aestheticsjournal.com

Regenlite Transform Dr Donna Freeman, Director of Clinical Research at Chromogenex, discusses the benefits of the new Regenlite Transform laser in treating dermatological conditions

Following the N-Lite and Regenlite, mode, making the treatments pain-free, heat-damaged layer associated with Chromogenex has now launched Regenlite very well tolerated, with no bruising or risk ablative resurfacing techniques and Transform the only laser proven to stimulate of hypopigmentation even in Fitzpatrick initiates collagen stimulation without the skin’s immune system by triggering an skin types V and VI. long-term impairment. The critical laser increase in Transforming Growth Factor It is also the release of these molecules, parameters engineered into the device Beta (TGFβ). Previously dermatological in particular TGFβ, which produces the to achieve bio-stimulation include pulse conditions such as psoriasis and eczema unique treatment results seen with this duration and temporal profile. The unique have been treated using the vascular mode laser. TGFβ is known to be a potent parameters ensure that erythrocytes of pulsed dye lasers. However, studies remain intact, there conducted with Regenlite and published Regenlite Transform introduces two unique modes is no endothelial cell in the British Journal of Dermatology of action, necrosis and the indicated that the effect on acne was • Bio-stimulation, a multi-application mode formation of immature primarily due to biostimulation, in particular • Thermal for vascular treatments elastic fibres can be in the upregulating of TGFβ, which is Delivering both double and triple pulse options, it uses low observed as soon involved in producing collagen and in fluency light to specifically target the microvasculature of as three days after downregulating the inflammatory cascade. the dermis and stimulate the tissue’s natural wound healing treatment(3). It uses (1) It is also known to be intimately involved response without any residual cell necrosis. Absorption of the a patented pulse in the acquisition of an immune response yellow light into these blood vessels results in a mild thermal profile innovation in the skin, to reduce the skin’s reactivity to effect and an inflammation that incites the release of cytokines of 100μs, which triggers such as bacteria and viruses. The and growth factors and leads to the stimulation of new collagen. delivers consistent study showed that as early as three hours reproducible after treatment with Regenlite there was a stimulus for neocollagenesis and a pivotal cutaneous immunological responses massive upregulation in TGFβ of between immunosuppressive cytokine. The action without tissue impairment. The pulse is 500 and 1500%. In our studies some of these is the promotion of inflammation generated by the ultra stable laser cavity, patients reported a reduction in the pain of resolution within early acne lesions and which produces the fast rise pulse and pure inflammatory acne and relief from itching in prevention of microcomedone formation 585nm yellow light output. The absorption eczema and psoriasis within hours of their that occurs as a result of keratinocyte characteristics of oxyhemoglobin highlight first treatment. hyperproliferation at the pilosebaceous unit. 585nm to be the perfect wavelength When the laser targets a small capillary; of light to combine maximum tissue With the new Regenlite we have focused 1) absorption in the oxyhemoglobin results penetration and maximum absorption. on the parameters that are most effective in heating of the capillary walls Wavelength stability is crucial to maximise for biostimulation, making it a major 2) inflammatory mediators are released the absorption in oxyhaemoglobin and advance in the treatment of inflammatory which stimulate fibroblast cells in the minimise unwanted purpura. Patients skin conditions such as acne, psoriasis, extracellular dermal matrix today are less likely to desire or tolerate rosacea, eczema and for warts and 3) these fibroblasts produce new collagen. systemic treatments such as antibiotics or verrucas. These new parameters use complicated and unpleasant ones as are much lower doses of light than in the Yellow laser light was originally used for traditional for psoriasis. I believe Regenlite vascular mode, and even better targeted the therapy of vascular lesions because Transform offers a more holistic treatment parameters than the previous biostimulation of their high absorption preference by that can improve patient safety, compliance oxyhaemoglobin. Following on from the and satisfaction. use of Argon (blue-green) laser light for Before After REFERENCES the treatment of Port Wine Stains, attention 1. Seaton et al, British Journal of Dermatology focused on pulsed yellow dye lasers to 2006; 155: 748-755 replicate the highly selective damage to 2. Tan OT, Arch Dermatol 1986; 122(9): 1016-22 cutaneous micro-vessels but with minimal 3. Omi et al, Lasers in Surg Med 2003; 32: 46-49 Psoriasis, Before and three months injury to the overlying epidermis.(2) after eight treatments. Dr Donna Freeman Careful consideration of the key parameters is director of clinical research and education Before After of the laser can enable the focus of the treatment to not be the normal ectatic or at Chromogenex, dilated vessels of a vascular irregularity but with a focusing on clinical research, instead the smallest of the microvasculature development of within the dermis. Biochemical stimulation new devices and Rosacea, Before and after rather than thermolysis of these micro- technologies, construction of technical three treatments. vessels mimics the effect of residual articles and documents.

34 Aesthetics | February 2014 chromogenex TM

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The world’s rst Super Fast Pulse 585nm laser for inammatory skin conditions

Introducing the world’s rst Super Fast Pulse 585nm laser, Safe, fast and e ective a major advancement in the treatment of inammatory treatment for: skin conditions such as psoriasis, rosacea, eczema and acne as well as rejuvenation of the skin and other • Psoriasis dermatological conditions. • Rosacea The Regenlite™ Transform is a new concept of • Eczema therapeutic laser and the only laser proven to stimulate • Acne the skin’s immune system by triggering an increase in Rejuvenation Transforming Growth Factor Beta (TGFβ) and engineered • to deliver consistent results using patented pulse pro le innovation. Enquire now visit www.regenlite.com

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Desirial and Desirial Plus for intimate rejuvenation Dr Elisabeth Dancey explores the treatment of labia majora hypotrophy with Desirial Plus

The menopause is characterised by decreasing ovarian Using Desirial Plus as an aesthetic practitioner and adrenal function, with alterations of growth hormone secretion. The skin and mucosa of the whole body are • Treatment with Desirial affected by the changes, due to the generalised nature of Plus is similar to any female sex hormone receptors. During the perimenopausal treatment with HA using a period, type 1 collagen decreases but type 3 increases. cannula. The area should There is a global loss of 1% collagen type 1 per year, leading be shaved and cleaned to a progressive hypotrophy and flattening of the dermo- with a bacteriocidal epidermal junction. The effects on the female genitalia can solution, avoiding chlorhexidine over the delicate mucosa. Local be summarised as the following. Labia majora hypotrophy anaesthetic is essential as this area is very sensitive. – involution of the adipose and cutaneous component. • Mark the insertion area with a skin marker. Select the upper part of the labia majora above and lateral to the clitoris. Inject with local Tissue loss is associated with function loss and the labia are anaesthetic such as lidocaine 1%. unable to protect the vulva and vagina. Aesthetically the labia • Make the pilot hole with the 19g needle provided in the pack. Aim the majora appears thin and wizened. (Fasola E, 2009) (Fasola needle so that the track runs parallel to the skin, beneath the dermis. et al 2010). (Macgregor JC 2008). The other is vulvo-vaginal • Assemble the cannula onto the syringe. Using the pilot hole, atrophy. The stratum corneum is non-keratinised and there gently insert the cannula so that it runs parallel to the skin, moving are no clearly demarcated layers as for the skin (Farage et al, downwards towards the base of the labia (about 5cm). Once in the 2011). There are no glands in the vaginal wall. Moisturisation correct position, press the plunger and retract the syringe, depositing and protection against disease is assured by the glands of 2ml into the length of the labia. Remove the syringe and repeat the the cervix, Skenes glands and Bartholins glands (however other side. currently under dispute). Bacteria ferment secreted glycogen • The main problem associated with this procedure is pain, which must thus assuring a bacteriostatic acid environment. Desirial is a be well explained to the patient. Local anaesthesia moderates this hyaluronic acid product created by Laboratoires Vivacy. It is pain. Infection is a potential complication as for any HA treatment but a patented cross-linked interpenetrated network with added pilot studies show this not to be the case with this treatment. mannitol to aid longevity and reduce swelling. Mannitol acts • It is essential that the technique is perfected in order to avoid specifically on hydroxyl radicals which destroy hyaluronic injection of the product into the Bag of Sappey. Inadvertent injection into this area will cause swelling, redness and pain similar to infection. acid, thus prolonging the effect of the HA and minimising Treatment with hyaluronidase into the lump will relieve the condition swelling and inflammation. (Back JF et al, 1979). Desirial Plus (1500 iu into the lesion). is created to reshape the labia majora and contains 21mg/g hyaluronic acid. It is presented in a 2ml syringe with 2 18 cannulae. Desirial Plus may be used by aesthetic doctors for REFERENCES • Back JF et al. Increased thermal stability of proteins in the presence of sugars and this purpose. Desirial contains 19mg/g hyaluronic acid and is polyols –Biochemistry – 1979 vol 18 No 23 p 5191 – 5196 created as a biostimulant/ rehydrating agent in the medium to • Chlebowski, RT, Hendrix SL, Langer RD, Stefanick ML, Gass M, Lane D, deep dermis. It restores volume, rehydrates the skin and the Rodabough RJ, Gilligan MA, Cyr MG, Thompson CA, Khandekar J, Petrovitch mucosa and stimulates fibroblast activity in the labia majora, H, McTiernan A. Influence of oestrogen plus progestin on breast cancer and vestibule and vagina. It is presented as 2 x 1ml syringes. mammography in healthy post-menopausal women. The women’s health initiative randomized trial JAMA 2003 289; 3243-53. Desirial should only be injected internally by a gynaecologist. • Eva LJ, Maclean AB, Reid WM, Rolfe KJ, Perrett CW. Estrogen receptor expression in vulvar vestibulitis syndrome Am J Obstet Gynaecology 2003 Aug 189 (2) 458-61 Treatment with Desirial for vulvu-vaginal conditions • Farage MA, Maibach HI, Morphology and physiological changes of genital skin Desirial should be used as part of a comprehensive treatment and mucosa. Curr Probl Dermatology 2011; 40: 9-19 programme for the menopause together with other modal- • Fsaola E, Anglana F, Basile S, Bernabei G,CavalliniM. A case of labia majora augmentation with hyaluronic acid implant. Journal Plastic dermatology 2010 (6)3. ities such as hormones, diet, creams and lifestyle changes. • Levine KB, Williams RE, Hartmann KE. Vulvo-vaginal atrophy is strongly associated The manufacturers insist that this treatment is carried out by with female sexual dysfunction among sexually active women. Menopause, 2008, a suitably trained gynaecologist. Desirial is a completely new 15 (4pt 1) 661 -666. treatment for an intimate area. It is essential that the treatment • Santoro, N and Komi J. Prevalance and impact of vaginal symptoms among is offered in a discreet manner to avoid connotations of the postmenopausal women. Journal of Sexual medicine, 2009, 6 (8) 2133 – 2142. sex trade. There may also be local taboos over discussing Dr Elisabeth Dancey has been practising cosmetic such a problem amongst menopausal women. However medicine since 1993. She introduced mesotherapy to the once these aspects have been overcome it is envisaged UK having studied at Liege, Belgium and has pioneered several other treatments and products. She now owns and that the treatment will have its adherents and will, in the right runs Bijoux Medi Spa in central London. She has trained and hands and with the correct introduction, be successful. demonstrated the use of various hyaluronic acid fillers over the last 20 years and will be one of the trainers for Desirial.

36 Aesthetics | February 2014 COME AND SEE US AT STAND 58

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measure of QoL for comparison, each Impact of Botulinum Toxin A on of the five cue scores was multiplied by the corresponding cue weight and the the Quality of Life of Subjects products of these calculations summed Following Treatment of Facial Lines together. RAVI JANDHYALA, MSc(LOND), MBBS(LOND), MRCS(GLASG), The cue score (range 0–100) was derived from the length of the bar (in millimetres) MFPM, LLM drawn by the patient for that particular The Jandhyala Institute, Banbury, United Kingdom cue. The cue weight was derived from the proportion of weighting the patient Demand for treatment of facial lines presenting at the Jandhyala Institute had assigned, using the direct-weighting continues to rise, botulinum toxin for incobotulinumtoxinA treatment for instrument, to that particular cue (range (BoNT-A) is especially popular due to moderate-to-severe wrinkles of the 0.00–1.00). its efficacy and tolerability1, 2 BoNT-A is glabella, forehead, or crow’s feet (as At the follow-up visit, patients completed now used in a wide range of aesthetic measured by Carruthers’ Scale16,17) the SEIQoLDW procedure using both applications in many areas of the face.3 were eligible for inclusion. Patients newly defined cues (subsequently labelled As such, full quantification of the benefits were excluded on the basis of previous ‘new cues’) and the cues defined at their of BoNT-A treatment is becoming treatment with, or contraindications to, pre-treatment visit (subsequently labelled increasingly important. A key area of BoNT-A treatment or a history of migraine. ‘old cues’). Cues are defined at each visit interest is whether treatment actually Patient history was taken and routine to ensure that the QoL scores derived are improves a patient’s day-to-day life. assessment carried out at the initial visit, maximally relevant to the patient at that Improvements in satisfaction, appearance, and standardised photos were taken at time. As a consequence, it is possible that mood, and related outcomes have been both visits. Ethical review was deemed a patient may define markedly different well reported,4–13 but to date, data on unnecessary according to the National cues at the follow-up visit as compared to whether these improvements translate to Research Ethics Service (NRES) guidance the initial visit. To account for this, the or correlate with changes in quality of life document, and the study was considered SEIQoL-DW protocol also recommends (QoL) are scarce. a service evaluation.18 assessment of the patients using the old Dayan et al14 recently reported that cues as defined at the initial visit.15 onabotulinumtoxinA treatment of The SEIQoL-DW tool was administered facial wrinkles significantly improved according to protocol.15 At the first visit, The use of new cues gives a measure QoL and self-esteem as compared to a standardised question was used to of QoL using the cues that the patient both treatment with placebo and pre- stimulate patients to independently feels are of greatest importance to them treatment baseline values using the identify the five life areas (cues) of most currently, while the use of the old cues Quality of Life Enjoyment and Satisfaction importance to them at that time. A list of facilitates direct comparison of QoL at Questionnaire—Short Form and the potential areas was available for use as each visit. Marked differences in the cues Heatherton and Polivy State Self-Esteem a prompt for patients who had difficulty identified or the importance ascribed measurement. In the present study, an completing this task. Patients then to these cues may necessitate further investigation of QoL in patients treated quantified their present status in each of investigation and consideration in the with BoNT-A was undertaken by using their five identified cue areas by drawing interpretation of the results. However, patient rather than questionnaire-defined a bar for each area against a criteria to measure QoL, before and 100mm scale, with a taller bar TABLE 1. Frequency of nomination as areas of importance after treatment, using the Schedule for indicating better current status Cue Area Visit 1 Visit 2 the Evaluation of Individual Quality of (the cue score). Finally, the Family 96.2% 90.6% Life Direct-Weighting (SEIQoL-DW) tool.15 patients weighted the five areas Work 62.3% 69.8% Furthermore, the hope was to establish as to their relative importance Finance 52.8% 58.5% whether there is any correlation between using the direct weighting Relationships 52.8% 45.3% patient satisfaction and changes in QoL. instrument, effectively Health 50.9% 60.4% producing a five-segment Appearance 43.4% 43.4% METHODS pie chart, with each segment Social life 35.8% 13.2% The study prospectively measured patient indicating the importance of Living conditions 34.0% 20.8% 15 QoL data using the SEIQoL-DW tool the corresponding cue area Leisure activities 32.1% 13.2% immediately before and 28 days after (cue weight). Patients were also Marriage 13.2% 7.2% treatment with BoNT-A (Bocouture® , asked to assess their overall Pets 13.2% 7.5% Merz Pharmaceuticals GmbH, Frankfurt, QoL using a visual analogue Partner 11.3% 11.3% Germany). Satisfaction with treatment scale (VAS) of 0 to 100 (0 being Divorce 3.8% 1.9% was also assessed by patients using the worst possible, 100 the Religion 3.8% 0.0% standardised photos taken during best possible). To produce the Education 1.9% 1.9% pre- and post-treatment assessments. final SEIQoL-DW index score, Friends 1.9% 1.9% All new patients aged 18 to 65 years which provides an overall Mother 0.0% 1.9%

38 Aesthetics | February 2014 COME AND SEE US AT STAND 58

(7% lidocaine & 7% tetracaine)

CLEAN, SIMPLE AND FAST ACTING

e) ain tetrac % 7 & e ain oc lid %

THE FIRST AND ONLY SELF-OCCLUDING (7 TOPICAL ANAESTHETIC

Indications: For use in adults to produce local dermal anaesthesia on intact skin prior to dermatological procedures

Pliaglis Prescribing Information (UK & Ireland) Precautions and Warnings: Avoid contact with eyes. Treated area but were generally mild and transient in nature. Reported adverse Presentation: 1 gram of cream contains 70mg lidocaine & 70mg should not be occluded before removing Pliaglis from skin. Should not reactions include: Very common (≥1/10): erythema, skin discolouration; tetracaine.Indications: For use in adults to produce local dermal be applied for a longer time than recommended. Local anaesthetics, Common (≥1/100 to <1/10): skin oedema; Uncommon (≥1/1,000 to anaesthesia on intact skin prior to dermatological procedures. Dosage including tetracaine, have been associated with methemoglobinemia. <1/100): pruritus, pain of skin, pain; Rare (≥1/10,000 to <1/1,000): and Administration: For procedures such as pulsed-dye laser therapy, It is not recommended to use Pliaglis before injection of live vaccines paresthesia, eyelid oedema, pallor, skin burning sensation, swelling Pliaglis should be applied at a thickness of 1mm for 30 minutes. For as lidocaine has been shown to inhibit viral & bacterial growth. Use face, skin exfoliation, skin irritation; Not known (cannot be estimated procedures such as laser-assisted tattoo removal, Pliaglis should be with caution in patients with hepatic, renal or cardiac impairment, and from available data): urticaria. Rare allergic or anaphylactoid reactions applied at a thickness of 1mm for 60 minutes. After the required time, in patients with increased sensitivity to systemic circulatory effects of associated with lidocaine and tetracaine or other ingredients in Pliaglis the peel must be removed from the skin prior to the procedure. The lidocaine and tetracaine. Avoid trauma to skin whilst under effects of can occur. Prescribers should consult the SPC in relation to other maximum application area should not exceed 400 cm2. For facial Pliaglis. Interactions: No interaction studies have been performed. side-effects. Packaging Quantities and Cost: UK-15g £22.95 (NHS), procedures, Pliaglis should be applied by healthcare professionals only. Interactions following appropriate use are unlikely as only low IRE-15g €27.00 MA Number: PL 10590/0059 (UK) & PA 590/26/1 Pliaglis should be applied with a flat surfaced tool, never with fingers. concentrations of lidocaine and tetracaine are found in the plasma after (IRE). Legal Category: POM. Full Prescribing Information is Pliaglis is for single patient use. Contraindications: Hypersensitivity topical administration of recommended doses. Patients taking drugs Available From: Galderma (UK) Limited, Meridien House, 69-71 to lidocaine, tetracaine, other anaesthetics of the amide or ester type, associated with drug-induced methemoglobinemia are at greater risk Clarendon Road, Watford, Herts, WD17 1DS. UK. Tel: +44 (0)1923 to para-aminobenzoic acid or any of the other excipients. Should for developing methemoglobinemia. Undesirable Effects: In clinical 208950 Fax: +44 (0)1923 208998. Date of Revision: May 2013 not be used on mucous membranes or on broken or irritated skin. trials, localised skin reactions at the application site were very common

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Galderma (UK) Ltd

Date of preparation: August 2013 PLI/034/0813

28607 Pliaglis A4 Ad.indd 1 28/08/2013 14:10 Clinical Practice Clinical Study aestheticsjournal.com

some variation is inevitable as patients’ after consideration of both the old (P at the second visit, it is also to use the priorities and concerns inevitably change <0.0001) and new cues (P <0.0001) at Visit old cues to facilitate direct comparison15. over time, and a key strength of the 2 (Table 3). It is reassuring to note that overall, the SEIQoL-DW approach is its ability to take Satisfaction increased significantly same cue areas were identified as being account of these changes. following treatment (median satisfaction most important at Visit one and Visit two, Patients also assessed their satisfaction score post vs. pre-treatment: 9.2 vs. 4.3, suggesting that as a whole, the patient with their appearance before and after P <0.0001), but evidence of any positive population was relatively stable in terms of treatment from the standardised digital correlation between satisfaction score non-treatment influences on their QoL. It is photographs taken at each visit using a and QoL or SEIQoL score was minimal. also interesting to note that while, perhaps VAS ranging from 0 (not satisfied at all) to Only QoL as defined by VAS following the surprisingly, ‘appearance’ was not one of 10 (completely satisfied). use of the old cues at Visit 2 was found the five most frequently selected cues in to significantly correlate to satisfaction determining QoL, among those patients RESULTS score at the same visit (P =0.0404, all other who did identify it as important, it could be 53 patients (aged 22–62 years [median correlations P >0.05). When considering considered a fundamental driver of QoL, as age: 39.5 years]; 87% women) were the change in these scores, 100% of evidenced by its prominent weighting. enrolled in this study. All patients patients indicated that their satisfaction successfully completed the independent with their appearance had increased. Perhaps surprisingly, the present nomination of five important areas of their However, not all patients indicated that study found no consistent evidence of lives and allocated current status and their QoL had increased. correlation between the level of patient relative importance to each. Following elicitation of the new cues, 79 satisfaction and their SEIQoL or overall Family, work, finance, relationships, and and 64% rated their QoL as improved QoL scores at either visit, despite all health were the five most frequently according to their overall assessment patients having an increase in satisfaction identified cues at each assessment (Table and using SEIQoL, respectively. Using the and the majority showing an improvement 1). According to the cue weights ascribed old cues, these figures increased to 91 in QoL, particularly when assessed (and considering only those cues and 75%. No evidence of any correlation following use of the old cues at their identified by more than 10 patients), the between the change in satisfaction score follow-up visit. It is also of interest to note five cues deemed to be most important and the change in QoL (as measured by that when the change in satisfaction score were family, appearance, health, VAS or SEIQoL) was found (all P >0.05). following treatment was analysed against relationships, and finance at both visits change in SEIQoL or overall QoL, there (Table 2). QoL before and after treatment DISCUSSION was no evidence of a correlation in the was significantly improved following The results of this study demonstrate that size of the change of the two measures. incobotulinumtoxinA treatment according QoL is significantly improved following This may in part be explained by the to the SEIQoL index scores generated incobotulinumtoxinA treatment. Both overall fact that satisfaction with appearance is using both the old (P =0.0006) and new QoL as assessed by VAS and SEIQoL one of many factors that contribute to cues (P =0.0235) (Table 3). scores were consistently higher following QoL and, as already alluded to, less than Overall QoL as measured by VAS following treatment, irrespective of whether the half of patients identified appearance identification and weighting of the SEIQoL old or new cues had been considered as a major determinant of their QoL. As cue areas was also found to significantly during the SEIQoL process. While the such, it is clear that while appearance is improve after treatment when assessed recognised procedure is to elicit new cues undoubtedly important to many patients

TABLE 2a. Mean weight ascribed to nominated areas at Visit 1 TABLE 2b. Mean weight ascribed to nominated areas at Visit 2 Cue Number of patients who Mean weighting visit 1 Cue Number of patients who Mean weighting visit 2 nomniated cue at visit 1 nomniated cue at visit 2 Family 51 33.9 Family 48 31.5 Appearance 23 21.5 Appearance 23 18.2 Health 27 19.8 Health 32 19.8 Relationships 28 18.5 Relationships 24 17.6 Finance 28 18.3 Finance 31 16.3 Work 33 13.9 Work 37 15.3 Living conditions 18 13.6 Living conditions 11 14.9 Social life 19 12.9 Social life 16 11.8 Leisure activities 17 11.7 Leisure activities 7 14.1 Marriage 7 22.2 Marriage 4 24.0 Pets 7 16.6 Pets 4 16.3 Partner 6 14.7 Partner 6 11.2 Friends 1 17.0 Friends 1 12.0 Religion 2 21.0 Religion 0 0.0 Divorce 2 20.0 Divorce 1 28.0 Education 1 11.0 Education 1 22.0 Mother 0 0.0 Mother 1 30.0

40 Aesthetics | February 2014 Clinical Practice aestheticsjournal.com Clinical Study

TABLE 3. Quality-of-life scores pre- and post-treatment Measure Comparison Visit 1 mean Visit 2 mean P-Value vs. old cues 72.3 P<0.0001 QoL (VAS) scores 58.7 vs. old cues 70.6 P<0.0001 vs. old cues 70.1 P=0.0006 SEIQoL indicies 63.7 vs. old cues 67.9 P=0.0235

receiving BoNT-A, the use of satisfaction scores alone may be an Dr Ravi Jandhyala is a member of the unreliable surrogate for QoL in day-to-day practice. These results, Royal College of Surgeons of Glasgow, and a in combination with those of Dayan et al,1 suggest that serious founding member of the UKBTGA. He has over consideration should be given to incorporating the measurement nine years experience in aesthetics and also of QoL as an outcome measure following BoNT-A treatment. consults for the pharmaceutical industry as a Further research is warranted in this area to further quantify the pharmaceutical physician. Mr Jandhyala owns impact BoNT-A treatment has on patients beyond the observed the Enhance clinic in Banbury and is a leading changes in appearance. voice on botulinum toxin.

REFERENCES DISCLOSURE 1. American Society for Aesthetic and Plastic Surgery 2010. http://www. The author has received research funding from Merz Pharma in relation surgery.org/sites/default/files/Stats2010_1.pdf. Accessed on Feb 14, 2013. to other studies. The study received support for medical writing and 2. Imhof M, Kühne U. A phase III study of incobotulinumtoxinA in the treat- medicinal products from Merz Pharmaceuticals. ment of glabellar frown lines. J Clin Aesthet Dermatol. 2011;4:28–34. 3. De Boulle K, Fagien S, Sommer B, et al. Treating glabellar lines with botulinum toxin type A-hemagglutinin complex: a review of the science, 16. Carruthers A, Carruthers J, Hardas B, et al. A validated grading scale the clinical data, and patient satisfaction. Clin Int Aging. 2010;5:101–118. for crow’s feet. Dermatol Surg. 2008;34(Suppl 2):S173–S178. Carruthers A, Carruthers J, Hardas B, et al. A validated grading scale 4. Sommer B, Zschocke I, Bergfiled D, et al. Satisfaction of patients after 17. treatment with botulinum toxin for dynamic facial lines. Dermatol Surg. for forehead lines. Dermatol Surg. 2008;34(Suppl 2):S155–S160. 2003;29:456–460. 18. Defining research. National Research Ethics Service. Ref: 0987 December 2009. www.nres.nhs.uk/applications/is-yourproject-research/. 5. Stotland MA, Kowalski JW, Ray BB. Patient-reported benefit and satisfaction with botulinum toxin type A treatment of moderate to severe gla- Accessed on: February 14, 2013. bellar rhytides: results from a prospective open-label study. Plast Reconstr 19. Lipton RB, Varon SF, Grosberg B, et al. OnabotulinumtoxinA im- Surg. 2007;120: 1386–1393. proves quality of life and reduces impact of chronic migraine. Neurology. 2011;77:1465–1472. 6. Fagien S, Carruthers JD. A comprehensive review of patientreported satisfaction with botulinum toxin type A for aesthetic procedures. Plast Reconstr Surg. 2008;122:1915–1925. 7. Carruthers A, Carruthers J, Dessain AS. Preliminary results with the Facial Line Outcomes (FLO) Questionnaire in the treatment of multiple upper face rhytids with botulinum toxin type A. Results from a single-center, dose-comparison, pilot study. Poster presented at: the AcademyLaser 2005 Support Services Laser Support Services meeting of the American Academy of Dermatology; July 20–24, 2005; Chicago, IL. Patient protective eyewear 8. Lewis MB, Bowler PJ. Botulinum toxin cosmetic therapy correlates with Laser safety eyewear a more positive mood. J Cosmet Dermatol.Disposable 2009;8:24–26. Laser, IPL and LEDLaser eyewear Support Services 9. Wollmer J, Wollmer MA, de Boer C, et al.Mouthguards Facing depression with botuli- • Patient protective eyewear num toxin: a randomized controlled trial. PsychiatrLaser surgical Res. instruments 2012;46:574–581. Patient protective eyewear 10. Fagien S, Cox SE, Finn JC, et al. Patient-reportedSafety signage outcomes with botuli- Laser safety eyewear • Laser safety eyewear Safety interlocks num toxin type A treatment of glabellarDisposable rhytids: Laser, a double-blind, IPL andLaser LED eyewear Support Services Laser safety curtains randomized, placebo controlled study. DermatolMouthguards Surg. 2007;33:S2–S9. Laser Support Services has been supplying laser • Disposable Laser, IPL and LED Laser surgical instruments 11. Carruthers A, Carruthers J. A single-center,productsPatient since dose-comparison protective 1990. All eyewear supplies conform study to current Safety signage of botulinum neurotoxin type A in femalesEC safety withLaser standards upper safetyLaser eyewear facial Supportrhytids: Services eyewear Safety interlocks Disposable Laser, IPL and LED Lasereyewear Support Services Ltd. assessing patients’ perception of treatment outcomes.Laser safety curtains J Drugs Dermatol.Laser Support Services Mouthguards School Drive - Ovenstone - Fife - KY10 2RR 2009;8:924–929. Laser Support Services hasTel: been 01333 supplying-311938 laser Fax 01333-312703 • Mouthguards Laser surgical instruments products sincewww.laser 1990. All-support.co.uk supplies conform — Email to current Enquiries@laser -support.co.uk 12. Carruthers J, Carruthers A, Monheit GD, etSafety al. signage Multicenter, randomized, Patient protectiveEC eyewear safetyPatient standards protective eyewear parallel-group study of onabotulinumtoxinA andSafety interlockshyaluronic acid dermal • Laser surgical instruments Laser safety eyewear Laser safety eyewear Laser Support Services Ltd. fillers (24-mg/ml smooth, cohesive gel) aloneLaser and safety in curtains combination School Drive for - Ovenstone lower - Fife - KY10 2RR Disposable Laser, IPL and LED eyewear facial rejuvenation: satisfactionDisposable and patient-reported Laser,Laser IPL Support and ServicesLED outcomes. eyewear has beenTel: 01333supplyingDermatol-311938 laser Fax 01333-312703 • Safety signage products Mouthguardssince 1990.www.laser All supplies-support.co.uk conform — to Email current Enquiries@laser -support.co.uk Surg. 2010;36:2135–2145. EC safety standards Mouthguards Laser surgical instruments 13. Beer KR, Boyd C, Patel RK, et al. Rapid onset of response andLaser pa Support- Services Ltd. • Safety interlocks Laser surgical instrumentsSafety signage School Drive - Ovenstone - Fife - KY10 2RR tient-reported outcomes after onabotulinumtoxinASafety treatment interlocks Tel: of 01333 moder-311938 - Fax 01333-312703 Safety signage www.laser-support.co.uk — Email [email protected] • Laser safety curtains ate-to-severe glabellar lines. J Drugs Dermatol.Laser 2011;10:39–44. safety curtains Safety interlocks 14. Dayan SH, Arkins JP, Patel AB, et al. A double-blind,Laser Support Services randomized, has been supplying laser placebo-controlled health-outcomesLaser safety surveycurtainsproducts of the since effect 1990. of All botulinum supplies conform to current Laser Support Services has been supplying laser EC safety standards products since 1990. All supplies conform to toxin type A injectionsLaser on qualitySupport of Serviceslife and self-esteem. has been supplying Dermatol laserSurg. 2010;36:2088–2097. Laser Support Services Ltd. current EC safety standards products since 1990. All supplies conformSchool to current Drive - Ovenstone - Fife - KY10 2RR 15. O’Boyle C, BrowneEC safetyJ, Hickey standards A, et al. The Schedule for the EvaluationTel: 01333-311938 Fax 01333-312703 of Individual Quality of Life (SEIQoL): a direct weighting procedurewww.laser-support.co.uk for — Email [email protected] Laser Support Services Ltd. Laser Support Services Ltd. quality of life domains (SEIQoLDW). Administration Manual. Ireland: Royal School Drive - Ovenstone - Fife - KY10 2RR College of Surgeons in Ireland; 1993. School Drive - Ovenstone - Fife - KY10 2RR Tel: 01333-311938 Fax 01333-312703 Tel: 01333-311938 Fax: 01333-312703 www.laser-support.co.uk — Email [email protected] www.laser-support.co.uk — Email [email protected] Clinical Practice Treatment Focus aestheticsjournal.com

BTL Vanquish: Radio frequency fat loss Lisa Littlehales discusses the mechanisms and benefits of the new device from BTL Aesthetics for the abdomen and flanks

Previously, when a patient had a large reduction for the abdomen was 4.8cm occurs due to polar molecule oscillation. abdomen, the only option for them was (measured 5cm above umbilicus), 5.4cm The fat cells are then macrophaged away by liposuction or abdominoplasty, which (measured over umbilicus) and 4.9cm the liver. Unlike cryolipolysis, which triggers can both cause pain and discomfort. (measured 5cm below umbilicus).1 The a slow metabolism of fat, radio frequency Additionally, anaesthesia poses a risk on an circumferential reduction was measured results in instant treatment. As metabolism is obese patient, and the chance of scarring at baseline and after the fourth treatment. rapid, it is advised that for 24 hours before and seroma is high. As a result, many plastic There were no significant changes in and after treatment, patients have a low-fat surgeons do not want to perform liposuction patients’ body weight during the therapy. diet and do not drink alcohol, due to the on patients with a BMI over 28/29. heavy workload of the liver. Vanquish radio frequency, F.D.A. approved, Figure A shows a 29-year-old female patient Unlike liposuction, there is no scarring offers an alternative form of fat loss for who underwent five sessions of Vanquish, because the heat produced targets fat cells those who need debulking of the abdomen demonstrating uniform reduction of fat by and bypasses the skin. The temperature and flank areas. It is a contactless device equal diffusion of heat. Anecdotally, one therefore rises in the fatty tissue, but that uses selective high radio frequency to patient has claimed that the treatment has surrounding tissue stays protected from generate heat only in subcutaneous adipose improved her stretch marks, and others have reaching high temperatures. The device tissue. At Beyond Medispa, we have used it claimed their skin tone has improved: this also measures the hydration levels of successfully in combination with cryolipolysis could be due to thermal injury in the area the areas being treated. Patients need technology Zeltiq’s CoolSculpting, which treated, which has stimulated fibroblasts to to be well hydrated before treatment, as can be used to shape after the endpoint produce collagen and elastin, improving the water is essential to allow polar molecule is achieved. Previously patients were quality of the skin. However, there are no oscillation to occur. In summary, Vanquish is recommended to lose weight prior to studies to support these claims. a contactless device, which uses selective undergoing CoolSculpting, which could then Patients are weighed prior to the treatment, HF to target subcutaneous adipose tissue be used to shape and reduce pockets of and photographs taken. This is essential, so specifically, allowing for quick and safe fat. By using Vanquish, the patient can reach patients’ consent must be obtained. They treatment. We opted for it at Beyond their endpoint much more quickly. are placed on their back, and an applicator Medispa because it can treat the largest The treatment programme for Vanquish is placed on them to protect the skin. The head area compared to other machines, and quick and effective, comprised of four half an of the machine is placed over the abdomen. focuses on the abdomen and flanks, the hour sessions ideally spaced a week apart, The patient’s skin temperature needs to most requested areas for fat loss treatment. with very little downtime. Patients typically reach 40°C for successful treatment. Additionally, it has increased the range of see results at two weeks, and the endpoint They should not be left unattended through- patients we can treat, and complements our is three months after their fourth treatment. out treatment; the clinician should regularly current sculpting device CoolSculpting and The patient is then called back to clinic for ask patients to score their comfort level skin tightening devices, which we hope to reassessment, to either continue with the between one and 10 and regularly measure invest in in the future. technology or move on to another non- the temperature of their skin to ensure it surgical fat reduction treatment. doesn’t exceed 42°C, as this could cause REFERENCES Clinical trials demonstrated that the system scarring. Abdominoplasty or appendix 1. Stoilova I, et Lozanova P (2013) Selective is safe without serious adverse events and scars must be monitored, as the numb- High Frequency (HF) Device for Non- produces consistent, statistically significant ness associated with surgical incisions can invasive Contactless Reduction in Size of reduction in circumference of the abdomen. impair the patient’s ability to feel heat. The Abdomen of the Body. Unpublished clinical 20 patients from 18 to 70 years of age selective high frequency (HF) generates heat study, conducted August – December 2013, underwent the four weekly treatments; in subcutaneous adipose tissue only, with available from BTL Aesthetics & CCF Media. results showed the mean circumferential no effect on the skin, and targets structures with high impedance, namely the Lisa Littlehales is a registered Figure A general nurse with 15 years adipose tissue. HF causes electron experience working in the movement, resulting in movement independent cosmetic surgery of atoms and molecules in the sector. She was previously adipose tissue. This generates National Training Manager and South East friction, which is transformed into Regional Manager for The Harley Medical Group, and is now General Manager of Harvey Nichol heat. The tissue temperature rises Knightsbridge and Beyond MediSpa Edinburgh, Before After to 44-45°C, at which point apop- specialising in non-surgical led treatments. She tosis, the natural death of fat cells, has no financial ties with any companies.

42 Aesthetics | February 2014 Clinical Practice aestheticsjournal.com Abstracts

A summary of the latest clinical studies

Title: Changes of eyebrow’s muscle activity with aging: Keywords: Dermal fillers, midface, perioral, US and Italy Functional analysis revealed by electromyography Abstract: There are numerous dermal fillers available to Authors: Yun S, Son D, Yeo H, Kim S, Kim J, Han K, Lee S, injectors in the US and Europe for the correction of age-related Lee J volume loss in the midface and perioral regions. Product Published: Plast Reconstr Surg. 2013 Dec 30 availability differs between these two aesthetic markets due to US Keywords: Eyebrow movements, electromyography, frontalis Food and Drug Administration (FDA) regulatory requirements. muscle The purpose of this study is to discuss differences in filler Abstract: This study evaluated the activity of frontalis muscle, selection by two practitioners in the US and Europe based upon corrugator supercilli muscle (CSM), and orbicularis oculi both stylistic approach and filler availability in each market. muscle (OOM) according to eyebrow movement and aging. Seven patients were selected for discussion and divided into Two random cohorts of women aged 20 to 30 years (young two groups: 1) those requiring midface volumization and 2) group, n=20, mean age: 24.8 years) and 50 to 70 years (old those undergoing perioral or lip volume replacement. Patients group, n=20, mean age: 55.8 years) were recruited prospectively. in the midface group were injected with Juvéderm Voluma® Surface electromyogram was used to evaluate motor unit action XC, Juvéderm® Volift® with lidocaine, Restylane- L®, Perlane-L® potential for each muscle in each of six eyebrow movements. or Radiesse®. Patients in the perioral and/or lip group were In both age groups, CSM activity was the highest for all six injected with Juvéderm® Volbella™, with lidocaine, or Belotero movements. Frontalis muscle activity was highest with maximal Balance™. Patients were photographed before and immediately frowning but not with maximal eye opening. OOM activity was after injection to evaluate aesthetic outcomes. In each case, filler significantly greater in the older age group than in the younger selection was based upon patient characteristics, anatomical age group for the most actions. When motion proportion of considerations and inherent filler properties. In conclusion, each muscle is compared, the respective OOM and CSM indices volume restoration in the midface and perioral or lip region were comparatively higher in the older age group than in the can be effectively achieved using a variety of dermal fillers. The young group. Eyebrows are maintained by the dynamic balance dermal filler portfolio available in Europe is exponentially larger of frontalis, CSM, and OOM, and various combinations of than that in the US. motor recruitment of these muscles determine the eyebrow position and shape. For youthful eyebrows, attenuation of the Title: Comparison of Validated Assessment Scales and 3D depressor muscle may restore the muscle balance in treatments digital fringe projection method to assess lifetime development for eyebrow rejuvenation. of wrinkles in men. Authors: Luebberding S, Krueger N, Kerscher M. Title: Neutralizing antibodies to botulinum neurotoxin type A Published: Skin Res Technol. 2014 Feb in aesthetic medicine: five case reports. Keywords: Wrinkles, validated assessment scales, 3D digital Authors: Torres S, Hamilton M, Sanches E, Starovatova P, fringe Gubanova E, Reshetnikova T. Abstract: The assessment of wrinkle severity is an important Published: Clin Cosmet Investig Dermatol. 2013 Dec 18 evaluation criterion to determine the efficacy of aesthetic Keywords: Facial rejuvenation, botulinum neurotoxin treatments. Aim of the present study was to compare Validated Abstract: Botulinum neurotoxin injections are a valuable Assessment Scales (VAS) and 3D fringe projection (PRIMOS(®) treatment modality for many therapeutic indications as well for the evaluation of facial wrinkles in men and to determine as in the aesthetic field for facial rejuvenation. As successful standard values for each level of the VAS. 150 male subjects treatment requires repeated injections over a long period of (20 to 70 years) were selected following strict criteria. Wrinkle time, secondary resistance to botulinum toxin preparations after severity at periorbital, glabella and forehead lines was evaluated repeated injections is an ongoing concern. We report five case using the 3D fringe projection and 5-point photonumeric VAS. studies in which neutralizing antibodies to botulinum toxin The results of both methods were matched by determining type A developed after injection for aesthetic use and resulted quantitative values for each level of the clinical rating scale. in secondary treatment failure. These results add to the growing High average correlation with age was found for VAS, Wd, number of reports in the literature for secondary treatment maxWd, lWd, Wv, aWa and pWa. With a Wd of 60 to 70μm failure associated with high titers of neutralizing antibodies crow’s feet and forehead lines are pronounced first, whereas in the aesthetic field. Clinicians should be aware of this risk glabella lines develop in subject’s mid-forties, by an Wd of and implement injection protocols that minimize resistance 180μm. Wrinkle severity increases at all locations every 10 development. years of age by one level of the VAS. This increase corresponds to an increase of Wd about 100 μm at glabella and forehead Title: Midface and Perioral Volume Restoration: A lines, and about 50 μm at crow’s feet. The presented reference Conversation Between the US and Italy values for the Validated Assessment Scale are an important step Authors: Gilbert E, Calvisi L towards an optimized assessment of skin aging and aesthetic Published: J Drugs Dermatol. 2014 Jan 1 dermatological treatments.

Aesthetics | February 2014 43 THE VOLUMISER DESIGNED TO STIMULATE COLLAGEN WITH RESULTS THAT LAST OVER 2 YEARS* HAPPY VALENTINE!

k since ar 19

*Clinical trial ended at 25 months M 9 9 E C

F 9 D 0 A 0 A 2 p ce proval sin

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Natural & gradual deep tissue regeneration Effective collagen stimulator Natural aesthetic results lasting over 2 years*

Sinclair IS Pharma 1st Floor Whitfield Court, 30-32 Whitfield Street London W1T 2RQ. United Kingdom www.sinclairispharma.com Date of preparation: January 2014 UK/SIPSCU/13/0020 ACE aestheticsjournal.com Special Focus

With the programme growing constantly there are now even more reasons not to miss the defining medical aesthetics event of 2014. With just over a month to go, places are going fast so register FREE for your entry today. Latest news on ACE 2014

Expert Clinic added to FREE Question Time is now FREE with Exhibition Programme Conference Bookings As the latest addition to our huge Evening Question Time hosted by programme of free Masterclasses, Business Peter Sissons will now be free to all Track workshops and Live those purchasing a one day or two day Demonstrations, we are delighted to be Conference Pass. This exciting session will hosting an Expert Clinic for the duration take place on Saturday March 8 offering of the event. Our Expert Clinic will provide Delegates the opportunity to observe and you with the opportunity to meet with participate with a panel of leading industry leading medical experts and witness them figures discussing the latest topics affecting demonstrate how they deliver the perfect treatment technique and aesthetic medicine today. Confirmed panellists include Dr Andrew also answer your questions. Experts include Dr Tapan Patel and Dr Vallance-Owen — member of Sir Bruce Keogh’s Cosmetic Raj Acquilla, who will be demonstrating a periorbital beautification Interventions Review team, Dr Leah Totton — winner of The and non surgical lower face lift during this exciting session. Apprentice, Dr Mike Comins, Dr Tracy Mountford, Sharon Bennett, Mr Dalvi Humzah and Dr Martyn King. The debate will take place Galderma and Allergan to host following a drinks and canapés reception providing attendees Masterclasses at ACE with a chance to network with peers and colleagues, and share We can now confirm that Allergan and knowledge gained from the conference so far. Galderma will join Sinclair IS Pharma, Skinceuticals and Zeltiq as part of our 59 CPD Points now on offer programme of Injectable Masterclasses. With the event programme constantly Access to Masterclasses is available to increasing there are now up to 59 CPD all healthcare professionals with a FREE points to choose from providing both exhibition pass or paid conference pass. conference and exhibition visitors with the Please provide your GMC, NMC or GDC opportunity to gain accredited education. number when booking. Watch this space for more details to be For a full breakdown of CPD points announced over the coming weeks! available visit www.ace2014.co.uk/CPD

More exhibitors confirmed ACE Event guide now available With numbers increasing on an almost For more information about the conference daily basis, it is with great pleasure that programme, exhibition schedule, workshop we welcome Cosmetic Courses, Beehive agenda, speakers and our steering Solutions, Blow Media, Cosmedic Pharmacy, committee, check out the ACE Event Guide Cross Medical and Lipo Angel to our list of free with your issue of Aesthetics journal. Exhibitors. For more information about all of You can also download the guide the exhibitors confirmed for The Aesthetics online, visit www.ace2014.co.uk Conference and Exhibition, check out the Exhibitor Directory on the ACE 2014 website. Med fx registration and consumables partner 3D-lipolite sponsor ACE It gives us great pleasure to welcome Med- Question Time fx as our Consumables and Registration lite We are delighted to announce that the Partner. Med-fx is part of one of the UK’s evening will be sponsored by 3D-lipolite, largest specialist medical product distribution groups and supplies a new three-dimensional weight loss programme combining a wide range of aesthetics and skin rejuvenation products. treatment with diet and exercise. For more information about all of our sponsors visit our website. Sponsored by:

Aesthetics | February 2014 45

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For further information or a demonstration www.3d-lipo.com call: 01788 550 440 www.3d-skintech.com

SPONSORED BY: www.ace2014.co.uk ACE Special Focus aestheticsjournal.com

10 Reasons why you can’t miss ACE 2014

1 STAY AHEAD As the first major aesthetics meeting of the year to be held in the UK, ACE provides visitors with a unique opportunity to get up-to-speed with the important treatments, techniques and trends for 2014.

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48 Aesthetics | February 2014 In Practice aestheticsjournal.com Revalidation

Revalidation Special Dr Paul Myers summarises how aesthetic doctors can be prepared and meet the requirements for revalidation

On December 3 2012 the GMC introduced INDEPENDENT SECTOR DOCTORS AND officer (RO) of each designated body (DB). revalidation, marking a turning point for RELICENSING This is the ‘revalidation submission date’ or every practising doctor in the UK. For the The Medical Profession (Responsible Of- RSD. If you are not aware of your RSD, you first time, a doctor who was registered ficer) Regulations 2010 came into force on should log in to the ‘GMC online’ section with the GMC could only continue to January 1st 2011. From that date, designat- of the GMC website to see confirmation practise medicine under strict conditions, ed organisations were required to nomi- of your designated body, and crucially the to which a time limit now applied. These nate or appoint a responsible officer with designated body that you have told the new regulations were introduced following statutory functions relating to the evalu- GMC will provide your ‘route to revalidation’. incidents such as the Shipman and Bristol ation of the fitness to practice and moni- Your DB is defined by your clinical practice Royal Infirmary heart scandals, in order to toring of the conduct and performance of and the organisation with which you are monitor doctors more closely. They were doctors with whom the body had a connec- associated. Examples of DBs for aesthetic also designed to reassure the public as tion. The following year, on December 3 doctors could be a private hospital or clinic it is claimed that revalidation will reduce 2012, all UK doctors were obliged to follow with which they are contracted, and which risks to patients. the relicensing regulations. Some of the has DB, or the British College of Aesthetic The method requires every doctor to show new regulations can be particularly chal- Medicine (BCAM), which is a designated that they are up-to-date, reflecting on their lenging for independent sector doctors: body in its own right, and provides a work, and practising according to Good those practising within the NHS have had revalidation service. Medical Practice Guidelines. Prior to this, a system of regular appraisals and clinical a doctor practising with the UK registra- governance for some years, which has be- HOW DOCTORS CAN MEET THE GMC’S tion could continue without supervision come part of the culture of practising within REQUIREMENTS FOR REVALIDATION IN indefinitely and would only have their the health service. However, independent THE FIRST CYCLE. registration threatened if a complaint or sector doctors may practise in isolation, The minimum requirements for doctors be- problem came to the notice of the GMC. and perhaps don’t have the administrative fore they will be able to be revalidated are Now doctors have to be licensed as well backup that is necessary for successful precisely defined by the GMC. Whichever as registered to provide clinical services revalidation. Aesthetic doctors also expe- organisation provides your annual apprais- in this country. The conditions of having rience specific problems with appraisal als and revalidates you, they all have to a licence are dictated by the ‘Responsi- and revalidation, particularly the difficulty in follow the regulations (found on the GMC ble Officer Regulations’. These state that collecting supporting information, such as website) and ensure that mandatory infor- doctors must have an annual appraisal, quality improvement data and feedback. mation has been provided. and must be assessed as to their fitness On the revalidation date the responsible to practice once every five years in the HOW TO REVALIDATE AND KEEP YOUR officer of the DB will look at all five of revalidation process. No other country LICENCE the previous appraisals, and based on has such a rigorous method of controlling The GMC have told all doctors the date the ‘output statements’ and the apprais- and assessing the medical competence of they want to receive their first revalidation er’s summaries, will decide whether to individual medical practitioners. recommendation from the responsible recommend relicensing to the GMC. The responsible officer also examines the information held about the doctor within the KEY REQUIREMENTS FOR ALL UK REGISTERED AND LICENSED AESTHETIC designated body, for example complaints DOCTORS or problems that have been encountered You must make sure: in the previous five years. In the first few • You are participating in an annual appraisal process, which has ‘Good Medical Practice’ as years of this process not all doctors will its focus • You are linked to a designated body have five consecutive appraisals, so the • You know your route to revalidation responsible officers will base their conclu- • The GMC have been notified of the name of your designated body sions on fewer appraisals. • You are collecting the appropriate information you need to be relicensed such as CPD evidence, colleague and patient feedback, quality improvement documentation, significant Dr Paul Myers is a events and review of complaints and compliments full-time appraiser ISSUES OF WHICH YOU MAY NOT BE AWARE for doctors in the • If you cannot demonstrate that you are having an appraisal each year, there is a risk that the independent sector. GMC will consider that you are not engaging with revalidation He worked as an • If your GMC licence is removed it is an offence to practice medicine in the UK NHS GP for 25 years, • There is a substantial difference between being licensed and being registered with the GMC • The GMC will bring forward your revalidation submission date if it thinks you are not and subsequently engaging with revalidation as a private GP with an interest in • If you cannot find a responsible officer or suitable person to revalidate you, the only way you aesthetic medicine, and medical lasers. can keep your licence is through the GMC’s ‘Alternative Route’, which will involve a GMC He is the director of Doctors Appraisal written examination, and a clinical examination, as well as the annual appraisal obligation Consultancy.

Aesthetics | February 2014 49 Lovelite Full Page JAN:Layout 1 26/11/13 11:26 Page 1

COME AND SEE US AT STAND 60 In Practice aestheticsjournal.com Revalidation Revalidation Special Emma Davies explains the proposed system of revalidation for aesthetic nurses

Since 1995, registered nurses have been The NMC have consulted with a variety of components. The document is designed required by The Nursing and Midwifery stakeholders and now begin a six month as a practical and flexible tool, which Council (NMC) as part of The Code public consultation to review and revise can be useful in a number of ways. As (NMC, 2008) to keep knowledge and The Code (NMC, 2008), which sets out the a personal route map to benchmark skills up to date, recognise and work standards of good nursing and midwifery current competency and identify personal within the limits of their competency and practice, and how the proposed model training and learning needs, it provides take part in appropriate learning and of revalidation can be implemented in suggestions for how competency may be practice activities to maintain and develop a variety of employment settings and evidenced and can be used with mentors, competence and performance. Post- scopes of practice. The new system is by educators, appraisers and employers. registration education and practice (Prep) expected to launch in December, 2015. The main challenge and concern for is a set of NMC standards and guidance The consultation will run in two parts, the nurses in aesthetic medicine is likely designed to ensure nurses provide a first will close on March 31, 2014. to be how they will access appropriate high standard of practice and care. Prep supervision, mentors and appraisal, if they standards are legal requirements which Nurses in aesthetic medicine work in a are currently working alone. BCAM has must be met in order for registration to be variety of ways; full time, part time, self- been pro-active in organising Responsible maintained. employed, alone, or as part of a team. Officers for appraisal and revalidation in 78% of BACN members work alone, 41% line with GMC requirements. Currently, THERE ARE TWO KEY STANDARDS. are self-employed, 82% work part time in nursing, there is no formal framework 1. A minimum of 450 hours practice with 47% continuing to work in the NHS or accreditation/authority for appraisal. in the previous three years. 2. Undertake and record continuing 100% have undertaken some form of The BACN will be engaging with the NMC professional development (CPD) CPD (aesthetics specific) in the last 12 consultation in a constructive way and over the three years prior to months, and 77% have undertaken more have been preparing to support members renewal of registration. This must than three days in the last 12 months, far to manage any necessary change. constitute a minimum of 35 hours of exceeding the NMC Standard. (BACN, learning activity relevant to practice. 2013). We know there will be aesthetic REFERENCES nurses who do not access quality CPD • British Association of Cosmetic Nurses (2013) At renewal of registration, nurses are activities and have had limited training, no Membership Survey, available to members only. required to sign a declaration that they supervision, mentoring or appraisal. Many • British Association of Cosmetic Nurses (2013) have met the standards for Prep and may of our members actively seek mentors An Integrated Career and Competency and would welcome the opportunity to be required to submit evidence as part of Framework for Nurses in Aesthetic Medicine, NMC audit, (NMC, 2011). learn from their peers, but opportunities BACN. Contact, www.cosmeticnurses.org In September 2013, The NMC met to are very limited and there is currently • Nursing and Midwifery Council (2008) decide upon a model for revalidation, “To no formal framework for mentoring, The NMC Code of Professional Conduct: increase public confidence that nurses supervision or appraisal. Standards for Conduct, Performance and and midwives remain capable of safe and Developing and maintaining skills in Ethics, London: NMC effective practice”. this constantly evolving field requires • Nursing and Midwifery Council (2011) The Prep “The system of revalidation that we adopt considerable investment in both time Handbook, London: NMC must contribute to our core regulatory and money. Treatments have become • Nursing and Midwifery Council (2014) purpose, which is public protection. We increasingly invasive and complex and Consultation on revalidation, available on-line http://www.nmc-uk.org/Nurses-and-midwives/ aim to deliver a proportionate, risk- the lack of regulation and the disconnect Revalidation/ based and affordable system that will from the regulators in place gives us great provide greater public confidence in the cause for concern. As an organisation, professionals regulated by the NMC. It the BACN has made a positive start in Emma Davies is chair of is also important that revalidation raises identifying the problems and constructively The British Association standards of care and promotes a culture ensuring they are addressed either of Cosmetic Nurses and of continuous improvement amongst by us, or by the appointed regulator. has been practicing in nurses and midwives.” (NMC, 2013) We have published ‘A Career and aesthetic medicine since 1998. She was a committee Competency Framework for Nurses in member of the Royal The main difference between Prep and the Aesthetic Medicine’, accredited by The College of Nursing Aesthetic Nurses Forum proposed system of revalidation appears RCN. The Framework recognises the 2003-2010, and has contributed to a number of to be an additional requirement to use evolving nature of aesthetic nursing and key publications. Her commitment to standards feedback, from service users, employers the need to provide clear guidance to and work on behalf of aesthetic nursing as a and colleagues, to review the way an help practitioners identify, evidence and specialist field of practice was recognised by individual works and confirmation from, develop competence. The practice of Cosmetic News ‘‘Services to Industry Award’ “Someone well placed to comment on examination, supervision, assessment, and ‘Aesthetic Practitioner of the Year Award’, their continuing fitness to practice”. appraisal and validation are key in 2012.

Aesthetics | February 2014 51 In Practice Finance aestheticsjournal.com Taxing Times?

Accountant Ben Korklin provides key advice that will make the end of the tax year less stressful for aesthetic practitioners

Whilst many aesthetic medical professionals and clinics will have Recent changes an accountant or advisor to take care of their financial matters, April 2013 saw the introduction of a new cash basis for calculating it is vital that all industry individuals have a clear understanding taxable income for small, unincorporated businesses. One of the of their finances in order to be able to effectively manage their measures allows any unincorporated business to choose to use flat business. As we approach the end of the tax year, I have set out rate expenses for the following items of business expenditure: some financial considerations that you should be aware of and how you can prepare accordingly. • Fixed allowances for business mileage • Expenses relating to business use of the home Tax year end • Adjustment for private use of business premises When thinking about your year-end, it is important to choose the right time for your business. Consider to what extent your Avoid the penalties business is seasonal: is there a time of year when it will be more It is vital to be aware of all relevant tax dates to ensure you convenient to close off your accounting records, ready for your prepare and send off your accounts in good time. The HMRC accountants? website will detail the deadlines by which all payments and From a tax viewpoint, the choice of a year-end early in the tax forms must be received by the relevant authorities. Or, in the year for an unincorporated business often means that an increase case of reclaiming tax, the date by which your application must in profits is more slowly reflected in an increased tax bill. have been received. HMRC also recently unveiled a plethora of changes to its penalties and regulations, as well as proposed Company vehicles increases in its powers and capabilities. While the company car remains a valuable part of the Another big change to the penalty regime is that the fines will no remuneration package for many, tax and national insurance longer be cancelled if the taxpayer owes no money to HMRC, costs may mean that you need to consider whether your because there was no extra tax to pay or because it had been paid. current arrangement represents the most tax-efficient option. The new penalties for filing tax returns late are as follows: The company car or van benefit is subject to a Class 1A national insurance charge of 13.8% payable by the employer. • Day one - Individuals will be charged an initial penalty of £100, even There is also a fuel benefit charge where fuel for private use if they have no tax to pay or have already paid all the tax owed is provided with the car. The rules also apply to employer- • Over three months late - Individuals will be charged an automatic provided cars and vans. daily penalty of £10 per day, up to a maximum of £900 Now may be a good time to review your company car policy, • Over six months late - Individuals will be charged further and to determine whether it could be more beneficial to pay penalties, which are the greater of 5% of the tax due or £300 employees for business mileage in their own vehicles, at the • Over 12 months late - Individuals will be charged yet more statutory mileage rates. penalties, which are the greater of 5% of the tax due or £300. In serious cases people face a higher penalty of up to 100% of the Excluded business expenses tax due. You’ve heard the expression regarding what counts as ‘business expenses’: “Anything that relates to your business”. Whilst this Awareness of these key considerations allows you to more closely is generally true, there are some expenses which, although monitor the success of your business and plan ahead for future genuine business expenses, are specifically excluded from tax financial years. With knowledge of appropriate tax year ends, penalties relief, such as: you could be subject to and attention paid to recent changes, you will be better equipped to manage your finances accordingly. • Business entertaining including the VAT (however input VAT on business entertaining of overseas customers is Ben Korklin qualified as a chartered certified recoverable) accountant in 2008 which led to him starting • Charitable subscriptions and donations, except to small his own firm in 2010, before joining Lawrence local charities Grant as a partner in 2013. Ben’s client portfolio • Political donations consists of UK companies and individuals, • Costs and fines for breaking the law including sole traders, partnerships and • Loan capital repayments limited companies, and he specifically • The withdrawing of funds from the business by the director/ provides specialist tax, business and accountancy knowledge to partner/principal the beauty sector.

52 Aesthetics | February 2014 2862 Med-fx Ad 2014_Med-fx Sales Ad 12/12/2013 15:31 Page 1

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programme created by a specialist, just for them. WHAT AESTHETIC Consider incorporating a skin care range that offers customised formulations that therapists can CLINICS CAN LEARN create right in the clinic, by adding antioxidants, peptides, retinol or other key ingredients to suit their patient’s skin’s individual needs. One example of FROM SPAS a customised procedure that speaks to this trend Wendy Lewis suggests that clinic owners and is the Silkpeel Dermal Infusion System, with which managers should take inspiration from high-end the specialist can develop the best protocol for spas to create a relaxing environment for patients each patient. An alternative is to develop your own signature branded treatments that are exclusively yours, and that patients cannot get anywhere else.

Maintaining detailed notes in patient charts can help therapists and practitioners stay on top of each patient’s progress and preferences. Imaging systems such as Visia® from Canfield also help facilitate this concept in clinics by tracking skin conditions, results, and educating the patient on his More often than not, as soon as you enter an upscale spa an immediate or her unique skin concerns. sense of calm immerses you. This comes from the aromatherapy candles infusing the air, the soft and flattering lighting, the handsomely upholstered TECHNOLOGY AND TREATMENT MERGE seating, and the warm and friendly welcome when you check in for a self- Spafinder Wellness 365, an online resource indulgent treatment. These factors, and other pampering amenities, elevate the for spa facilities, also predicts that for 2014, the spa-goer’s experience, and according to the Global Spa and Wellness Summit, application of ‘Wired Wellness’, a combination of in 2013 we were loving it to the tune of $1.9 trillion US dollars worldwide. health and technology, has the potential to change So what distinguishes the leading spas of the world? First and foremost, their the way we both look at and approach our overall goal is to guarantee the ultimate spa experience to all customers, and to wellbeing. Their definition of “Wired Wellness” is deliver five-star service at all times. “any point where digital and wellbeing intersect By contrast, think about the last aesthetics clinic you visited, including your – from digital devices that track our every move own or the one where you work. What adjectives come to mind? Pampering, to straightforward online booking engines. These relaxing, indulgent, exclusive, and caring? Or is it more like rushed, rude, examples of digital connectivity that aid our disorganised, sterile, and impersonal? Regrettably, I see more clinics where the access to wellness is something we’ve come not latter applies far more than the former. only to expect but also to demand.” Let’s look at what aesthetics clinics can learn to benefit from the world of high- This confirms that patients today want to have end spas. Below are some key spa trends that may serve as inspiration for an efficient clinic experience, in line with other taking your patients’ clinic experience to the next level. service businesses they frequent. Think boundary- pushing technology like Apple. Accept credit STAY CALM & SPA ON and debit cards for payments by using one of the The relaxation aspect of spas is what draws us in. It is a chance to unwind and many apps or programmes on offer, and send block out the sensory overload of an overscheduled modern lifestyle. This patients their receipts in the same manner. Offer resonates with busy mums, stressed out executives, frequent travellers, as well online bookings, cancellations, and service and as pensioners and housewives alike. product purchasing through your website or social media pages. Use a software program to confirm According to the new Spafinder Wellness 365™ 2014 Trends Report, “The appointments by email or text. This has the physical benefits of spa and wellness activities have long been known to dual advantage of both saving on staff time and reduce stress and relax our bodies, but in 2014 and beyond there will be a reaching patients on their mobile devices, where sharp focus on interweaving mindfulness techniques into these practices to they are likely to be at their most accessible and help us reach a whole new place of serenity and calm.” responsive. Spa-goers want to be taken care of and pampered. They crave a little, “me time”. But don’t confuse that with fluffy beauty treatments that don’t deliver Technology takes some of the messy business, visible improvements. Spa-goers want both an atmosphere of indulgent payment and scheduling details out of the serenity plus a selection of the most advanced clinical procedures available, experience so patients don’t have to sweat about and your patients should be able to expect the same. the small stuff. They can just sit back and relax in the capable hands of your clinic staff. CUSTOMISED THERAPIES The total patient experience is paramount in a One of the cornerstones of the spa experience is not adapting a one-size climate where favourable online reviews, ratings fits all approach to clients. Customised solutions rate high with spa-goers and personal recommendations are powerful and they are willing to pay a premium for the exclusivity of having a treatment influencers for getting patients through the door.

54 Aesthetics | February 2014 In Practice aestheticsjournal.com Patient Experience

10 EASY WAYS TO UPGRADE THE CLINIC important human factor. It’s about getting EXPERIENCE the right people on board who share the vision of the clinic manager or owner, 1. Brighten up entrance and waiting areas with good lighting and window and buy into a service culture that is so coverings that allow natural light in important today. It takes a cohesive team 2. Refresh fraying carpets, paint, floors, soiled furniture to make that happen. Ultimately, how your 3. Spruce up restrooms with a large mirror, a supply of makeup remover, team interacts with each other as well as concealers, facial wipes and cleansers with your patients or clients can ensure 4. Add a self- service beverage cart with coffee system and waters that the experience of visiting your clinic is 5. Offer free Wi-Fi and charging stations in waiting area and rooms intimate, personal, unique and memorable, 6. Manage waiting times to fall within 15-30 minutes maximum not unlike that of a high-end, luxurious 7. Give patients spa-style gowns, robes and slippers to change into spa. Think service, service, service to 8. Restrict mobile phone usage for staff in patient areas achieve this. 9. Enter patient birthdays into your database to send a Birthday Special Offer 10. Implement a VIP Programme with unique benefits for your loyal patients who Wendy Lewis is refer their friends and family president of Wendy Lewis & Co Ltd, The patient experience begins with their picked up? If you answered yes to any of Global Aesthetics first contact with your clinic, which may be the above, it’s time to take a closer look at Consultancy, the online, by phone, or walking or driving past what is going on under your roof. author of 11 books your street. Every little detail factors into Running an efficient clinic and getting it on anti-ageing the overall experience of each patient in right is not a simple task. It is not merely and cosmetic your clinic. Consider every element of your a matter of spending a fortune to build surgery, and founder/editor in chief clinic. Was the clinic hard to find? Is the the most beautiful facility, and bringing of Beautyinthebag.com. She is an décor cold and icy? Does the clinic staff’s in state-of-the-art treatments. It is not just international presenter and lecturer and attitude correlate to the décor? Does it about providing effective treatments at has written over 500 articles for medical take too many rings before the phone is a fair price either. There is also the all- journals and consumer publications.

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Remove is obviously the ideal option, but hard to accomplish. Do consider that if you’re getting negative reviews regularly, you probably need to look within your practice to examine what might be causing these issues. Let’s say however that you know the feedback to be inherently inaccurate, false or defamatory, or even left by someone who is not a patient. Your first port of call should be to look at the website’s own terms and conditions in detail. Many of these sites state that reviews must only be left by genuine customers. Therefore, someone who was rejected at the consultation stage or is the partner or relative of the patient cannot, by explicit policy, be allowed to leave a review. Or, say, they are complaining about a procedure which you simply do not offer, therefore it can only be untrue. Additionally, certain forums ask that individual doctors/nurses/surgeons not be named. If any of these situations apply and the policy prohibits them, you can cite the terms and conditions, which automatically means that the Damage website is obligated to remove the comment. This way, there is no need for contact with the person, whoever they may be.

Address is probably the most likely and appropriate avenue to explore, if you don’t want to leave the review or comment control: unchallenged. But beware to keep your cool in this situation. It can be all too easy to take comments personally and react defensively but this is precisely what the reviewers are seeking to activate as a Do you know how to react to negative online response. If the issue is negative comments on social media, try to reviews? Publicist Tingy Simoes reveals the take the dialogue offline as quickly as possible. three essential rules of engagement that will Reply publicly if you can, explain that you’re sorry they’re having a difficult time and that your office would be glad to discuss help you protect your reputation online their concerns with them. Offer a phone chat, a face-to-face visit, anything to get the conversation away from the prying The vast proliferation of Yellow Pages-type directories and review sites, eyes of everyone on Facebook, Twitter or on forums. Come the number of which are growing almost daily, present today’s clinicians across as polite, diplomatic and helpful, and whatever you do, with a new and very open digital environment. Though this environment do not engage in tit-for-tat! The patient will always appear more can offer valuable marketing opportunities, it can also on occasion sympathetic to those reading. leave clinics and clinicians vulnerable to attacks on their reputation. You are ethically obliged to keep quiet the medical details of a As a publicist with over 15 experience in the private medical sector, I patient’s case so you cannot win in a public slanging match. If the have often had to deal with negative comments on behalf of my clients. review site in question offers you a right to reply, your response I have also had to advise on steps to take after receiving unpleasant could be along the lines of, “I can’t tell who you are, but the feedback, merited or not. information here doesn’t seem to fit with our procedures at the In the big bad World Wide Web, it’s easy for reviewers to cloak clinic…” and calmly point out the inaccuracies. Alternatively, if you themselves in anonymity. Thus a patient who smiled in your consulting think you know who the patient is, you could try to raise this with rooms and gave you a hug may easily walk out the door and seek to them directly, for example, “I have reason to believe you may shred your reputation via online forums, without you ever knowing who have posted xyz. I can’t believe it was you really, but perhaps we that person might be. Anonymity also protects competitors or even can address any issues professionally” etc. As you well know, no disgruntled employees (impersonators) who are out to maliciously hurt two patients are alike and what works with one, may not with the your practice’s reputation. Reviewers can of course be genuine patients other – so trust your instincts. wishing to air a bad experience, but sometimes they are extorters, e.g. those who threaten with, “Refund my money, or I will leave negative Some of the biggest sources of complaints tend to be reviews about you online.” expectation failures and financials so always make sure to Whether the negative comments are deserved or not, there are various be entirely up front with your practice’s policies for aftercare, approaches that should be considered in regards to dealing with them. revisions or refunds from the very beginning. If the disgruntled There are three levels of action for unfavourable online reviews: patient wants a refund and you decide to offer it to them, make sure you work out a confidentiality clause. If, despite receiving > Remove < compensation, they continue to publicly discuss details of the > Address < case, perhaps they waive their right to confidentiality as well. Always examine options with an experienced solicitor before > Suppress < handing out any cash.

56 Aesthetics | February 2014 In Practice aestheticsjournal.com Public Relations

Suppress: At the American Society of to standardise and optimise your site, and Whilst I do recommend seeking legal advice Aesthetic Plastic Surgeons (ASAPS) annual make sure you and your team regularly if comments are defamatory or outright conference last year I heard this statement audit your online image. This can be done libellous, I suggest you leave the threat of in relation to online attacks: “The solution to easily with free tools such as Google Alerts legal action as a last resort. As mentioned pollution is dilution”. The key message here which notifies you of online coverage, or in previously, the perception is that doctors is to do your best to drown the reviews in a more sophisticated and targeted way via and surgeons are ‘well-off’ and sympathy positivity. Suppressing or diluting the impact specialist agencies. Remember to also give will always go to the seemingly defenceless of negative feedback requires you to be the public a little bit of credit for being able patient. Having said all that, when all other truly active. The era of sitting quietly behind to differentiate between genuine reviews avenues have been explored, you may be a brass plaque in Harley Street, ignoring and someone who seems unreasonable left with no other choice. Legal action is advertising, PR and social media marketing and disgruntled. costly, so really question whether the online is well and truly over. Keenly encourage feedback is hurting your practice’s reputation happy patients to leave positive reviews on Most people who take to the Internet to or whether it is simply your ego. all the most common sites. Make this part of air their grievances do so because they your practice and have your team ask from don’t feel listened to. Perhaps they have Ultimately, if something was done wrong, the start whether patients are active online, been calling the practice and not receiving saying sorry works. It is known that patients and whether they’d be willing to review what they perceive to be help, or are being don’t sue according to outcome, they sue their experience. ignored. Try doing the opposite of this: over- according to their perception of caring. This may seem counterintuitive but it will communicate. Tell them you’ve seen the Show them that you do. help you maintain control of your image feedback they left and you are committed to Tingy Simoes is online and take ownership of what appears resolving the issues. Contact them regularly managing director of on those crucial first few Google pages. and keep them informed – many queries Wavelength Marketing One or two negative comments will simply pop up post-procedure, so stay in touch. Communications (www. wavelengthgroup.com) be lost in a sea of positive ones. However, if Turn lemons into lemonade by engaging and author of ‘How to the negative feedback is the only feedback and responding tactically. Always respond Cut it in the Media: A that pops up, you’re in trouble. If this is the professionally; thank them and say you look PR Manual for Aesthetic Plastic Surgeons and case, work with your SEO and PR providers forward to discussing the issues in person. Professionals in Cosmetic Medicine’

COME AND SEE US AT STAND 5 In Practice In Profile aestheticsjournal.com “You must never stop learning in this industry” Sharon Bennett, founding member of the British Association of Cosmetic Nurses and UK lead on the BSI committee for aesthetic non-surgical medical standard, describes her journey to becoming a leading aesthetic nurse.

Sharon began her career at Southampton and Midwifery Council, and this business University Hospital where, although she loved can be terribly lonely,” she says. “So I joined Q & A the work, she discovered that working in an RCN’s forum.” However, when the forum was What advice would you offer NHS hospital wasn’t her long-term goal. “I dissolved shortly after, she was left feeling other nurses? loved the patients, the camaraderie and the that there was a distinct lack of commitment to Don’t try to be an expert at educational element, but I didn’t take kindly aesthetic nurses from any existing professional everything: if you can do one thing to being ordered around,” Sharon says. In body. “We didn’t have any supporting brilliantly, you will feel more confident. 1986, she applied for a position at the newly association to turn to,” she says. “Everyone Additionally, don’t work in isolation: opened Harley Medical Group to find her was scattered across the UK: how would surround yourself with peers, a men- independence. After two years, she decided anyone hear our voice?” In 2009, this concern tor, and a multi-disciplinary team. You to take her skills across the globe; travelling led Sharon to form the British Association of will feel supported, and your patients with her husband, she worked as a general Cosmetic Nurses (BACN), alongside fellow will feel safe. nurse in a poor state hospital in the interior RCN steering committee members Emma of Brazil. “It was an eye opener: the hospital Davies and Liz Bardolph. What’s the best advice you’ve didn’t even have disposable needles and Through the BACN, she became involved in received? syringes,” she says. “But it was so fulfilling.” the British Standards Institute (BSI), the British The suggestion to take my prescribing Following this, she moved to Lisbon, Portugal, representative for the European Committee course; without it, you can’t move on where she was asked by Harley Medical for Standardization (CEN). In 2013, Sharon in this business. My course at Leeds Group to open a clinic for them. She moved was asked to be the aesthetic non-surgical University was incredibly fulfilling: doing back to the UK in 1995, and managed a small UK representative and assist in forming further courses in aesthetics or derma- cosmetic surgery clinic on Harley Street a standards document, which is currently tology arm you with more knowledge. alongside plastic surgeon Peter Ashby. In pending approval by CEN. “I’ve thrown myself 1996, she flew to Sweden with a colleague into standards because I’m passionate about What’s been your biggest to clear the UK distribution for promising new making the industry safe and well-respected,” mistake? product Restylane, which would later become Sharon says. “The most important person Occasionally making assumptions the biggest dermal filler in the world. “Prior is the patient but I also want aesthetics to about patients: sometimes I have to this, we’d all been injecting collagen,” she be regarded as a specialty of nursing and already decided what I want to do says. “With Restylane, there was no need medicine, rather than a beauty treatment before they open their mouth. Take for an allergy test and we could inject into associated with money and superficiality. My your time in consultation; listen to what areas such as the body of the lip, not just the goal is that the BACN Competencies along they’re saying. border.” Her role then expanded to include with the CEN non-surgical standard will be training, as she taught UK doctors and nurses adopted as the gold standard in non-surgical What’s your favourite treatment? how to inject the new filler. “This was the aesthetics in the UK.” Alongside her work to Dermal fillers: I’ve been doing them for start of a new age of aesthetics,” she says. “It improve industry standards, Sharon is also so long, the syringe is practically my made so much more possible.” focusing on her business, having just opened third hand. Sharon then spent two and a half years living a new clinic in the centre of Harrogate and a in the South of France, commuting monthly second branch within Harrogate BMI Hospital. What’s your industry pet hate? to the London clinic before moving back She is also looking for other opportunities My patients assuming that I’m a to the UK permanently in 1999. She set up to continue her own personal professional beauty therapist: sometimes they her own fixed base clinic with her business development and education. “There’s a don’t realise how much academia and partner in 2007. “I’m quite headstrong dermatology course at Stirling University I further education we do. and entrepreneurial, so I wanted to work would like to enrol on,” she says. “You must for myself,” she says. Until recently, she never stop learning in this industry. Every What’s your favourite thing about also worked alongside dermatologists at patient who comes in is different and brings the industry? Harrogate Hospital. She joined the Royal with them new challenges.” And with this in The wonderfully supportive friends College of Nurses (RCN) aesthetics forum, mind, she’s set to stay in aesthetics for good. I’ve made: they’re my second family and was co-opted on to their steering “Aesthetics fell into my lap, I didn’t plan to do and are more important than any committee. “Aesthetic nurses work outside of it,” she says. “But now I could never go back financial gain. the NHS with little support from the Nursing to straightforward nursing.”

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diet, and genetics. There is a very real fear amongst those in the public eye of being exposed as having aesthetic procedures, probably because they are aware that it may lead to ridicule and negative press. At the same time, we the public collaborate in the charade, buying magazines and enjoying the schadenfreude of the celebrity being “outed”. Perhaps because it invalidates their good looks and makes us feel good about ourselves. Embarrassment around the use of aesthetics forces patients to conduct their research and procedures clandestinely. Too often there are stories heralding a new death from complications of silicone buttock The Last injections; a patient who has lost her breast as a result of post operative infection from a procedure carried out in unhygienic conditions; another who undergoes liposuction and dies as a result Word of perforation. When Angelina Jolie underwent a double mastectomy to reduce her risk of developing breast cancer after discovering she Is it time for celebrities to come out of the closet? carried the faulty BRAC1 gene in 2013, she was lauded for raising awareness of the condition and Stars’ secrecy around aesthetic treatments has negative effects on women the procedure. The media praised the actress and the industry, argues Dr Sarah Tonks. for her decision to go public with the information. A quick flick through any glossy magazine demonstrates a confusing fetishisation It was hoped that this action would promote of the female body in our culture. Attention grabbing headlines such as“21 understanding, diminish the fear of surgery and Shocking Bodies That Will Make You Feel Normal!” (Now Magazine 24 ultimately save lives by encouraging women to December 2013) change to “Screw the diet!” (Now Magazine 31 December 2013) discuss the option with their doctors sooner. It could the very next week in the same magazine, demonstrating the ebb and flow of only be a positive thing if there were a similar A-list this fashionable tide in popular culture. From accepting and embracing the way role model for cosmetic procedures. Someone you look, to single mindedly pursuing self-improvement, the pendulum swings who would be able to help diminish the stigma of back and forth. One thing that never changes is admiration for natural beauty. In the industry, and promote discussion and dialogue almost every context, effortless and inherent beauty is praised whilst those who around the topic. It could only be beneficial to the choose to enhance the way they look are ridiculed. There is some thing sad self-esteem of girls and women to see that the about her, it’s sad that she feels she needs it, she doesn’t have good priorities in unattainable expectations we all place on ourselves life, she is vain and lacks character, she is desperate, she is wasting her money. cannot be met without some assistance. In a society constantly reminding women that they don’t look good enough, it For us as practitioners, this scenario would is ironic that those who pay more attention to the way they look are shamed undoubtedly be good for business. Once fear and embarrassed for all to see. The reason for this is unclear. Improvement and and mystique are removed from the equation, enhancement of natural beauty provokes strong reactions; although she has celebrities have the potential to become examples always denied any surgery herself, Joan Collins once rather judgmentally said, of the results possible with good enhancement “Plastic surgery is the plain woman’s revenge,” demonstrating the intense depth and rejuvenation. Patients would then become fully of feeling connected with the subject. educated in the potential of specific treatments, It is no secret that women, especially celebrities, are under enormous pressure and would be more likely to openly research their to look a certain way. We are all supposed to care about they way we look, whilst options rather than falling into the hands of rogue at the same time act modestly, like it isn’t a big deal. In today’s society, intrinsic providers. An open dialogue such as this could beauty is in, enhanced beauty is out. The ideal is for cosmetic interventions to also generate an uptick in the number of patients appear as if you didn’t need them in the first place, to look natural, whilst at the seeking out qualified practitioners. same time making you look “better” than the natural you. Now, we just have to find a suitable spokesperson. However, as we all know in the aesthetics industry, celebrities aren’t born with My vote is for Demi Moore, who at 51 has an special celebrity genes. There is a reason Halle Berry looks better at 47 than she enviable appearance due to a Hollywood-worthy did at 37, and why Jennifer Anniston is growing more beautiful each year. So why regime of diet, exercise and the work of a very don’t celebrities like to talk about the procedures they have had done? Although skilled aesthetic team. Simon Cowell once famously stated that to him botulinum toxin was, “No more unusual than toothpaste,” most celebrities are extremely coy about any beauty Dr Sarah Tonks is an regime that may involve more than a facial. Cameron Diaz recently stated that aesthetic doctor and previous she tried Botox but said it changed her face “in such a weird way,” and Jennifer maxillofacial surgery trainee Anniston apparently, “Tried Botox once but it was not good.” These stars have with dual qualifications in been reported as dabbling with injectables, but it is difficult to find an A-lister who both medicine and dentistry. is willing to admit their fresh looks may not be down to simple exercise, good

60 Aesthetics | February 2014 COME AND SEE US AT STAND 61

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