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VOLUME 1/ISSUE 9 - AUGUST 2014
Nutraceuticals
CPD Article
Dr Raina Zarb Adami examines the literature
surrounding nutraceuticals
Neck & Jaw
Tightening
A discussion of nonsurgical options for
tightening the jaw and
smoothing the neck
Skin Health
Clinic Design
Practitioners share
advice on how to
effectively prepare
the skin for aesthetic
procedures
From traditional
to modern, we
take a look at four
compelling clinic
designs
Introducing the NEW
One Treatment
NEW FDA Clearance
Ultimate Body Platform
More Power
Innovative Design
www.syneron-candela.co.uk | info@syneron-candela.co.uk
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 • August 2014
INSIDER
06 News
The latest product and industry news
14 On the Scene
Out and about in the industry this month
16 The future of the industry
An insight into the BACN’s role in the HEE Expert Reference Group
CLINICAL PRACTICE
Nutraceuticals
Page 24
CLINICAL PRACTICE
18 Special Feature: Neck & Jaw Tightening
Practitioners discuss non-surgical options for tightening the jaw and smoothing the neck
24 CPD Clinical Article
Dr Raina Zarb Adami examines the literature surrounding nutraceuticals
30 Techniques
Dr Sarah Tonks explores mesobotox as an alternative use of botulinum toxin
34 Clinical Focus
A discussion of the importance of primed skin prior to a procedure and the best ways this can be achieved
38 Treatment Focus
Dr Jenna Burton examines how cheek fillers can provide an all-in-
one anti-ageing procedure
42 Clinical Focus
Micheal Pugliese explores the role of peptides in cosmeceuticals
46 Spotlight On
Dermatologists discuss prescribing Mirvaso gel for the treatment of rosacea
50 Abstracts
A round-up and summary of useful clinical papers
IN PRACTICE
52 Design
We take a look at four compelling clinic designs
58 Business Process
Annalouise Kenny offers advice on building a successful clinic
60 Marketing
Dan Travis highlights the effective outcomes of email marketing
62 In Profile
Karen Betts shares her experiences as a medical tattooist
64 The Last Word
Roseanne Aitken argues for the importance of product traceability
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for medical aesthetic professionals.
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IN PRACTICE
Clinic Design
Page 52
Clinical contributors
Dr Sarah Tonks is an aesthetic doctor and
previous maxillofacial surgery trainee with dual
qualifications in both medicine and dentistry.
She practices cosmetic injectables and hormonal
based therapies.
Dr Jenna Burton is an aesthetic physician
working between the UK and Dubai. After founding
her company ‘Prescribing Beauty’ in 2012, she is
now working towards her American Medical Board
Specialist Status.
Dr Raina Zarb Adami is a surgeon whose private
practice, Aesthetic Virtue, is dedicated to non-invasive
facial aesthetic medicine. She is the medical director
of The Academy of Aesthetic Excellence, which
provides foundation and advanced training courses.
Michael Pugliese is a skincare specialist and CEO
of skincare company, Circadia. He is a member of
the Society of Cosmetic Chemists and regularly
attends their education events to stay on the cutting
edge of new product development.
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Editor’s letter
Here we are in August already: a time for
some to take a break and for others to
maintain the on-going business and develop
new ways of retaining and attracting clients
through the warmer months.
Amanda Cameron
As we move towards the awards season
Editor
(watch this space for finalists of The Aesthetics
Awards), I’ve become reflective about our industry.
I have been involved in this profession since its inception and
have seen many changes, none more so than in recent years as
the market grows at an exponential rate.
I first became involved in the aesthetics industry in 1989 as a
territory and training manager for Collagen Corporation. This
was a time when when dermal fillers were a virtually unknown
concept and the thought of putting a bovine tissue in human skin
to improve the appearance of wrinkles was thought of as strange
to say the least. It is no surprise that, at the time, the industry was
viewed as taboo by many, yet nowadays treatment modalities are
in the nation’s daily vocabulary.
My early years were spent training plastic surgeons and cosmetic
doctors to chase lines by injecting a prescription medicine into
the dermis: injectable collagen was a POM!
So have we come full circle in the evolution of the aesthetics
market? Over the years many new treatment modalities have
come and gone and large organisations have attempted to
apply pharmaceutical principles to this highly skilled area of
medicine. Needless to say those companies who invest in
novel, innovative and safe products whilst ensuring competence
amongst the healthcare professionals who use them, grow from
strength to strength and set a benchmark for new entrants to
aspire to. We now live in an aesthetics world where we have
many events and many resources for learning – none of which
existed in the early 90’s.
At the journal we pride ourselves on offering the best we can in
education to help to grow both your clinical knowledge and your
business.
This month we discuss the topical issue of nutraceuticals in our
CPD article, how to achieve optimum skin health for treatment
and injection techniques and methods for lifting and tightening
the neck and jawline. We also take a look at the design of some
stunning clinics and provide advice on email marketing and
opening a new clinic.
I hope this issue offers some useful information to support you
during the holiday season. Have a great summer and let us
know what topics and articles are of interest to you – get in touch
with us on twitter @aestheticsgroup
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 Raj Acquilla is a cosmetic dermatologist with over 11 years
experience in facial aesthetic medicine. UK ambassador, global
KOL and masterclass trainer in the cosmetic use of botulinum toxin
and dermal fillers, in 2012 he was named Speaker of the Year at
the UK Aesthetic Awards. He is actively involved in scientific audit,
research and development of pioneering products and techniques.
Dr Mike Comins is president and Fellow of the British
College of Aesthetic Medicine. He is part of the cosmetic
interventions working group, and is on the faculty for the
European College of Aesthetic Medicine. Dr Comins is also
an accredited trainer for advanced Vaser liposuction, having
performed over 3000 Vaser liposuction treatments.
Mr Dalvi Humzah is a consultant plastic, reconstructive and
Sharon Bennett is chair of the British Association of
Cosmetic Nurses (BACN) and also the UK lead on the BSI
committee for aesthetic non-surgical medical standard. Sharon
has been developing her practice in aesthetics for 25 years and
has recently taken up a board position with the UK Academy of
Aesthetic Practitioners (UKAAP).
Mr Adrian Richards is a plastic and cosmetic surgeon with
12 years of specialism in plastic surgery at both NHS and private
clinics. He is a member of the British Association of Plastic and
Reconstructive Surgeons (BAPRAS) and the British Association of
Aesthetic Plastic Surgeons (BAAPS). He has won numerous awards
and has written a best-selling textbook.
Dr Christopher Rowland Payne is a consultant
Dr Sarah Tonks is an aesthetic doctor and previous
dermatologist and internationally recognised expert in cosmetic
dermatology. As well as being a co-founder of the European
Society for Cosmetic and Aesthetic Dermatology (ESCAD), he was
also the founding editor of the Journal of Cosmetic Dermatology
and has authored numerous scientific papers and studies.
maxillofacial surgery trainee with dual qualifications in both
medicine and dentistry, based at Beyond Medispa in Harvey
Nichols, she practises cosmetic injectables and hormonal
based therapies.
PUBLISHED BY
EDITORIAL
Chris Edmonds • Managing Director
T: 0203 096 1228 | M: 07867 974 121
chris@aestheticsjournal.com
Suzy Allinson • Associate Publisher
T: 0207 148 1292 | M: 07500 007 013
suzy@aestheticsjournal.com
Amanda Cameron • Editor
T: 0207 148 1292 M: 07810 758 401
mandy@aestheticsjournal.com
Betsan Jones • Journalist
T: 0207 148 1292 | M: 07741 312 463
betsan@aestheticsjournal.com
Chloé Gronow • Journalist
T: 0207 148 1292 M: 07788 712 615
chloe@aestheticsjournal.com
ADVERTISING
Hollie Dunwell • Business Development Manager
T: 0203 096 1228 | M: 07557 359 257
hollie@aestheticsjournal.com
Craig Christie • Administration and Production
T: 0203 096 1228 | support@aestheticsjournal.com
MARKETING
Laura Weir • Marketing Manager
T. 0203 096 1228
laura@aestheticsjournal.com
Claire Simpson • Events Manager
T: 0203 096 1228 | claire@aestheticsjournal.com
DESIGN
Peter Johnson • Senior Designer
T: 0203 096 1228 | peter@aestheticsjournal.com
Chiara Mariani • Designer
T: 0203 096 1228 | chiara@aestheticsjournal.com
aesthetic surgeon and medical director at the Plastic and Dermatological Surgery. He previously practised as a consultant plastic
surgeon in the NHS for 15 years, and is currently a member of the
British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS). Mr Humzah lectures nationally and internationally.
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ARTICLE PDFs AND REPRO
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© Copyright 2013 Aesthetics. All rights reserved. Aesthetics
Journal is published by Synaptiq Ltd, which is registered
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DISCLAIMER: The editor and the publishers do not necessarily agree with the views
expressed by contributors and advertisers nor do they accept responsibility for any errors in the
transmission of the subject matter in this publication. In all matters the editor’s decision is final.
Insider
News
Talk Aesthetics
Dermatology Times / @DermTimesNow
“The goal of #aesthetic medicine is not
necessarily to be beautiful, but to feel
beautiful.” ow.ly/yXoYr #dermatology
InjectAbility Beauty / @InjectAbility
Have you heard of “Brotox”?!? Women aren’t
the only ones who want to “throwback” time.
#tbt #Botox #Men #FrownLines
Anne-Marie Sharman / @IAMAesthetics
Have just realised that my friends spend
more on #alcohol than looking after their
#skin hmmm…feel a blog coming on
Dr Harold Lancer / @DrLancerRx
Having a consistent workout regime isn’t just
good for your body, but it’s also great for your
skin! #skincare #beautytips
Safetyinbeauty / @safetyinbeauty
If you know of any public exhibitions or
events selling Botox or Dermal Fillers
please contact us urgently we are trying
to ban them
To share your thoughts follow us on
Twitter @aestheticsgroup, or email us at
editorial@aestheticsjournal.com
Nursing
BACN respond
to NMC public
consultation
The second part of a public consultation on the
revision of the Nursing and Midwifery standard of
good practice will close on August 11. In part one,
the Nursing and Midwifery Council (NMC) focused
on how the proposed model of revalidation could
be implemented in different employment settings.
Andrew Rankin, BACN representative on the HEE
board, said, “It is important that all nurses have
their say. The BACN encourage our members to
respond to NMC matters in the same way that we
encouraged them to contribute to the Keogh report.”
Part two will concentrate on the draft Code and
focused engagement. Focus groups will take
place and any interested parties can complete an
online survey. Rankin outlined that, from the BACN’s
perspective, there were no particular issues that
need be addressed, and said it is important that the
Code reflects the principles of nursing. “As cosmetic
nurses it is important that we remember these
underlying principles, which apply in any and every
environment,” he said.
6
@aestheticsgroup
Aesthetics Journal
Aesthetics
aestheticsjournal.com
Industry
Merz to acquire Ulthera
for $600m
International pharmaceutical company Merz will buy US-based medical device
company Ulthera for $600 million in upfront cash and milestone payments.
Founded in 2004, Ulthera focuses on developing and commercializing technology
for aesthetic and medical applications. Using ultrasound technology, The Ulthera
System is the only lifting and tightening device to receive FDA clearance. Merz
Pharma Group’s CEO, Philip Burchard said, “We have a vision to be the most
innovative company in aesthetics, and expanding into the rapidly growing field of
energy devices will position us for long-term success in this area.” The company said
the acquisition is an important milestone that will aid their expansion of treatment
options. The transaction is expected to close in the third quarter of 2014.
Distribution
Galderma gains full rights to
US distribution of Restylane,
Emervel, Sculptra and Dysport
Galderma has gained full rights to distribute Restylane, Emervel, Sculptra and
Dysport in the US, from Valeant Pharmaceuticals International. Humberto C.
Antunes, CEO of Galderma worldwide, said, “We at Galderma are delighted
to bring Restylane, Perlane, Emervel, and Dysport home to the US. Adding
Sculptra to our global portfolio allows us to bring additional indications to our
broad range of medical solutions.” Restylane Silk, a new formulation to smooth
perioral lines and enhance lips, recently received FDA clearance. It is an
injectable gel composed of a non-animal-based formulation of hyaluronic
acid and 0.3% lidocaine.
Journal
Aesthetics journal appoints
Dr Christopher Rowland Payne
to Editorial Advisory Board
Aesthetics journal has announced the addition of a new member
to their editorial advisory board, consultant dermatologist, Dr
Christopher Rowland Payne. Based at The London Clinic, Dr
Rowland Payne has worked in dermatology for the past 23 years.
An internationally recognised expert in cosmetic dermatology and
a co-founder of the European Society for Cosmetic and Aesthetic Dermatology,
Dr Rowland Payne has contributed to numerous publications, delivered plenary
lectures, and taught students across the globe. Along with these achievements,
Dr Rowland Payne is the Founding Editor-in-Chief of the Journal of Cosmetic
Dermatology and has been widely recognised for his contribution to the field. He
is active in all areas of clinical and surgical dermatology, especially the treatment
of skin cancer and, in 2005, was instrumental in establishing the mole-mapping
service, MoleMonitor. Dr Rowland Payne was also a co-author of the first paper in
world literature to describe skin manifestations of AIDS and HIV. Along with the
other leading figures in the medical aesthetic community on the Aesthetics journal
Editorial Advisory Board, his wealth of experience will help steer the direction of
educational, clinical and business content.
Aesthetics | August 2014
@aestheticsgroup
Aesthetics Journal
Awards
Finalist
countdown has
begun for
The Aesthetics
Awards 2014
After receiving
hundreds of
entries, The
Aesthetics
Awards are
now closed and
the finalists
are being decided. The overwhelming
response is even more impressive
given the stricter entry criteria for the
2014 Awards. Entrants were required
to provide detailed information, studies
and testimonials to support their entry,
meaning that those chosen as finalists
and, eventually, winners truly represent the
highest standards in medical aesthetics.
Following the success of last year’s
glamorous celebration, the 2014 event
is sure to be another night not to be
missed. To be held at the four star Park
Plaza Westminster Bridge Hotel in Central
London, the awards will feature finalists
in 20 categories and the winner of the
special Lifetime Achievement Award,
along with entertainment and a delicious
sit down dinner.
Tickets for The Aesthetics Awards 2014 are
available now at www.aestheticsawards.com.
Aesthetics
aestheticsjournal.com
Insider
News
Standards
CEN aesthetic standards update
By Sharon Bennett
Last month the CEN aesthetic surgery draft standard was approved for
publication as a European standard. Sharon Bennett, the UK lead on
BSI/CEN non-surgical medical cosmetic standards gives us an update
on the latest developments. What does this mean to us as cosmetic
medical practitioners? Essentially not much – the standard only addresses
surgical procedures, as the non-surgical content has been removed in
anticipation of a separate draft standard. For those who do carry out cosmetic surgical
procedures, these standards are guidelines on which to base safe practice, not only protecting
the patient but the surgeon as well. The standard represents the minimum expectations
required in Europe, so is not something practitioners must aspire to, but it does provide a
sound benchmark to map best practices against. The approval of the surgical standard was
not without contention; there was heavy lobbying from the Netherlands against the document
and the CEN voting procedure. In some countries, notably Germany, there are A-deviations in
place where legislation conflicts with the standard’s recommendations. The CEN only allows
these deviations in exceptional circumstances. The UK has been granted an A-deviation to
allow relevantly qualified dentists and nurse prescribers to be recognised as ‘practitioners’,
and another deviation allows the use of lasers and IPL by non-healthcare practitioners, such as
beauty therapists, who have relevant qualifications in this area.
All aspects of the patient and practitioner journey are covered by the standard. It includes
guidelines on operating facilities, qualifications, legal advice, staffing, consultations, care
of the patient, and commercial aspects such as advertising and promotion.
The non-surgical draft standard will include minimally invasive surgical treatments that may
not have been included in the surgical standard. There will not be an exhaustive list of nonsurgical and minimally invasive surgical cosmetic treatments; instead they will be grouped into
sections such as cosmetic injectables, laser and IPL. Like the surgical standard it is meant to be
a benchmark of good, safe practice and will cover all aspects of cosmetic medical treatments,
including facilities and qualifications – subject to national legislation.
Last month the outline of the non-surgical standard was presented for approval as a working
draft item, however it was rejected by the CEN. It could require revision and expansion but
ultimately, this means that there might not even be a CEN non-surgical aesthetic standard.
CEN delegates will meet in Vienna in September to discuss its future. The decision will be
based on an electoral procedure, which can be confusing as the process is focused on
consensus rather than voting. As with all things that rely on this method, there can be many
surprises so, at the moment, I am reluctant to hazard a guess as to what will happen.
Industry
Ackman criticizes Allergan in open letter
William Ackman, the CEO of Allergan’s
largest shareholder, Pershing Square Capital
Management, has sent an open letter to
Allergan criticising their attitude towards
Valeant and urging them to not delay a
shareholders meeting.
It is likely that Mr Ackman would replace six
of the nine Allergan directors in the board
meeting, opening the door for cash and stock
offers to proceed. Allergan can delay the
meeting until November.
“We, on behalf of Allergan’s other
shareholders, ask that you do not delay the
inevitable any further,” Mr Ackman wrote in
the letter. “What legitimate board of directors
attempts to silence or otherwise delay hearing
what its own shareholders have to say?”
He also called Allergan’s criticism of Valeant a
“scorched earth response”, and claimed that
Allergan were guilty of “market manipulation”
for spreading what he described as “false
and misleading information”. Mr Ackman said
Allergan directors had breached their fiduciary
of care and urged them to first apologize and
then negotiate. In its response Allergan said,
“Pershing Square’s letter to the Allergan board
is not based on facts, and is rooted in selfinterest and innuendo.”
Allergan claim that Mr Ackman is trying to
distract their stockholders and says the
Aesthetics | August 2014
Valeant proposal is “grossly inadequate and
substantially undervalues Allergan.”
With a 9.7% stake in Allergan, Ackman
is attempting to gain support of other
shareholders. The hedge fund billionaire
has teamed up with Valeant CEO J. Michael
Pearson in their bid to acquire the Botox
manufacturing company. They believe the
takeover would create a platform for growth
and value creation in healthcare.
Valeant’s current bid stands at $72 billion USD,
an increase of $19 billion USD from its original
offer of $53 billion USD. Allergan has rejected
all offers and says Valeant’s business model is
unsustainable and would cripple its future.
7
Insider
News
@aestheticsgroup
Aesthetics Journal
Hair
Aesthetics
aestheticsjournal.com
Distribution
Arthritis drug allows alopecia
patient to grow full head of hair
Dermatologists at Yale University say tofacitinib citrate, an oral rheumatoid arthritis drug,
allowed an alopecia patient to grow a full head of hair.
The 25-year-old male patient, who had never been treated for alopecia before, was
referred to the dermatology department for psoriasis treatment. (Researchers have recently
discovered that the drug was also an effective method for treating psoriasis – with patients
noticing a 75% reduction in the disease after taking tofacitinib twice daily.) There, the
patient was diagnosed with alopecia universalis, leaving him hairless everywhere but in the
psoriasis plagues on his head. Assistant professor of dermatology, Dr Brett King, decided
to treat him with tofacitinib, knowing it had also been used successfully in trials to treat
mice with alopecia. Initially the patient was given 10mg daily for two months that improved
his psoriasis. After an additional three months of 15mg daily treatments, the patient had
regrown hair on his head, eyebrows, eyelashes and armpits – all of which he lacked
before the treatment began. It is thought that tofacitinib blocks immune system attacks on
hair follicles, prompted by alopecia, to encourage hair growth. Dr King said he hoped to
duplicate the results in other alopecia patients and, along with his colleagues, is proposing
a clinical trial to test a tofacitinib-based cream to treat the hair loss disease.
Acne
Can Ultherapy be used to treat acne?
In a presentation to the delegates at Vegas Cosmetic Surgery 2014 on June 20, Dr
Michael Gold discussed the potential for Ultherapy, an ultrasound-based skin tightening
system, to be used for the treatment of acne.
According to Dr Gold, Ulthera – the manufacturers of the product – have recently submitted
a clinical article for publication describing study results for acne treatment. In the study, 22
patients with moderate to severe acne were treated with Ultherapy, using the 1mm transducer
(Amplify tip) for superficial skin treatment. At the three and six-month follow-up, a significant
number of participants (80% to 90%) noticed improvement. Patient satisfaction was around
80%. Despite these positive results, pain control continues to be an issue, with most patients
in the study reporting moderate pain during treatment.
Rosmetics
to distribute
Stylage, Cebelia
and Revitacare
Rosmetics Ltd has announced it is the
exclusive UK distributor for French products
Stylage, Cebelia peptide skincare and
Revitacare. Stylage, manufactured by Vivacy
Laboratories, is the first hyaluronic acid
dermal filler that uses local anaesthetic and an
antioxidant within one product.
Injected into the dermis using mesotherapy
techniques, Stylage claims to offer longlasting hydration, improved skin tone and
optimized restructuring of the skin, delaying
skin-ageing.
According to Rosmetics, volume is restored
to the subcutaneous tissues and deep skin
depressions are immediately corrected,
lasting 12-18 months.
Cebelia and Revitacare claim to support
the skin after treatment and compliment
aesthetic results. Clive Shotton, sales director
at Rosmetics, said, “Cebelia and Revitacare
have fitted in to our own clinics successfully,
increased our range of effective treatments
and helped our practitioners work excel.”
Cebelia’s products aim to aid the skins
recovery while prolonging results of
aesthetic treatments, while Revitacare is a
mesotherapy range that claims to rehydrate
the skin, help smooth fine lines and
improve skin elasticity. Managing Director of
Rosmetics, Ros Bown, said, “The addition of
these prestigious products come at a great
time for Rosmetics. They sit well within our
current product offering and will assist us
in our efforts to be among the UK’s leading
aesthetic distributors.”
beautifully matured
The unique CaHA collagen stimulating dermal filler
10 years’ experience with almost 5 million syringes sold
FDA Approved
no wonder you
Best Customer Service
Winners in 2011, 2012, & 2013
RAD092/0314/FS Date of Preparation: March 2014
Tel: +44(0) 333 200 4140 Fax: +44(0) 208 236 3526
Email: customerservices@merz.com
@aestheticsgroup
Aesthetics Journal
Aesthetics
aestheticsjournal.com
Vital Statistics
Awards
New sponsors announced for
The Aesthetics Awards 2014
Syneron Candela, Sinclair IS Pharma and Rosmetics are the latest
sponsors to be announced for The Aesthetics Awards 2014.
Syneron Candela will be supporting the ‘Best Clinic Scotland’ category
at the awards, to be held on Saturday 6th December at the Park Plaza
Westminster Hotel in London. General manager at Syneron Candela,
Michaela Barker, said, “As a company we value aesthetics clinics who are
raising standards in patient experience and safety, and therefore we are
pleased to be able to promote this through such a prestigious event. As
a previous sponsor of The Aesthetics Awards, we have found it a great
opportunity to celebrate the best of medical aesthetics and we are looking
forward to another night to remember this year!”
Sinclair IS Pharma has announced that they will be supporting the category
for Best Clinic Wales. Andrew Morrison, country operations director,
commented, “At Sinclair we understand that practitioners and clinics play
a crucial role in our aim to provide patients with safe, effective treatments
and great outcomes. Therefore we are very proud to be involved in The
Aesthetics Awards 2014 by celebrating the clinics who demonstrate their
commitment to offering outstanding service and care to their patients.”
Ros Bown, managing director of Rosmetics who will sponsor Best Clinic
North England, said, “We are always keen to be involved in prestigious
events that recognise the best in the industry and this is a fantastic
opportunity to show clinics how much we value their hard work and
achievement. We look forward to presenting the winner with their trophy in
December!”
Finalists for The Aesthetics Awards 2014 will be announced in the
September issue of the Aesthetics journal.
Tickets for the event are available now at www.aestheticsawards.com.
Insider
News
50%
of 50-year-old
men are affected
by hair loss
Hair Restoration Blackrock
The European market
for cosmetic surgery,
facial aesthetics and
medical lasers will grow
to an estimated $1.18
billion by 2019
ReportsnReports
Acne affects more than
three-quarters (80%)
of 11 to 30-year-olds
Acne Academy
In 2013 the Botox
market in the UK
was worth £18m
Transform
384,672 men in
America had botulinum
toxin injections in 2013
American Society for Aesthetic Plastic Surgery
Legal
Pollution and the
sun causes 90% of
visible ageing
Lawsuit against Clinipro rejected
The Provincial High Court in Barcelona has rejected a two-year lawsuit
against Spanish aesthetic manufacturer Clinipro.
Zeltiq Aesthetics, another medical technology company specialising in fat
reduction, prompted the lawsuit for an alleged infringement of patents.
Clinipro’s arguments have been agreed, confirming that the patents of
Zeltiq Aesthetics are nullified, due to the lack of inventive activity (the
procedure patent) and to the lack of new items (the device patent).
Philippe Plan, Clinipro CEO, said, “The confirmation of Zeltiq-MGH patents’
invalidity, added to the worldwide success of LipoCryo and the new
lipocryolysis evolution system, LipoContrast, definitively encourages us to
focus our next input to the American market.”
Founder of NUA Aesthetics, the UK distributors of LipoContrast, DonnaMarie McBride said, “This is a positive result as it will give the UK market
great confidence in purchasing other Cryo machines that are more
affordable in a tough climate. It gives the opportunity for new technologies
like LipoContrast to grow and develop.”
The Skin Cancer Foundation
1.4m
Aesthetics | August 2014
in
2007
Laser hair removal
procedures declined
38% from 1.4m procedures
in 2007 to 883k in 2012
883k
in
2012
Medical Insight Survey
An estimated 400,000
cases of skin cancer
each year are related to
indoor tanning
Centers for Disease Control and Prevention
9
Insider
News
Events diary
12th - 13th September 2014
F.A.C.E.2f@ce Conference, Cannes
www.face2facecongress.com/en
20th September 2014
British College of Aesthetic Medicine BCAM Conference 2014, London
www.bcam.ac.uk
25th - 26th September 2014
The British Association of Aesthetic Plastic
Surgeons - BAAPS Meeting 2014, London
www.meetings.baaps.org.uk
3rd-4th October 2014
British Association of Cosmetic Nurses BACN Meeting 2014, London
www.cosmeticnurses.org
6th December 2014
The Aesthetics Awards 2014, London
www.aestheticsawards.com
7th - 8th March 2015
The Aesthetics Conference and Exhibition
2015, London
www.aestheticsconference.com
Social media
FDA drafts social
media guidelines
for pharmaceutical
companies
The American Food and Drug Administration
(FDA) has released a draft of guidelines for
pharmaceutical companies to adhere to when
using social media. In the draft, the FDA said that
companies must be sure to disclose the “most
serious risks” when discussing the benefits of their
products on social media sites, as well as specifying
the most precise indications for each product.
The FDA acknowledged that, “For some products,
particularly those with complex indications or
extensive serious risks, character space limitations
imposed by platform providers may not enable
meaningful presentations of both benefit and risk.” If
this is the case, the agency said companies should
provide hyperlinks to sites where more complete
information can be found.
10
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Aesthetics Journal
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Cryotherapy
NUA Aesthetics launch new
cryotherapy technology
A cryotherapy product to
remove warts, skin tags
and other skin problems
has been launched by NUA
Aesthetics this week.
NUA claim that CryoPen
transforms cryotherapy
into a quick outpatient
procedure that does not
need preparation or follow-up care. Dr Robert Barot from Paris, has used the
technology and said, “CryoPen instruments have added to our efficiency. We
are impressed by the instruments ease of use and by the positive reactions of
our patients.” CryoPen claims to penetrate the skin tissue at approximately 1mm
per five seconds and takes only ten seconds to treat a 2mm lesion, with no
anaesthesia necessary. According to NUA, the high-pressure cryogen jet means
all lesions can be treated regardless of size, including those that would normally
have been referred – increasing practitioner’s patient numbers. CryoPen has
been successful abroad and is available in the UK now.
Government
Jeremy Hunt says cosmetic
surgery should not be
available on the NHS
Health secretary, Jeremy Hunt has said cosmetic surgery such as tummy
tucks and breast enlargements should no longer be available on the NHS.
Speaking at a lunch for political journalists, it was reported that he said he was
“purely against cosmetic work” being carried out for free by the health service.
His views come in light of official figures, released in a parliamentary answer at
the end of last year, that stated in the last six years, nearly 8,000 people have had
tummy tucks on the NHS, at an estimated cost of £50 million to the taxpayer.
“We should not be doing cosmetic work on the NHS,” he said. “The decisions are
taken on the basis of clinical need, but I have made it very clear that I am against
purely cosmetic work.” Mr Hunt did however agree that in some circumstances
mental-health needs call for state-funded surgery, when deemed appropriate by
a local doctor. “But I do completely understand people’s reservations about some
of the things that happen,” he said.
Industry
Red Dot Award for Restylane
Skinboosters system
Galderma’s Restylane Skinboosters SmartClick delivery system has won
the Red Dot Award for High Design Quality 2014.
The Restylane Skinbooster syringe uses the SmartClick system to provide
built-in dosage control, dispensing ~10 microlitres of product with every
audible click. The Red Dot Design award panel consisted of 40 international
design experts, and the SmartClick system faced competition from over
1,800 international entrants.
Aesthetics | August 2014
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Aesthetics Journal
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Mesotherapy
Mesoestetic launch treatment
kits for transcutaneous use
Two new lines of mesotherapy solutions have
been developed by mesoestetic to treat a range of
aesthetic concerns.
c.prof and m.prof belong to meso.prof, a range of
solutions and specific active substances in sterile
ampoules for transcutaneous use.
The c.prof line consists of highly concentrated cocktail
formulas, designed to treat ageing, dark spots, cellulite,
facial and body flaccidity and fluid retention.
Facial, figure and capillary aesthetic concerns can
be treated with the m.prof range. The range consists
of six treatment kits; antiox, mesolift, hair loss, hard
cellulite and soft cellulite. The products can be used
with transcutaneous penetration equipment and
devices such as rollers, microneedling, electroporation,
iontophoresis, ultrasound, cavitation and IR
thermotherapy. They are available in the UK now.
Conference
Inaugural ACE 2015 Steering
Committee meeting held in
London
The first official Aesthetics
Conference and Exhibition 2015
Steering Committee meeting
was held in London on July 17.
Members of the Aesthetics team
and the Steering Committee,
including Mr Dalvi Humzah, Dr Raj
Acquilla, Dr Tapan Patel were in
attendance. During the meeting,
the Committee discussed the main
conference agenda, presentation
topics and innovations designed to
maintain ACE’s status as the leading
non-surgical medical aesthetics
conference in the UK. Dr Raj Acquilla said, “I’m delighted to be part of the expert
committee helping to put together a world class programme for ACE 2015. Last
year it was the biggest UK medical aesthetic conference and exhibition and
our exciting new plans for the dynamic live anatomy/injection symposium for
this year will ensure that once again ACE is the event not to be missed for any
professional in the industry.”
Encompassing all areas of the profession through the huge exhibition and
education programme, ACE 2015 will be held in London on 7 and 8 March
next year and will feature even more live clinical demonstrations, expert
presentations and the extremely popular business track.
More details about the conference and updates on the agenda can be found
at www.aestheticsconference.com.
Aesthetics | August 2014
Insider
News
60
Eddie Hooker, managing director
at Hamilton Fraser Insurance
With regards to cosmetic
insurance, what changes
have occurred recently?
A significant change, which
may potentially affect
many nurses and aesthetic practitioners, is
the withdrawal of indemnity cover for elective
aesthetic procedures from the Royal College of
Nursing’s membership package. The change
took place on the 1st of July 2014, and whilst
unconfirmed, is more than likely due to the
high risk of claims associated with this area of
medicine. The removal of this cover requires
nurses for the most part to source external
insurance protection.
What does this mean for aesthetic
practitioners?
The RCN withdrawal leaves nurses exposed,
and has knock on effects for other practitioners
in the sector. There is now clear evidence that
malpractice claims are rising and insurance
premiums are coming under pressure, especially
for higher risk procedures. It is vital that nurses,
and the wider cosmetic industry, ensure they
check their cover as to what they are actually
covered for, and whether past treatments carried
out are also covered.
What advice can Hamilton Fraser offer to
practitioners concerned about the situation?
Hamilton Fraser Cosmetic is able to offer
reassuring advice to practitioners who are
potentially concerned about their defence body
coverage. This advice and expertise comes from
20 years of experience in dealing with aesthetic
practitioners. Our advice is to check what cover
defence bodies are offering you – never assume.
Are you protected for all the procedures that
you practice? This is important. Practitioners are
able to arrange standalone cover with us to be
covered for specific treatments. If you are not
receiving the right answers from your defence
body it is advisable to take out a stand-alone
cover, for guaranteed protection. But it’s important
not to be hasty and cancel your defence
body membership. Hamilton Fraser Cosmetic
Insurance and defence body protection often
goes hand in hand, providing cover for both
your general practice and your
aesthetic practice you can simply
downgrade your membership
level and create a package of
covers that will ensure complete
protection.
11
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News
@aestheticsgroup
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News in Brief
Acne
FDA warns of risks associated
with over-the-counter acne
products
The Food and Drugs Administration (FDA) has warned consumers of the
risk of over-the-counter acne treatments that could cause potentially lifethreatening allergic reaction or severe irritation.
Topical products, sold globally under well-known brand names, often contain
benzoyl peroxide or salicylic acid, which have been linked to serious cases of
hypersensitive reactions. At the moment the Drug Safety Communication (DSC)
cannot determine if the reactions were triggered by the acne products’ active
ingredients, benzoyl peroxide or salicylic acid, the inactive ingredients, or by a
combination of both. From 1969 to January 2013 the FDA received 131 cases of
hypersensitivity reactions with serious outcomes. The majority of the cases were
reported since 2012.
Manufacturers of over-the-counter topical acne products have the option to
add label directions for sensitivity testing. They are encouraged to add these
directions and consumers are advised to follow them. The FDA said they
are continuing to monitor and evaluate the safety issue, and will work with
manufacturers regarding any future label changes that would address the risk of
severe hypersensitivity reactions.
Technology
Evidence-based health apps
are “promising tools” for
practitioners
Chicago-based researchers claim mobile apps are an effective method of
distributing medical information.
After creating a free app that conveyed evidence-based content on diet and acne,
the team found it was downloaded to 5507 devices in 98 countries.
In a report published in JAMA Dermatology in June, the researchers, Dr Diane
Cohen and colleagues, said, “Well-designed apps remain promising tools
for collection of data from large populations and for dissemination of health
information, particularly the predominantly adolescent and young adult acne
population that increasingly use smartphones.”
The researchers added an optional survey to the app that was completed by 110
people. Results showed 37.3% of respondents had not seen a doctor for their
acne and 87.3% reported acne duration greater than one year.
The data demonstrates that people are frequently seeking medical information
online, supporting practitioners’ views that the underutilization of online resources
for providing information qualifies as a practice gap.
Dermatologist, Dr Ashish Bhatia, said in the invited commentary, “This gap can
be closed by creating a credible resource that uses this format compiled and
produced by medical societies, speciality thought leaders, or journal task forces.”
With annual downloads for health apps set to reach 142 million by 2016, he said
the information must be updated regularly, be easy to understand and provided to
the patients freely or inexpensively.
“As our patients’ preferences for the way they seek information evolve, we need
to adapt to these changes to ensure that credible information is easily available.
Not only will this help avoid patients searching for and finding incorrect or poorquality information on their condition, it will also help reinforce the information we
provide at the point of care,” said Bhatia.
12
Aesthetics
Aesthetics | August 2014
Sinclair recruiting aesthetic account
managers
International pharmaceutical company,
Sinclair IS Pharma is recruiting nationwide
aesthetic account managers.
Country operations director, Andrew Morris
said, “Due to rapid extension, after acquiring
many new products over the last few months,
we are actively looking to recruit aesthetic
account managers for various sales roles –
experience of the industry is essential.”
Spectra’s Gold Handpiece launches in
the US
Following a successful launch in Europe, the
Middle East and Asia, Lutronic Spectra’s Gold
Handpiece is now for sale in the US.
Lutronic claim that studies prove that the
laser device allows practitioners to get a
superior reduction in the redness that often
remains after acne has been treated. The
gold 585nm handpiece is now available on
the Spectra Q-switched laser.
Facial aesthetics report launched
Market research company Research and
Markets has announced the launch of Facial
Aesthetics Market to 2020.
The report predicts that the global facial
aesthetics market will be valued at $5.4
billion by 2020. It claims that this growth is
fuelled by an increasing awareness among
consumers of the various facial injectable
products available, as well as sustained
economic recovery in developed countries.
RSM to hold dermal filler course
The Royal Society of Medicine (RSM) will
hold a fully accredited dermal filler course
on December 2. A certificate of attendance
will be provided to those who pass the
assessment at the end of the training day.
This is the first time the RSM have run the
course and there are still spaces available.
Duration of US acne antibiotic use
decreasing
A study, published in the Journal of the
American Academy of Dermatology, found
that the mean antibiotic course duration
was 129 days, a decrease compared to
previous data. Among the 31,634 courses
assessed, 93% lasted fewer than nine
months, but 17.53% of courses exceeded
six months. Researchers said if these were
shortened to six months, $580.99 could be
saved per person.
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On the Scene
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The British Association
of Dermatologists Annual
Conference, Glasgow
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PelleFirm launch,
London
The 94th annual meeting of The British
Association of Dermatologists (BAD)
was held in Glasgow between 1-3 July.
With 1, 125 delegates in attendance at
the Scottish Exhibition and Convention
Centre, the conference was host to
an international audience. Attendees
included Dr Rachael Clark from Boston,
USA, and Professor Robert Moots from
Liverpool, Professors Vijay Sharma and
Amrinder Kanwar, both from India. Chris Garrett of the British Association of
Dermatologists said, “The annual meeting committee worked hard to provide
a blend of new scientific presentations with updates from experts in various
fields, covering a huge range of skin conditions. A particular highlight from
this year’s event was the first ever ‘Dermatology Question Time’. Open and
free to all members of the public and chaired by Martyn Lewis (CBE), the
session gave the public the opportunity to ask questions about any aspect of
dermatology. It proved to be a big success with over 110 attendees and plenty
of very interesting and varied questions.”
Dr Rita Rakus hosted a launch of
the PelleFirm system on Tuesday
June 24 at her Knightsbridge
clinic. The new FDA-approved
PelleFirm system is a non-invasive
treatment for the tightening of
the skin on the body, which the
manufacturers claim results in a
firmer, more toned appearance.
Use of the small spheres on the
device’s massage head aims to reduce the appearance
of cellulite by encouraging movement of underlying
fluids into areas where they can be naturally excreted via
the body’s lymphatic system. Dr Rakus is titled the The
World’s Biggest User of Pellevé-GlideSafe and winner of
the first Premier Pellevé Partner Award, having treated
over 3,000 patients to date. Demonstrations of the
system using the Pellevé machine were accompanied
by presentations of other treatments offered at Dr Rakus’
clinic including Coolsculpting, Aqualyx, Mesogun U225
and Cellulaze.
Facial Aesthetics Conference and Exhibition, London
The annual Facial Aesthetics Conference and Exhibition (FACE) took place at the Queen Elizabeth II Conference Centre in London on June
20-22. The three-day event included agendas devoted to hair, skin, facial injectables, lasers, radio frequency and other facial rejuvenation
devices, as well as business and marketing. The exhibitor workshops agenda saw a host of industry names present on the latest products and
services. On the first day of the conference, Dr Sabrina Fabi and Dr Tapan Patel ran an Ultherapy workshop on lifting and tightening of the neck
area. Dr Michael Kane played host to a Merz symposium, spanning
subjects such as ageing of the temple, the effect of pollution on the
skin and facial attractiveness. Meanwhile as part of the Equipment
agenda, Dr David Eccleston gave a detailed presentation on fractional
radiofrequency for the rejuvenation of the eye, sponsored by Syneron
Candela. Saturday saw Dr Linda Eve and Dr Askari Townshend present
on Sculptra, and Dr Christoph Martschin hold a session on Restylane
Skinboosters for Galderma, exploring the ways in which the treatment is
able to rejuvenate the face, neck, decolletage and hands. Practitioners
in attendance included Dr Beatriz Molina, who said, in a session on the
importance of improving skin quality in an aesthetic procedure, that she
believed, “Ageing cannot be corrected, we must [instead] age gracefully.”
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Andrew Rankin gives an insight into
the BACN’s role in the HEE Expert
Reference Group
The Future of the Industry
The BACN is privileged to be involved in the work of Health
Education England (HEE) in reviewing education and qualifications
within the medical aesthetics industry. We have, in the past several
months, led the project’s phase 1 work on assessing the education
and training requirements for delivering the treatment modalities of
botulinum toxins and dermal fillers. This project will undoubtedly shape
the future of the cosmetic medical industry and will have an impact on
all those yet to be involved. Most of all, it will have an impact on the
patient – the end user who forms the focus of our every objective.
Transparency at every level, user involvement, informed consent,
standards; these are but a few of the buzz words which signal the
drive towards a new, cohesive, patient-centred industry. From the
perspective of the BACN, work began as early as November 2013
when we presented our report (Medical aesthetics. An educational
framework. A Review of the Industry for the purpose of regulation
(2013)) to HEE. This 6,000-word report complemented the BACN
competencies framework, and provided significant detail for nonexperts (i.e. HEE) in terms of outlining the industry. It described the
various problems and concerns evident to those familiar with the
industry, and made recommendations that would close loopholes and
promote a secure future for the industry.
The Expert Reference Group (ERG), set up by Health Education
England to advise and work with them to create a formal framework
of education for the non-surgical cosmetic industry, is broad.
Representatives include nurses, doctors, dentists, surgeons,
pharmacists, beauty and industry spokespersons and experts from
laser and hair transplant fields. Importantly, the table at which we sit
is, metaphorically speaking, round. That is to say, all have an equal
opportunity to present their perspective, and decisions made are a
consensus reflecting the breadth and depth of the group. It is perhaps
the first time the industry has been so unified and working in this way
is hugely rewarding. This unified approach is important on several
Aesthetics Journal
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levels. We are able to more readily agree on (and therefore influence)
the issues where there is such strength of feeling.
Phase 1
The remit of phase 1 has been to agree the framework of education
which will lead to a formal qualification, and then to populate it
with the relevant indicative content. The framework, set out in
the table, describes a process for medics and non-medics alike,
enabling them to achieve minimum standards at various levels for
specific treatment modalities. With regard to botulinum toxins and
dermal fillers, Levels 4 and 5 represent theoretical knowledge only,
developing to the point where at level 6, practical experience can
begin. The principle of Accreditation of Prior Experiential Learning
(APEL) is key and it is anticipated that as nurses, we can demonstrate
many of the prerequisites required for levels 4 and 5. During phase
1 the Department of Health (DoH) have also signalled their intent
to support this work with legislation. The form this will take will not
involve a prescription status for dermal fillers, as anticipated. Instead,
legislation is aimed at a requirement for all dermal filler treatments (in
the first instance, and other treatments later) to require a face to face
consultation with a (statutory) regulated (e.g. NMC, GMC) practitioner
who holds the above qualification. They would then be able to
delegate treatment administration to any practitioner who also holds
the appropriate qualification. Further work is still required on what this
will mean in practice and any ‘supervision’ requirements.
Phase 2
Following our report to HEE, the BACN sought to agree the principles
it contained with the British College of Aesthetic Medicine and the
British Association of Dermatologists, thereby setting the foundation
for the close working relationship we currently enjoy. As mentioned
above, supervision will be one of a number of factors to consider
during this second phase. Who can supervise – doctors, dentists and
nurses only, or are there others? What does supervision entail? Will it
be open to abuse? These have to remain questions at the moment,
rather than answers, but it is important to consider the factors involved
in reaching an eventual decision. As part of our initial recommendation
for HEE, BACN defined supervision as the following:
Common Themes
Training framework
Hair
Restoration
Surgery
Chemical peels
and skin
rejuvenation
Botulinum
toxin
Dermal
fillers
Lasers,
IPL & LED
treatments
Module(s)
Module(s)
Module(s)
Module(s)
Module(s)
LEVEL 8
PRO level
Module(s)
Module(s)
Module(s)
Module(s)
Module(s)
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Masters Degree
level
Module(s)
Module(s)
Module(s)
Module(s)
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16
Aesthetics | August 2014
• Under supervision
Under supervision means to work within the same legal entity
as the supervisor, that the supervisor is in-house at the time
of treatment, able to assist where required and respond to
emergency situations.
• Independent practice
Holistic management of a patient’s assessment, treatment and
intervention in complication and emergency - without immediate
recourse to peers or superiors. These definitions should give a
flavour of what we wish to achieve. Further, the ERG will make
recommendations to close loopholes where we see a potential
for abuse of the system. From experience so far, it is fair to say that
Expert Reference Group recommendations are given the merit
they deserve by HEE and the Department of Health.
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Regulation
The DoH has been actively considering options for governance
within the industry. The prospect of a voluntary register is a
real one, as is an overarching “competent authority” to provide
industry oversight. The BACN has made recommendations to
HEE and the DoH, suggesting the format that a new industry
structure might take. Such potential change affects everyone.
However, the fact that we have been able to work so closely with
our medical colleagues to agree on this direction is testament to
a developing, cohesive industry, as described earlier. The BACN
have also been advising a new organisation — Save Face – of
the requirements of a voluntary register. They are committed to
providing both a voluntary register, and significantly adding value
to patients and members alike. We have described to them what
such a register should look like, providing them with the insight
necessary to achieve these patient-centred aims. Finally, the
position of nurse prescribers holding prescription medicines as
stock will need to be addressed as the project moves forward.
Of the developments, HEE performance and delivery manager
Carol Jollie, said, “It is clear that there is genuine and unanimous
stakeholder desire for greater consistency in training standards
to contribute to improved patient/user safety in the non-surgical
cosmetics industry. HEE will shortly be publishing its report on
phase 1 of its project reviewing the qualifications required for
non-surgical cosmetic interventions, and we look forward to
continuing to lead this important and challenging programme.”
Phase 2, due to be completed in April 2015, will provide more
answers, and result in a picture of the industry emerging with
greater clarity. Contrary to various criticisms, concerns and
uninformed opinions, I am confident the medical nature of our
industry will not be compromised. To my mind, the future is bright.
It may not be faultless, but nevertheless a single, unified industry,
based on a formal qualification and designed around both the
patient and the principle of professional, statutory responsibility
is a significant stride in the right direction. Importantly, the
voluntary professional bodies have demonstrated that they can
work together to achieve a common objective. A process of
continuous improvement is feasible, and should go a long way
towards securing the future of the industry.
Andrew Rankin was the original consultant editor for
the Journal of Aesthetic Nursing and is currently chair
of the BACN Education Committee and a member of
the board. Andrew was invited by HEE to be one of the
final members of the Expert Advisory Group in the UK
and was leading the group on toxins and dermal fillers.
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Clinical Practice
Special Feature
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with a list of procedures and [I] just agree to do
them. Patients need our expertise to recommend
what is going to have the most impact on their
problem – they have a choice, but it must be an
informed choice,” says Mr Karidis.
When is surgery the best option?
Jaw and neck
rejuvenation
Many women aged 40-60 want a tighter
jaw line and a smoother neck. Surgery is
certainly one option, but what else is available
to patients who don’t want to opt for such an
invasive procedure? Kathryn Senior speaks to
practitioners about their recommendations.
Who can benefit from jaw and neck lifting?
Aesthetic practitioners and cosmetic surgeons report that enquiries for neck
and jaw work are made mainly by women aged 40 to 60. According to the
aesthetic practitioners interviewed for this article, between 80% and 90% of this
demographic is female, but this does not mean that the procedures available do
not work in men. Surgical and non-surgical techniques have similar effects and
satisfaction rates in both sexes. “The treatments that boost collagen production
and lift the skin through dermal heating can in fact work better in men as they
tend to have thicker skin and more collagen than women of the same age,”
comments Dr Patrick Bowler, founder of the Courthouse Clinics, who offers
predominantly non-surgical options in his ten clinics throughout the UK.
Making informed decisions
The ageing process varies between individuals. An important first step in
advising a patient of the options most suitable for them is to assess both the
patient’s physical appearance and their expectations.
Mr Alex Karidis, lead cosmetic surgeon at the Karidis Clinic, based in The
Hospital of St John & St Elizabeth in St Johns Wood, London, offers both surgical
and non-surgical options. “When a patient first comes to see me I ask them to
describe what they want. Those first 5-10 minutes are the key to establishing
how the patient views their face and neck, and their expectations,” he says.
Mr Karidis does this by asking patients to look at themselves in a mirror and
demonstrate how they would like to look. The response varies. “It’s usually
clear very quickly if the patient needs surgery – they pull their skin back to
demonstrate their need for a drastic change.” Some patients are happy with the
recommendation and opt for a surgical procedure, but others do not want to
go anywhere near an operating theatre. “Someone who is not keen to follow
a surgical path needs to understand what can and can’t be achieved with
non-surgical treatments. We don’t want them to spend money on non-invasive
treatments if they are not going to be happy with the results,” he adds.
Although patients are important in the decision making process, the aesthetic
practitioner is there to provide expert input and direction. “I spend a lot of time
asking the patient what they want to achieve, but I don’t expect them to come
18
Aesthetics | August 2014
Cosmetic surgeon, Mr Jan Stanek, is convinced
that surgery is the only option for men and women
with advanced signs of ageing. “One of the most
common complaints is of sagging in the cheeks,
jowls and some degree of fullness and sagging
under the chin. As the platysma muscle in the neck
relaxes, this also causes sagging of the skin down
towards the chest,” he explains. “Non-surgical
treatments can have only minor effects; if you
want significant improvements, surgery is the way
forward,” he says.
The jaw and neck are intimately associated with
the face, and patients who may think they just
need a facelift, are advised to have a combination
procedure for a more pleasing effect. “If you tighten
up the face without paying any attention to the
neck, the result can look very odd because you are
treating only one part of the problem. It’s really not
worth doing as far as I’m concerned,” stresses Mr
Stanek. “I will always be honest with a patient and
explain to them what can be achieved with surgery.”
Mr Karidis agrees, as does Dr Bowler, who confirms
that some patients are beyond the scope of what
he can provide. “Even the best techniques that
make use of radiofrequency, dermal fillers, Botox,
ultrasound or laser therapy, or any combination
of these techniques, have their limitations. If a
patient has a neck with a lot of loose skin, very
little collagen structure and advanced ageing, we
recommend they have surgery,” he confirms. In his
practice, he regularly turns away patients who want
non-surgical treatments but whose expectations
are unlikely to be met.
The non-surgical approach
Cosmetic surgery may provide the most drastic
reversal in the signs of severe ageing in the neck
and jawline but a surgical procedure is not right for
everyone. “Some patients just don’t want surgery,”
says Dr Bowler, “But they want to achieve some
improvements and accept the limitations. We also
see many middle-aged women who want to be
told they look ‘well’, rather than receive questions
about who has done their cosmetic work,” he says.
The gradual improvements that can be achieved
by non-surgical techniques suit this demographic
very well.
Following a programme of non-surgical jaw and
neck tightening procedures, over months or even
years, can keep the skin and underlying tissues
in good condition, delaying the ageing process.
“But you only get the maximum effect if you are
persistent, attending for regular treatments,” says
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Clinical Practice
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Mr Karidis. Non-surgical interventions are less invasive and in many
cases patients do not have downtime. Many procedures can be
done as ‘lunchtime’ appointments and produce no visible adverse
effects. “This is a significant advantage to many of the women I
see, who don’t want to be out of action and certainly don’t want
swelling, bruising or scars,” notes Dr Sam Robson, medical director
Aesthetics Journal
Aesthetics
aestheticsjournal.com
at the Temple Medical clinic in Aberdeen. Appearance is not the
only factor that is important. “Patients that have the Harmony
Clear Lift treatment often report that the feel of their skin has
improved noticeably, and this is one of the aspects that they are
most pleased with. Feeling better and looking better are intimately
linked,” says Dr Bowler.
Non-surgical procedures available for the jaw and neck
Devices
Local heating of the dermis causes contraction of the collagen
fibres already in the skin at the time of treatment. This causes
a contraction of the underlying tissue, which pulls the surface
skin. When treatment is targeted carefully, the overall effect is to
lift the skin, removing fine lines, making the skin look smoother
and more toned. The heat also stimulates fibroblasts in the
dermis to produce more collagen; over the course of several
treatments this thickens the skin and provides more collagen to
work on, so the effects build over several weeks.
Different technologies are available to cause sub-dermal heating:
• Radiofrequency, eg the Endymed RF system used by Dr
Robson, or the Exilis by BTL
• Ultrasound, eg Ultherapy, favoured by Mr Karidis
• Laser, eg the Harmony Clear Lift system used by Dr Bowler
Microneedling causes minor physical damage to the dermis, which
also stimulates fibroblast activity.
Injectables
Botulinum toxin injections carefully placed in the muscles of the
neck, around the jaw and in the lower face, can inhibit contractions
of the muscles that pull the skin down. Botulinum toxin works in a
completely different way to techniques that cause heating, so can
be used concurrently and can accentuate the non-surgical lifting
Combination treatments
Different practitioners have their own views on what works best for
which patient, but most incorporate some type of energy device.
“Radio-frequency, ultrasound or deep laser treatments heat the
underlying tissues, stimulating the formation of new collagen,
which leads to shrinkage and tightening of the skin. That’s the
basic premise on which these energy devices work,” explains
Mr Karidis. Like any interventional process, a balance between
sufficient heating to have a positive effect and too much heating
that could cause burning, is essential. “Today’s technology can
target the tissues in a very precise manner but even so you
can get burning, so you have to accept shorter treatment times
and lower settings for the maximum therapeutic effect without
damage,” he adds.
The field certainly seems to be moving in the direction of
combining multiple treatments, either concurrently, or over
a period of months. The techniques work in different ways,
targeting different tissues and processes, so do appear to have a
cumulative effect.
Mr Karidis personally avoids radiofrequency because of what he
deems its ‘scattergun’ approach, and favours Ultherapy. “I prefer
ultrasound because of its precision. You can focus exactly on the
depth and area that you want to target and you can use fewer
20
effect. Dermal fillers add volume underneath the skin, and can
reduce the appearance of jowls and smooth folds around the
mouth and creases around the lip line.
Threads
Absorbable ‘threads’ are used to lift and realign sagging tissue
and work to support the neck. The surrounding tissues hold
the threads in place, eliminating visible scars. French cosmetic
doctor Dr Jean-Louis Sebagh, who uses Silhouette Soft to
perform this treatment, says, “There are a number of benefits
to the patient when using Silhouette Soft to lift and tighten the
neck and jaw area. It does not require a general anaesthetic
and the treatment itself can be performed in 30 to 60 minutes.
In addition, as the procedure requires no incisions to be made,
the downtime and recovery is minimal, with the patient feeling
well immediately after treatment and any potential downtime
is limited to a week or so – unlike surgery which comes with a
recovery time of six weeks plus.
“The results last for up to 18 months – thanks to the threads
being made of polysaccharide, they gradually dissolve over
a 12-18 month period but the collagen that is created after the
treatment is carried out helps to extend the period of lifting and
tightening. For some patients, Silhouette Soft will allow them
to delay or even avoid the need for cosmetic surgery, which
is excellent news. If carried out correctly by an experienced
doctor, the results are remarkable and rewarding.”
treatments. It is very useful for sculpting the jawline and neck
area,” he comments. Ultherapy is used in combination with other
treatments in patients who don’t want surgery and also in those
who have had a surgical face and neck lift. “It’s not all about just
lifting the skin. That’s where Botox and fillers and skin peels go
hand-in-hand. I use the non-surgical treatments after surgery for
maintenance in the years following. It’s an on-going process,” he
explains.
In Dr Bowler’s practice, the emphasis is on a bespoke treatment
plan for each patient, which can involve injections of botulinum
toxin, dermal fillers based on hyaluronic acid as well as the
Harmony Clear Lift laser system that he favours. “The Harmony
Clear Lift system is fairly new technology but we have treated
many patients now and we are impressed,” he comments. “Not all
patients are suitable; the laser used within the system causes a
targeted heating effect that stimulates fibroblasts to produce more
collagen, but if a patient has very little collagen left in their neck, it
is unlikely to achieve very much,” adds Dr Bowler.
Dr Robson’s preferred treatment for tightening up the jawline is
to use the Endymed RF system but within a combination protocol
that also offers fractional resurfacing, microneedling, Skinboosters,
Ominlux, botulinum toxin, dermal fillers, PRP and surface skincare.
“We are currently devising a complete non-surgical facelift that
Aesthetics | August 2014
duction
Fat Re
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Cavitation
Complete start up and support
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Key advantages of this technology are high treatment efficacy,
Cavitation is a natural phenomenon based on low frequency
ultrasound. The Ultrasound produces a strong wave of pressure
to fat cell membranes. A fat cell membrane cannot withstand this
pressure and therefore disintegrates into a liquid state. The result is
natural, permanent fat loss.
Duo Cryolipolysis (New)
Using the unique combination of electro and cryo therapy 20-40%
of the fat cells in the treated area die in a natural way and dissolve
over the course of several months.
Two areas can now be treated simultaneously.
Radio Frequency Skin Tightening
Focus Fractional RF is the 3rd generation of RF technology. It
utilises three or more pole/electrodes to deliver the RF energy under
the skin. This energy is controlled and limited to the treatment area.
no pain as less energy is required, shorter treatment services and
variable depths of penetration.
3D Dermology RF (New)
The new 3D-lipomed incorporates 3D Dermology
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“I am so pleased to be given the opportunity to have the first medical version of the
award winning 3D Lipo machine in my new clinic. This multi-platform technology
offers a powerful non-surgical alternative to lipo suction with the addition of skin
tightening and cellulite reduction modalities. I’m so proud to be able to offer my
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For further information or a demonstration
call: 01788 550 440
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Clinical Practice
Special Feature
@aestheticsgroup
can be applied to anyone, but predominantly aimed at women
aged 40 to 60. The treatments are done over several months
and everyone will see at least some improvement since we
are stimulating collagen production, restoring lost volume and
improving skin health,” she reports.
Aesthetics Journal
Aesthetics
aestheticsjournal.com
Robson is confident that all patients can benefit from non-surgical
treatments, even those with marked signs of ageing. “If someone
does not want surgery, there is still plenty that can be done. It is
a matter of expectation,” she notes. “Patients need to understand
that improvements will be gradual and that there are limitations.”
Case study: example combination systems
Although aesthetic practitioners are devising their own bespoke
combination treatment protocols, some manufacturers have also
developed treatment systems that combine different modalities.
Alma’s Accent Ultra V
Technology involved: Combines cavitational ultrasound with high
power radio frequency for deep thermal heating.
Treatment details: Cold ultrasound sheer waves are applied to the
neck and jawline. This breaks down fat cells, which are large (50150 microns) and so easily shocked by the vibration, but leaves the
smaller cells that make up blood vessels and nerves (5-15 microns)
undamaged. This is followed by an application of radiofrequency
for deep heating, which increases the metabolism and stimulates
collagen production.
How long does it take? Approximately 30 minutes.
How many treatments? Four to six sessions, each two weeks apart.
Advantages and benefits: Can be combined with other treatments.
Can be adjusted to the individual needs of the patient.
Harmony Clear Lift
Technology involved: Deep thermal non-ablative laser that targets the layer of skin up to 3mm
below the surface. It leaves no surface effects.
Treatment details: A Pixel Q-switched laser targets the deep dermis using multiple fractions of
energy. This encourages collagen production, which has a tightening effect.
How long does it take? Approximately 30 minutes.
How many treatments? Three to six sessions, each two weeks apart.
Advantages and benefits Can be done as a lunchtime treatment and effects can be noticeable
immediately and then build over the weeks of treatment. Most practitioners advise a follow-up
treatment six to twelve months later for maintenance. Improves skin texture and reduces pigmentation.
Sygmalift
Technology involved: A combination of high
frequency ultrasound and a 635nm laser.
Treatment details: The HIFU line probe
remodels fat effectively while the Trimicro focal
ultrasound probe produces local heating in the
dermis to stimulate collagen production. The
LLLT probe stimulates deeper skin layers.
How long does it take? Approximately 30
minutes.
How many treatments? Three to six sessions,
each two weeks apart.
Advantages and benefits A treatment that
can be done at lunchtime with no visible
adverse effects. The coupling of the laser and
ultrasound produces a glow to the complexion,
as well as underlying changes in collagen.
22
Before
Before
Before
After
After
After
Aesthetics | August 2014
A New Dimension in Non-Surgical Technology
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Here are just some of the reasons why 3D-skintech will become
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• Complete treatment portfolio for anti-ageing,
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Utilising the latest technology available you can work in conjunction
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Radio Frequency
Tri-polar Radio Frequency is the most advanced technology
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Mesotherapy
Non-invasive mesotherapy ensures that the active ingredients are
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LED
Full canopy LED ensures both rapid treatment time and excellent
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3D-skintech peels and clinical skincare
A compact range of medical grade peels and cosmeceutical skincare
products complete the Skintech’s unique offering and enables you
to both use as a “stand-alone” service or combine with equipment
protocols.
‘To compliment our core injectable business the 3D-skintech has added an array of
new result driven facial services to our clinic’s menu as well as the combination services
for our more curative patients. We recognized that this device offered the stand alone
quality of each technology in a unique machine that will ensure that we both deliver the
results but equally can make money from the start due its affordability. As a clinician
too many times in the past we have invested huge sums of money in a single concept
that has proven difficult to profit from. In my opinion this type of system represents the
future in our industry.’ Dr Martyn King – GP and Clinical director Cosmedic Skin Clinic
www.3d-skintech.com
www.3d-lipo.com
Clinical Practice
CPD Clinical Article
one
point
@aestheticsgroup
Aesthetics Journal
Aesthetics
aestheticsjournal.com
From Mouth
to Dermis
Dr Raina Zarb Adami discusses the literature surrounding nutraceuticals
The notion of improving the condition of skin through the
ingestion of nutrients has longstanding roots in history. A food
or food product that imparts medical or health benefits, other
than its primary nutritive purpose, is considered a nutracuetical.
literature of the science pertaining to the employment of nutrients
for the improvement of the dermis and the skin as a whole, and
their anti-ageing properties.
THE AGEING TRAJECTORY OF THE SKIN
The term is a combination of the words nutrition and
pharmaceutical, initially coined by Dr. Stephen L. DeFelice1,
founder and chairman of the Foundation of Innovation Medicine
(FIM), Crawford, New Jersey. Nutraceuticals are not subject to
the same testing and regulations as pharmaceutical drugs nor
are they classified as medical devices. The human integument
is continuously exposed to fluctuations in internal and external
environments that may influence its anatomy and physiology.
These may include photo-ageing, inflammatory processes,
immune dysfunction, imbalanced epidermal homeostasis, and a
whole plethora of other skin disorders.2 Advances in nutritional
science scrutinise the relation between food intake and
subsequent health, and impacts ingredients that may have cause
to be biologically relevant at a cellular level for optimising skin
conditions. Nutraceuticals refer to medicinal foods whose role is
to partake in the maintenance of well-being, immune modulation
and disease prevention, as well as treatment.3
HISTORY
Since the time of the Sumerians, Chinese, Indians and Egyptians,
food has been employed for its medicinal purposes.4 It is well
documented that even Hippocrates, the ancient Greek physician
and ‘father’ of medicine, said, “Let food be thy Medicine”. Recent
years have seen a trend towards more natural remedies and
plenty of research has been devoted to understandingthe
development of dietary supplements, isolated nutrients,
genetically engineered foods and their absorption and translation
at a cellular level. Dietary supplements are receiving increasing
recognition as being beneficial in various conditions such as
ischaemic heart disease, malignancy, osteoporosis and chronic
and degenerative diseases such as diabetes, Alzheimer’s or
Parkinson’s.5 The industry has met with considerable monetary
success, partly owing to the increasing momentum in popularity of
all things natural pertaining to health and wellbeing, and the trend
away from traditional medicinal products by much of the Western
and Asian worlds.6 The US, Japan and India are responsible for
the vast majority of nutracuetical consumption and this mammoth
industry is continuing to gain momentum, growing at 7-12% per
annum.7 There is an abundance of skepticism among medical
professionals surrounding this concept as these foods are not
classified as drugs or medical devices and minimal regulation
governs their use. The research studies supporting these claims
are somewhat limited.8 This article is a succinct review of the
24
The ageing trajectory of the skin’s dermis and epidermis could be
roughly divided into two broad categories: intrinsic chronological
ageing and extrinsic ageing, often referred to as photo-ageing,
the latter term coined by Kligman in 1986.9 Chronological ageing
occurs over time – in sun-protected skin – independent of
environmental insults. These are unpreventable changes that
are mainly dependent on the hormonal changes throughout life.
Increasing age presents a progressive decline of a response
to growth factors in keratinocytes and fibroblasts, resulting in a
compromise to their synthetic capacity.10
The macroscopic appearance of such skin is saggy, but smooth
and unblemished. The epidermis is thinner with a normal
stratum corneum and loss of the undulation of the rete ridges,
with increased prominence in vasculatory and fragility.11 The
dermis shows irregularly stored elastin. The collagen synthetic
capacity of the fibroblast is much lower compared to young
(sun-protected) individuals.12 Skin that has suffered the prolonged
subjection to environmental insults, such as UVA and UVB
damage, pollution and smoking, among others, is leathery,
rough, wrinkled and exhibits a variegation of pigment.13 The
sratum corneum has thicker acanthotic epidermal cells and
basal keratinocyte irregularity.10 The dermis shows a depletion
of hyaluronic acid,14 and a reduction and improper orientation
of collagen and elastin fibres. In 1995 Bernstein and Uitto
described, contradictorily, an increase in hyaluronic acid and
glycosaminoglycans in the skin. However, these compounds are
not stored in the papillary dermis.15 The abnormal storage of such
proteins in the dermal extracellular matrix, termed elastosis,16
disallows them to impart their elastic properties. Hyaluronic acid is
hygroscopic, therefore its depletion results in a more dehydrated
skin and thinner dermis. Oxidative stress plays a significant
role in both types of skin ageing, through the potentiation of
matrix metalloproteinases, which accelerate the degradation11,13
and impede the fibroblast’s synthesis of collagen, elastin and
hyaluronic acid, leading to abnormal matrix degradation and the
accumulation of nonfunctional matrix components in the dermis
and epidermis.17 In 1998, Campisi stated that cellular attrition of
replicative senescence is a powerfully protective, albeit imperfect,
mechanism of mitotically active cells against the development of
cancer, also known as tumorigenesis.18
The ageing effect of sugars (fructose and glucose) on the skin is
due to the covalent cross-linking of the amino acids in collagen
and elastin fibres, in an irreversible process termed glycation.19
Aesthetics | August 2014
@aestheticsgroup
Aesthetics Journal
Aesthetics
aestheticsjournal.com
These advanced glycation end products disallow the compounds
to impart their innate properties to the skin.
OBJECTIVES FOR THE USE OF NUTRACEUTICALS
FOR THE IMPROVEMENT OF THE SKIN
Condition
Anti-ageing strategies aim to reduce further damage and
restore the key molecules to the dermis. Prevention of reactive
oxygen species derived damage is achieved through the
employment of various anti-oxidant substances. Evidence
surrounding anti-oxidant theories, their role in the inhibition of
matrix metalloproteinase activity and DNA renewal capability
potentiation is well documented in literature. Replenishment
of the building blocks of the dermal extracellular matrix, i.e
collagen, and glycosaminoglycans through ingested nutrients
is more complex. Skin improvement may be difficult to assess
through discrete objective measurements. An increase in dermal
thickness, skin lustre improvement, increased skin hydration and
a decrease in the depth of fine lines and wrinkles are among
the variables assessed. Patient improvement scales are also
taken into consideration. In vivo studies in rodents examined
the breakdown and absorbance in the gut versus the amounts
of compounds excreted using radiolabelled isotopes, as well as
histological examination of the soft tissues with various staining
methods for the individual compounds under scrutiny.20
The availability of scientific evidence surrounding nutraceuticals
is rapidly improving, however, there remain concerns surrounding
the validation of these products. These include the security of
the composition of such food products, together with the market
of ‘other substances’. Security in composition is also a concern,
along with supply chain, production, storage and sale, definition
and quantification of influence of metabolic aspects, and
regulatory aspects such as the claims definition.21
COMMON NUTRACEUTICAL COMPONENTS FOR
DERMAL PRODUCTS
The skin requires replacement of its components lost through
the ageing trajectory, namely collagen, elastin, hyaluronic acid
and the nutrients to prevent further damage and to halt or stall
further attrition. This latter group includes trace elements, fatty
acids, fish oils and anti-oxidants. Ongoing research provides
evidence of improvement in the skin secondary to the oral
ingestion of nutrients.22 Evidence suggests that the mechanism of
action of such natural compounds exert influence on a wide array
of biological processes, the activation of antioxidant defence
pathways, signal transduction pathways, gene expression
associated with cellular attrition, proliferation and differentiation.5
Collagen
Collagen is a very large molecule, which if ingested in its natural
form, is broken down and its 3-dimensional helical structure
denatured in the gut, hence compromising its bioavailability.
The individual amino acids generated as a by-product of this
process would not be absorbed.23 In order to be absorbed intact,
a smaller molecular moiety is required.
Hydrolysed bovine collagen, at 3kDa per molecule, is an FDA
approved food product. Collagen hydrolysate ingestion stimulates
a statistically significant increase in synthesis of extracellular
matrix macromolecules.24 This is marketed as Arthred. Its
Clinical Practice
CPD Clinical Article
initial indication was for osteo arthritis and rheumatoid arthritis
sufferers, to increase their intra-articular collagen content. Bovine
hydrolysed collagen peptides more closely resemble those of
human collagen, with the predominant amino acids being glycine,
proline, hydroxylysine, lysine and especially hydroxyproline. In
1993, Beuker et al conducted a double-blind, placebo controlled
trial involving 52 athletes to investigate hydroxyproline serum
levels over a four month period. Hydroxyproline was used as a
marker in blood serum to quantify absorption of Arthred. It was
continuously and significantly elevated during supplementation
with Arthred compared to the placebo group, and by week 10
hydroxyproline levels were 200% higher in serum blood tests.25
Bioavailability of Arthred is superior to free form amino acids or
other conventional collagen products due to its low molecular
weight.26 An 11 day study showed that once Arthred is absorbed
it is transported to cartilage, i.e. collagen containing tissue, and
positively stimulates collagen biosynthesis.26 Oesser et al20
compared the time course of hydrolyzed collagen absorption, as
well as its subsequent distribution in various tissues and organs
in mice, via 14C radiolabeled Arthred hydrolysed collagen, to
a control group. Plasma and tissue radioactivity was measured
over 192 hours. 95% of orally administered Arthred hydrolysed
collagen was absorbed within 12 hours. Distribution of Arthred
hydrolysed collagen, compared to the control group, shows
double the accumulation of Arthred hydrolysed collagen in
collagen containing tissue such as cartilage.20
Proksch et al27 conducted another double blind placebo
controlled trial with 114 women aged 45-65 years old with Bovine
hydrolysed collagen or placebo for eight weeks. After this time
the bovine hydrolysed collagen group significantly reduced eye
wrinkle volume between 20-49.9%. Pro-collagen type I increased
by 65% while elastin increased by 18%. A positive long-lasting
effect was also observed four weeks after the last bovine
hydrolysed collagen administration.
Hyaluronic acid
Hyaluronic acid (HA) is a mucopolysaccharide comprised of
tandem repeats of D-glucuronic acid and N-acetyl glucosamine.28
Benefits of exogenous HA are limited due to its high molecular
weight and generally positive results are via injectable form only.28
Synovoderma is formulated via a proprietary, patented enzymatic
process that reduces the molecular weight of HA from 1200–1500
kDa to 50-200 kDa, making Synovoderma hyaluronic acid highly
absorbable and bio-absorbable, and is available in oral form.29
Sato et al have found that ingested HA supplementation identical
to Synovoderma is directly correlated to measured increases
in skin moisture, increased skin smoothness, and amelioration
of wrinkles. A double blind study was carried out wherein 35
subjects, who frequently suffer from dry, rough skin were given
either a dietary HA supplement or a placebo over a four week
period. The results showed that the group who had ingested HA
had a significant increase in skin moisture.
Microscopic skin surface analysis also showed an increase in skin
smoothness and lessening of wrinkles. 30
Anti-oxidants
Dietary anti-oxidants such as grape seed proanthocyanidins,
resveratrol, apigenin, curcumin, silymarin, and green tea
polyphenols, protect against free radical damage. Flavonoids and
ellagic acid have been shown to attentuate the action
Aesthetics | August 2014
25
Clinical Practice
CPD Clinical Article
@aestheticsgroup
of metalloproteinases and improve the appearance of
wrinkles.31 They have also been proven to play a role against
photocarcinogenesis in in vitro and in vivo systems.32 Grape seed
extract in particular, derived from unfermented chardonnay, merlot
and muscadine grapes,33 has been found to be instrumental in the
inhibition of carcinogenesis through a reduction in UVB-induced
oxidative damage and tissue fat content in mice.34 The antioxidant
power of these flavonoids – oligomeric proanthocyanidins – is 20
times greater than vitamin E and 50 times greater than vitamin C.
Abundant research supports the theory that grape seed extract
is beneficial to skin health because of its capability of bonding
with collagen, promoting youthful skin, cell health, elasticity,
and flexibility.35 Phenolic compounds which include catechins,
epicatechin and some dimers and trimers are also found in
abundance in grape seeds.36 Peroxyl radical scavenging activities
of phenolics present in grape seeds or skins, in decreasing order,
were resveratrol, catechin, epicatechin, gallocatechin, gallic
acid and ellagic acid. The results indicated that dimeric, trimeric,
oligomeric, or polymeric procyanidins account for most of the
superior antioxidant capacity of grape seeds.31
Resveratrol (3,5,40-trihydroxystilbene), a polyphenol also derived
from grape skin (Vitis vinifera) and in a variety of berries, peanuts,
and medicinal plants, such as Japanese knotweed, has recently
been on the receiving end of a plethora of attention.37 In vitro
studies show resveratrol’s protective properties towards normal
human fibroblasts, from the damaging effects of hydrogen
peroxide, in a dose-dependent manner.38 A 12-week, doubleblind, placebo controlled study of 60 women found that green tea
catechins (active polyphenol, found in green tea extract) are able
to improve skin characteristics, including elasticity, roughness,
scaling, density, and water content. Additionally, less UV radiation
damage was seen in the group that was supplemented with
green tea catechins. The study also showed that after 12 weeks,
oral green tea extract boosted oxygen flow to the skin.39 In
vitro and in vivo studies suggest that green tea polyphenols
(particularly epigallocatechin-3-gallate) are photo-protective in
nature and, in the future, may be employed as pharmacological
agents for the prevention of UVB light-induced skin disorders,
such as photo-aging, melanoma and non-melanoma skin
cancers.40 Alpha lipoic acid is a water and fat-soluble antioxidant
that is capable of regenerating other antioxidants, such as
vitamins C and E.41 In vitro research on humans in cell-culture
systems show that following oral ingestion, the acid helps to
prevent cellular damage. By protecting fibroblasts this helps to
slow down the ageing process in the skin and stimulate repair.
Ascorbic acid (vitamin C) appears capable of overcoming the
reduced proliferative capacity of elderly dermal fibroblasts,
as well as increasing collagen synthesis in elderly cells.42 It is
an essential cofactor for hydroxylases needed for collagen
biosynthesis, as it stimulates collagen specific mRNA for collagen
synthesis.
Trace elements
The synthesis of mature elastin and collagen take place and
is controlled by the availability of copper. A dietary deficiency
can induce defective crosslinking of collagen and elastin, which
in turn can cause problems such as premature ageing and
wrinkling of the skin. It is an essential cofactor for activation and
synthesis of lysyl oxidase, which is the only enzyme involved in
healthy collagen crosslinking.43 Manganese is required for the
26
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activation of prolidase, an enzyme that functions to provide the
amino acid, proline, for collagen formation in human skin cells.
It is an essential cofactor for the glycosylation of hydroxylysine.
This process strengthens newly formed collagen molecules and
influences its fibril size. The highest glycosylation enzymes are
found in the young and decrease with age.44
Manganese superoxide dismutase is integral to the mitochondrial
reactive oxygen species formation and has been proven to be
instrumental in skin ageing.45 Zinc is a cofactor for procollagen
N-Proteinase & procollagen C-Proteinase, whose role is to
produce procollagen, the precursor to collagen.
The rate of collagen breakdown is decreased by the
administration of zinc.46 Zinc deficiency results in significant
reduction of collagen synthesis and turnover, and thus poor
wound healing due to poor quality collagen formation. It is a
useful nutrient for combatting intrinsic and extrinsic skin ageing
factors by enabling superoxide dismutase, an antioxidant enzyme,
to help protect against oxidative stress.47
Fatty acids
Fish oils have long been known for their beneficial effects.
A pilot study carried out by Segger et al48 found that a dietary
supplement rich in fish oils, known as the Eskimo Skin Care,
examined the hypothesis that supplementation with an oral oil
formulation rich in natural stable fish oil can alter skin elasticity,
transepidermal water loss (TEWL), and skin roughness in
healthy women. This single-blind randomised trial revealed an
improvement in skin elasticity but no change in texture.
A mild increase in skin hydration was noted.
NUTRACEUTICALS
Nutraceuticals often contain a variety of such compounds.
Various studies on different combinations are underway to
determine optimal synergistic combinations of compounds to
yield the maximal restorative and preventative benefits to the
dermis and epidermis. Udompataikul et al8 studied the impact
of a nutraceutical containing minerals, antioxidants, and glycosamino-glycans on cutaneous ageing. This was a double-blind,
placebo-controlled trial involving 60 women between the
ages of 35 to 60 years, over 12 weeks. It showed a statistically
significant improvement in the skin smoothness and fine wrinkles
in the treatment group, with a 21.2% improvement versus a 1.7%
improvement in the placebo group. Similarly patients reported
a statistically significant reduction in pore size and improvement
in texture and rhytids, however they noted there was no change
in pigment. An earlier preliminary study in 2001 showed that
oral supplementation of a combination of glucosamine, amino
acids, minerals and anti-oxidants had the potential to improve
visible wrinkles. However, it did not have any effect on the
epidermal hydration.49 In 2004 Segger and Schönlau studied
the effects of Evelle, a nutritional supplement containing
vitamins E and C, carotenoids, selenium, zinc, amino acids and
glycosaminoglycans, blueberry extract and pycnogenol on 62
women in a double-blinded, randomised placebo-controlled trial.
It was found that skin roughness decreased and skin elasticity
increased significantly.50 DermaVite, a preparation containing
marine proteins, alpha-lipoic acid, pine bark extract, vitamins and
minerals was studied in 40 women with symptoms of ageing
skin in 2005.51 Objective measurements included skin thickness,
elasticity wrinkles, roughness and teleangiectasia. Changes were
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evaluated after two, four and six months’ treatment. A statistically
significant improvement was seen when compared to placebo,
and it was concluded that it was a useful oral supplement to
combat cutaneous ageing.51 A six month double blind, placebo
controlled, randomised study on healthy post-menopausal
females was performed, examining the cutaneous changes
following the ingestion of a dietary supplement that contained
soy extract, fish protein polysaccharides, extracts from white tea,
grape seed and tomato, vitamins C and E as well as zinc and
chamomile extract – Imedeen Prime Renewal. Photo evaluation
and ultra-sound evaluation showed a statistically significant
improvement in proved condition, structure and firmness of the
skin in the facial, peri-orbital, neck and décolletage areas.52
LIMITATIONS
Nutraceuticals still face many challenges until their efficacy is
proven further. Generally, these products are safe and well
tolerated, however interpretation of the collective results tend to
be heterogenous and inconsistent, and reconcile an apparent
structural benefit with absence or modest effect on symptoms
remains a conundrum.53 With regard to anti-oxidant needs, the
normal blood oxidative stress parameters in a given individual
have not yet been objectively established. Hence antioxidant
or other dietary supplementation dosaging remains a rather
grey area.22 Nutritional factors are certainly instrumental in
exerting promising actions on the skin, however clinical evidence
pertaining to the effects of low-to-moderate doses of nutrients,
consumed long term by healthy individuals, is lacking in the
literature available, as is data on direct effects on basal skin
properties, including hydration, sebum production, and elasticity.2
Due to a relative lack of hard evidence and an absence of
regulation, consumers are given little direction to objectively
assess the vast array of health claims that adorn most
nutraceuticals’ packaging and marketing schemes.54
As the fields relating to nutritional skin care further expand their
scope into the beauty sector and the age reversal phenomenon,
the introduction of regulatory agencies will become warranted.
A multi-disciplinary approach combining medical, nutritional and
dietary professional input is needed in order to treat and prevent
the ageing integument.
REFERENCES:
1. Kalra E, ‘Nutraceutical--definition and introduction’, AAPS Pharmaceutical Science, 5 (2003), p.25.
2. Boelsma E, Hendriks H, Roza L, ‘Nutritional skin care: health effects of micronutrients and fatty acids’, American Journal of Clinical Nutrition, 73 (2001), 853-864.
3. Ramaa C, Shirode A, Mundada A, Kadam V, ‘Nutraceuticals – an emerging era in the treatment and prevention of cardiovascular diseases’, Current Pharmaceutical Biotechnology, 7 (2006), 15-23.
4. Misra L, ‘Traditional Phytomedicinal Systems, Scientific Validations and Current Popularity as Nutraceuticals’, International Journal of Traditional and Natural Medicines, 2 (2013), 27-75.
5. Mandel S, Packer L, Youdim M, Weinreb O, ‘Proceedings from the “Third International Conference on Mechanism of Action of Nutraceuticals”’, Journal of Nutritional Biochemistry, 16 (2005), 513-520.
6. McFadden K, Hernández T, Ito T, ‘Attitudes Towards Complementary and Alternative Medicine Influence Its Use’, Explore New York, 6 (2010), 380-388.
7. Pandey M, Rastogi S, Raway A, ‘Indian Traditional Ayurvedic System of Medicine and Nutritional Supplementation’, Evidence Based Alternative Complementary Medicine, 1 (2013)
8. Udompataikul M, Sripiroj P, Palungwachira P, ‘An oral nutraceutical containing antioxidants, minerals and glycosaminoglycans improves skin roughness and fine wrinkles’, International Journal of Cosmetic Science, 31 (2009), 427-437.
9. Kligman L, Kligman A, ‘The nature of photoageing: its prevention and repair’, Photodermatology, 3 (1986), 215–227.
10. Gilchrest B, ‘A review of skin aging and its medical therapy’, British Journal of Dermatology, 135 (1996) 867–875.
11. Mukherjee S, Date A, Patravale V, Korting H,Roeder A, Weindl G, ‘Retinoids in the treatment of skin aging: an overview of clinical efficacy and safety’, Clinical Interventional Ageing, 1 (2006), 327-348.
12. Varani J, Dame M, Rittie L, Fligiel S,Kang S,Fisher G,Voorhees J, ‘Decreased Collagen Production in Chronologically Aged Skin’, American Journal of Pathology, 168 (2006), 1861-1868.
13. Kang S, Fisher G, Voorhees J, ‘Photoaging: Pathogenesis, prevention and treatment’, Clinical Geriatric Medicine, 17 (2001), 643–659.
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FUTURE DIRECTIONS
As research into the science of nutraceuticals progresses, efforts
appear to be concentrating on nutrigenomic concepts.
Nutritional interventional studies are underway on a large scale.
They aim to provide individuals who are genetically at risk of
developing metabolic or degenerative disease the opportunity to
practice preventative health through nutraceauticals.55
This concept will in no doubt be applied to the anti-ageing milieu.
Metabolomics is another novel concept in the prevention or
stalling of the skin’s ageing trajectory.
This science seeks to provide direction for intervention and
nutrition through the examination of blood and tissue metabolite
under defined conditions.56 Dietary antioxidant vitamins, minerals,
and phytochemicals in addition to n-3 polyunsaturated fatty
acids, n-9 monounsaturated fatty acids, and low pro-inflammatory
n-6 polyunsaturated fatty acids, have demonstrated protective
properties against UV radiation.57
Harnessing this phenomenon to provide ingestible sun protection
is an avenue currently under intense exploration.
The development of an orally-administered systemic agent,
that could reduce the effects of UV exposure on skin, could
potentially modulate the photo-ageing trajectory, as well as play a
pivotal role in the prevention of skin malignancies.58
CONCLUSION
The demand for preventative and curative anti-ageing skin
treatments, both traditional and non-traditional, will continue
to grow. A growing body of evidence provides a rationale for
the use of nutraceuticals for this indication. It would appear
that ingesting specific ingredients really can create anti-ageing
solutions ‘from within’. Ongoing and future research will provide
the necessary data for nutraceuticals to be more specific, of
optimal quality and high purity in order to ensure therapeutic
levels are bioavailable for body utilisation within the skin.
Dr Raina Zarb Adami is a Maltese surgeon whose private
practice, Aesthetic Virtue, is dedicated to non-invasive
facial aesthetic medicine. She is the medical director of
The Academy of Aesthetic Excellence, which provides
foundation and advanced training courses in Aesthetic Medicine to
medical professionals.
14. Dai G, Freudenberger T, Zipper P, Melchior A, Grether-Beck S, Rabausch B, de Groot J, Twarock S, Hanenberg H, Homey B, Krutmann J, Reifenberger J, Fischer JW, ‘Chronic ultraviolet B irradiation causes loss of hyaluronic acid from mouse dermis because of down-regulation of hyaluronic acid synthases, American Journal of Pathology, 171 (2007), 1451-1461.
15. Bernstein E, Uitto J, ‘Connective tissue alterations in photoaged skin and the effects of alphahydroxy acids’, Journal of Geriatric Dermatology, 3 (1995), 7-18.
16. Laga A, Murphy G, ‘The Translational Basis of Human Cutaneous Photoaging’, American Journal of Pathology, 174 (2009), 357-360.
17. Pillai S, Oresajo C, Hayward J, ‘Ultraviolet radiation and skin aging: roles of reactive oxygen species, inflammation and protease activation, and strategies for prevention of inflammation-induced matrix degradation’, International Journal of Cosmetic Science, 27 (2005), 17-34.
18. Campisi J, ‘The Role of Cellular Senescence in Skin Aging’, Journal of Investigative Dermatology Symposium Proceedings, 3 (1998), 1-5.
19. Danby F, ‘Nutrition and aging skin: sugar and glycation’, Clinics in Dermatology, 28 (2010), 409-411.
20. Oesser S, Adam M, Babel W, Seifert J, ‘Oral Administration of 14C Labeled Gelatin Hydrolysate Leads to an Accumulation of Radioactivity in Cartilage of Mice (C57/BL)’, The Journal of Nutrition, 129 (1999), 1891-1895.
21. Nicoletti M, (2012) ‘Nutraceuticals and botanicals: overview and perspectives’, International Journal of Food, Science and Nutrition, 63 (2012), 2-6.
22. Ravi Subbiah M, ‘Application of Nutrigenomics in Skin Health Nutraceutical or Cosmeceutical?’, Journal of Clinical Aesthetic Dermatology, 3 (2010), 44-46.
23. Mullen W, Edwards C, Serafini M, Crozier A, ‘Bioavailability of pelargonidin-3-O-glucoside and its metabolites in humans following the ingestion of strawberries with and without cream’, Journal of Agricultural Food Chemistry, 56 (2008) 713-719.
24. Bello A, Oesser S, ‘Collagen hydrolysate for the treatment of osteoarthritis and other joint disorders: a review of the literature’, Current medical Research and Opinion, 22 (2006), 2221-2232.
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25. Beuker F, Stehle P, Ritsch M, Theel H, ‘The influence of regular gelatin substitution at the amino acid levels in blood plasma’, Ernährungs-Umschau, 5 (1993), 40-64.
26. Oesser S, Seifert J, ‘Stimulation of type II collagen biosynthesis and secretion in bovine chondrocytes cultured with degraded collagen’, Cell and Tissue Research, 311 (2003), 393-399.
27. Proksch E, Segger D, Degwert J, Schunck M, Zague V, Oesser S, ‘Oral supplementation of specific collagen peptides has beneficial effects on human skin physiology: a double-blind, placebo-controlled study’, Skin Pharmacology and Physiology, 271 (2014), 47-55.
28. Tashiro T, Seino S, Sato T, Matsuoka R, Masuda Y, Fukui N, ‘Oral Administration of Polymer Hyaluronic Acid Alleviates Symptoms of Knee Osteoarthritis: A Double-Blind, Placebo-Controlled Study over a 12-Month Period’, Scientific World Journal, 1 (2012).
29. SynovoDerma 150 Softgels (Allergan Research Group, 2014) http://www.allergyresearchgroup.com/
SynovoDerma-150-Softgels-p-236.html [15/7/14].
30. Sato T, Sakamoto W, Odanka W, Yoshida K, Urishibata O, ‘Clinical Effects of Dietary Hyaluronic Acid on dry, rough skin’ Aesthetic Dermatology, 12 (2002), 109-120.
31. Bae J, Choi J, Kang S, ‘Dietary compound ellagic acid alleviates skin wrinkle and inflammation induced by UV-B irradiation,’ Experimental dermatology, 19 (2010), 182-190.
32. Baliga M, Katiyar S, ‘Chemoprevention of photocarcinogenesis by selected dietary botanicals’, Photochemical and Photobiological Sciences: Official Journal of the European Photochemical Association and the European Society for Photobiology, 5 (2006), 243-253.
33. Yilmaz Y, Toledo R, ‘Major flavonoids in grape seeds and skins: antioxidant capacity of catechin, epicatechin, and gallic acid’, Journal of Agricultural and Food Chemistry, 52 (2004), 255-260.
34. Mittal A, Elmets C, Katiyar S, ‘Dietary feeding of proanthocyanidins from grape seeds prevents photocarcinogenesis in SKH-1 hairless mice: relationship to decreased fat and lipid peroxidation’, Carcinogenesis, 24 (2003), 1379-1388.
35. Shi J, Yu J, Pohorly J, Kakuda Y, ‘Polyphenolics in grape seeds-biochemistry and functionality’, Journal of Medicinal Food, 6 (2003), 291-299.
36. Xia E, Deng G, Guo Y, Li H, ‘Biological Activities of Polyphenols from Grapes’, International Journal of Molecular Science, 11 (2010), 622-646.
37. Buonocore D, Lazzeretti A, Tocabens P, Vincenzo Nobile V, Cestone E, Santin G, Bottone M, Marzatico F, ‘Resveratrol-procyanidin blend: nutraceutical and antiaging efficacy evaluated in a placebo controlled, double-blind studY’, Clinical Cosmetic Investigative Dermatology, 5 (2012), 159-165.
38. Jagdeo J, Adams L, Lev Tov H, ‘Dose-dependent antioxidant function of resveratrol demonstrated via modulation of reactive oxygen species in normal human skin fibroblast in vitro’, Journal of Drugs and Dermatology, 9 (2010), 1523-1526.
39. Heinrich U, Moore C, De Spirt S, Tronnier H, Stahl W, ‘Green tea polyphenols provide photoprotection, increase microcirculation, and modulate skin properties of women’, The Journal of Nutrition, 141 (2011), 1202-1208.
40. Katiyar S, ‘Skin photoprotection by green tea: antioxidant and immunomodulatory effects’, Current Drug Targets. Immune, Endocrine and Metabolic Disorders, 3 (2003), 234-242.
41. Roy S, Packer L, ‘Redox regulation of cell functions by alpha-lipoate: biochemical and molecular Clinical Practice
CPD Clinical Article
aspects’, Biofactors, 7 (1998), 263-267.
42. Phillips C, Combs S, Pinnell S, ‘Effects of ascorbic acid on proliferation and collagen synthesis in relation to the donor age of human dermal fibroblasts’, Journal of Investigative Dermatology, 103 (1994), 228-232.
43. Romero-Chapman N, Lee J, Tinker D, Uriu-Hare JY, Keen CL, Rucker RR, ‘Purification, properties and influence of dietary copper on accumulation and functional activity of lysyl oxidase in rat skin’, Biochemistry Journal, 275 (1991), 657-662.
44. Anttinen H, Oikarinen A, Kivirikko K, ‘Age-related changes in human skin collagen galactosyltransferase and collagen glucosyltransferase activities’, Clinical Chim Acta, 76 (1977) 95-101.
45. Treiber N, Maity P, Singh K, Ferchiu F, Wlaschek M, Scharffetter-Kochanek K, ‘The role of manganese superoxide dismutase in skin aging’, Dermatoendocrinology, 4 (2012), 232-235.
46. Tengrup I, Ahonen J, Zederfeldt B, ‘Influence of zinc on synthesis and the accumulation of collagen in early granulation tissue’, Surgery, Gynaecology and Obstetrics. 152 (1981), 323-326.
47. Aricioglu A, Bozkurt M, Balabanli B, Kilinç M, Nazaroglu N, Türközkan N, ‘Changes in zinc levels and superoxide dismutase activities in the skin of acute, ultraviolet-B-irradiated mice after treatment with ginkgo biloba extract’, Biological Trace Element Research, 80 (2001), 175-179.
48. Segger D, Matthies A, Saldeen T, ‘Supplementation with Eskimo Skin Care improves skin elasticity in women. A pilot study’, Journal of Dermatological Treatments, 19 (2008), 275-283.
49. Murad H, Tabibian M, ‘The effect of an oral supplement containing glucosamine, amino acids, minerals, and antioxidants on cutaneous aging: a preliminary study’, Journal of Dermatological Treatments, 12 (2001), 47-51.
50. Segger D, Schönlau F . ‘Supplementation with Evelle improves skin smoothness and elasticity in a double-blind, placebo-controlled study with 62 women’, Journal of Dermatological Treatments, 15 (2004), 222-226.
51. Thorn E, ‘A randomized, double-blind, placebo-controlled study on the clinical efficacy of oral treatment with DermaVite on ageing symptoms of the skin’, Journal of International Medical Research, 33 (2005), 267-272.
52. Skovgaard G, Jensen A, Sigler M, (2006), ‘Effect of a novel dietary supplement on skin aging in post-
menopausal women’, European Journal of Clinical Nutrition. 60 (2006), 1201-1206.
53. McAlindon T, ‘Nutraceuticals: do they work and when should we use them?’, Best Practice and Research: Clinical Rheumatology, 20 (2006), 99-115.
54. Brower V, ‘A Neutraceutical a Day may keep the doctor away’, European Molecular Biology Organization Report, 5 (2005), 708-711.
55. Kaput J, ‘Developing the promise of nutrigenomics through complete science and international collaborations’, Nutrition, 60 (2007), 209-223.
56. Goodacre R, ‘Metabolomics of a Superorganism’, Journal of Nutritional, 137 (2007), 259-266.
57. Shapira N, ‘Nutritional approach to sun protection: a suggested complement to external strategies’, Nutritional Review, 68 (2010), 75-86.
58. Jackson M, Jackson M, McArdle F, Storey A, Jones S, McArdle A, Rhodes L, ‘Effects of micronutrient supplements on u.v.-induced skin damage’, The Proceedings of the Nutrition Society, 61 (2002), 187-
189.
Clinical Practice
Techniques
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Aesthetics Journal
Mesobotox
Dr Sarah Tonks explores the alternative use of
botulinum toxin to achieve whole-face rejuvenation
Botulinum toxin has been widely used for
facial rejuvenation. Today it is common
for practitioners to treat the whole face
with the toxin, rather than confining it to
individual areas. The traditional discord
seen when the upper face is successfully
treated and the hyperkinetic lower is left
untreated is now increasingly recognised
as a failure of aesthetic result — the
disharmony of the face is a certain giveaway
of cosmetic intervention. It is our job to
educate patients about the use of toxins
and other rejuvenation procedures in the
mid-face, lower-face, neck and décolletage,
as this is something not often covered in the
media and patients may be unaware of the
options. In order to achieve this whole-face,
global change we can use a technique of
dilute botulinum toxin, judiciously placed in
specific areas.
Mesotherapy was introduced as a medical
procedure by Pistor in 1958. It consists
of intradermal injection of pharmacologic
substances that have been diluted, with the
aim of restoring healthy texture of the skin.
Material used can include vitamins, minerals,
enzymes and other reagents. Mesotherapy
promotes rejuvenation by increasing
hydration and activating fibroblasts.1
Hyaluronic acid injected into the skin can
cause fibroblasts to produce collagen type 1,
matrix metalloprotease 1 and tissue inhibitor
matrix metalloprotease 1.1 An additional
study suggested dermal injection of vitamins
causes stimulation of collagen production.2
30
Mesobotox
“Mesobotox” is a term coined for the
application of botulinum toxin by papule
needle injection into the dermis of the skin.
Often these toxins are more dilute than
those traditionally used for treating areas
such as the glabellar, and in some cases
mesotherapy products such as hyaluronic
acid, are added to the mixture. It is the
injection not of specific muscles, but the
treatment of large areas of dermis with
dilute botulinum toxin. Mesobotox has four
advantages and can be used successfully
in people of all skin types. Botulinum
toxin has been shown to decrease sebum
production and improve acne, so can
be used in oily and sebaceous skins.3,4
Botulinum toxin can be used to improve
older skins with fine lines and wrinkles
by diminishing the pull of the facial
depressors, resulting in an improvement of
the facial contour.5
Botulinum toxin blocks production of
eccrine sweat glands which can give a
smoother appearance of the skin.6
The addition of mesotherapy products can
produce an additional benefit to the health
of the skin.1,2
The facial muscles are classified into
levators (frontalis, zygomaticus major and
minor, levator labii superioris, alequai nasi,
anguli oris) and depressors (procerus,
corrugator supercilii, orbicularis oculi,
platysma, depressor anguli oris, depressor
labii inferioris). Levators and depressors
Aesthetics | August 2014
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aestheticsjournal.com
are balanced in younger people but with
ageing, this balance shifts towards the
depressors. By injecting into the dermis,
rather than a muscle, we can reduce the
strength of the depressors. This works
because the facial muscles insert onto the
skin rather than onto bone, so when toxin
is injected into the dermis it blocks the
superficial fibres of the muscle inserted
into the skin. Intradermal injection is
suitable for flat, sheet like muscles rather
than muscle bundles. It can be used where
the skin is lax with poor tone. A flat, thin
muscle, like platysma, has a medium motor
endplate concentration whilst a short, thick
muscle, such as corrugator, has a high
concentration of motor endplates near the
point of injection, influencing the choice of
concentration used for the injections.6
In a study of 275 patients selected for
cheek droop and mid-cheek groove,
24.9% attained high improvement with
the cheeklift, softening of the nasolabial
folds and redefining of the facial contour.5
The pattern of injection can be seen in
figure 1 with the results in figure 2 and 3.
An alternative pattern of injection, more
suitable for oily skin, can be seen in
figure 4. Mesotherapy can be used as an
alternative to the Nefertiti lift, performed
by injecting botulinum toxin into the
platysma and posterior bands to release
the downward pull of the platysma. Those
with poorly defined posterior bands or skin
laxity might not be good candidates, so
the intradermal technique may be useful.
Botulinum toxin blocks eccrine sweat
glands innervated by cholinergic
sympathetic nerve fibres. Apocrine sweat
glands are unaffected, innervated by
adrenergic sympathetic nerve fibres. This
can result in smoother skin after injection.6
Some patients suffer from excessive facial
sweating and use of botulinum toxin for
nasal hyperhidrosis has been reported.7
Some physicians have claimed that
intradermal botulinum toxin injections can
cause collagenesis, although, to date,
no placebo-controlled trial has been
conducted that supports this.8 However
the acetylcholine receptor is present on
the surface of melanocytes, keratinocytes
and other dermal tissue so it is possible
that it may give a wider effect than initially
thought.9
One of the most compelling studies, a
split face study of nine patients, noted a
global improvement in skin texture in six of
the patients, and moderate improvement
in resting and dynamic facial lines, with
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Clinical Practice
Techniques
maximal effect lasting two months.10
Interestingly, histologic samples taken
from this study showed no significant
difference in haematoxylin and eosin
staining with the exception of increased
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Aesthetics Journal
staining density of procollagen. For those
with oily skin, botulinum toxin can offer
relief. Extraneuronal acetylcholine plays
a role in sebum production and sebocyte
differentiation.9 In a study of 25 patients,
aestheticsjournal.com
91% reported a 50-75% improvement in
the oil production.3 In a separate study of
20 patients, 17 noted an improvement in
sebum production and decrease in pore
size.4
Figure 1. Reproduced from
Technique
Injection pattern and reconstitution vary according to the issue
needing treatment and a practitioner’s clinical judgement. To
prepare the skin, it is first cleaned with chlorhexidine while
anatomical landmarks and injection points are marked up, if
lifting the mid-face. For oily skin I use Azzalure, reconstituted
with 130 Speywood units bacteriostatic saline, mixed with 1
ml Filorga NCTF 135HA, applied via a bevel up superficial
nappage technique to the dermis using a 32g, 6mm (TSK)
needle, causing a blanching effect in the skin. Points are
placed approximately 5mm apart and areas with excessive
oiliness, such as the T-zone, are targeted. For drier areas of
skin on the oily face, the remaining 2ml mesotherapy product
is used plain, without the addition of toxin unless facial
sculpting is indicated. Areas such as the cheeks, neck, hands
and décolletage can be targeted. The patient is reviewed at
two weeks and the treatment can be repeated if indicated.
If not, the patient undergoes a further four mesotherapy
treatments using the Filorga NCTF 125HA alone, in order to
derive the maximum benefits from mesotherapy.
For patients with mid-face droop, the skin can be assessed
by pulling it in the direction of the contraction of platysma
to determine the strength of the depressor muscles and
points of injection. Here I use Azzalure reconstituted with
bacteriostatic saline and applied to the dermis with a 34g,
8mm needle (Japan Bio Products), into predetermined
injection points, causing blanching. For the platysma the
first row starts from the TMJ down the mandibular joint at
1cm intervals. The second row is placed 1cm superiorly to
this with the injection points between the ones beneath.
The lateral orbicularis oculi injections are made across the
lateral border of the muscle in the temporal area, as seen in
figure 1. Each injection placed in the superficial dermis should
cause blanching of approximately 3-4mm diameter. For these
patients I use Azzalure reconstituted with 130 Speywood
units. Bacteriostatic saline is mixed with Filorga 135HA in
a 1:1 ratio and is applied to the remaining skin, as seen in
figure 4. Practitioners’ should use their clinical judgement
to decide which areas of the patient’s face would benefit
from treatment. The most common areas are the cheeks
and forehead. The remaining Filorga is used plain in other
areas such as the hands and décolletage. The patient is
then reviewed at two weeks and a further four sessions of
mesotherapy are carried out. A clinical judgement should be
made to decide whether to add more toxin at the follow up
or not.
“Mesobotox” is a safe way of improving the texture and tone
of the skin, often giving a subtler and more global result
compared with using botulinum toxin in the upper face alone.
It is a way of bridging the gap for patients who are not ready
to make the jump into having traditional dermal fillers and
botulinum toxin.
32
Aesthetics
‘Midface lifting with botulinum toxin:
intradermal technique’, Journal of
Cosmetic Dermatology 2009;8:312-6. C
Petchnagaovilai.
Figure 2. Reproduced from
‘Midface lifting with botulinum toxin:
intradermal technique’, Journal of
Cosmetic Dermatology 2009;8:312-6. C
Petchnagaovilai.
Figure 3. Reproduced from
‘Midface lifting with botulinum toxin:
intradermal technique’, Journal of
Cosmetic Dermatology 2009;8:312-6. C
Petchnagaovilai.
Figure 4. Reproduced from ‘The
wrinkles soothing effect on the middle
and lower face by intradermal injection
of botulinum toxin type A’, International
Journal of Dermatology 2008; 47:12871294. SH Chang, HH Tsai, WY Chen, WR
Lee, PL Chen.
REFERENCES
1. F Gao, Y Liu, Y He, Y Wang, X Shi, G Wei, ‘Hyaluronan oligosaccharides promote excisional wound healing through enhanced angiogenesis.’ Matrix Biologu 29 (2010), 107-116.
2. JC Geesin, LJ Hendricks, PA Falkenstein, JS Gordon, RA Berg. ‘Regulation of collagen synthesis by ascorbic acid: Characterization of the role of ascorbate- stimulated lipid peroxidation.’ Archives of Biochemisty and biophysics 290 (1991), 127-132.
3. Rose, DJ Goldberg, ‘Safety and efficacy of intradermal injection of botulinum toxin for the treatment of oily skin’ Dermatological Surgery, 39 (2013), 443-448.
4. AR Shah, ‘Use of intradermal botulinum toxin to reduce sebum production and facial pore size’, Journal of Drugs in Dermatology, 7 (2008), 847-850.
5. C Petchnagaovilai, ‘Midface lifting with botulinum toxin: intradermal technique’, Journal of Cosmetic Dermatology, 8 (2009), 312-316.
6. C Le Louarn. ‘Botulinum toxin A and facial lines: The variable concentration’, Aesthetic Plastic Surgery, 25 (2001), 73-84.
7. MI Tammi, AJ Day, EA Turley, ‘Hyaluronan and homeostasis: A balancing act’, Journal of Biological Chemistry, 277 (2002), 4581-4594.
8. H Kurzen, KU Schallreuter. ‘Novel aspects in cutaneous biology of acetylcholine synthesis and acetylcholine receptors’, Experimental Dermatology, 13 (2004, 27-30. H Kurzen, KU Schallreuter.
9. E Geddoa, AK Balakumar, TRF Paes, ‘The successful use of botulinum toxin for the treatment of nasal hyperhidrosis’, International Journal of Dermatology 47 (2008) 1079-1080.
10. SH Chang, HH Tsai, WU Chen, WR Lee, PL Chen, TH Tsai. ‘The wrinkles soothing effect on the middle and lower face by intradermal injection of botulinum toxin type A’, International Journal of Dermatology 47 (2008), 1287-1294. SH Chang, HH Tsai, WU Chen, WR Lee, PL Chen, TH Tsai.
Aesthetics | August 2014
Dr Sarah Tonks is an aesthetic doctor and
previous maxillofacial surgery trainee with
dual qualifications in both medicine and
dentistry. She practises cosmetic injectables
and hormonal based therapies.
ELEGANT • FULFILLED • MY TIME
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 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: November 2013.
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 medical.information@merz.com or on +44 (0) 333 200 4143.
1. Bocouture 50U Summary of Product Characteristics. Bocouture SPC 2012 September Available
from: URL: http://www.medicines.org.uk/emc/medicine/23251. 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.
1139/BOC/NOV/2013/LD Date of preparation: March 2014
Clinical Practice
Clinical Focus
@aestheticsgroup
Allie Anderson speaks to practitioners
about the role of primed skin in the run
up to an aesthetic procedure
Optimised skin health:
preparing the skin
before a procedure
It’s said that beauty is only skin-deep, but when it comes to
medical aesthetics it seems the two are irrevocably entwined.
Beauty – in the aesthetic sense at least – fundamentally entails
healthy skin, and there is an ever-increasing appreciation, by
both practitioners and patients, of the association between inner
health and outer beauty. No wonder, then, that optimum skin
condition, both on the surface and from the inside, is fundamental in
performing a successful aesthetic treatment.
“When patients come to you, they have to appreciate that they have
a certain canvas, and there’s only so much fillers and Botox can do
for you,” says consultant dermatologist Dr Sandeep Cliff. “People
seem to think that these treatments are a panacea for complete skin
rejuvenation. But if you’re given a poor canvas, then while you can
make some improvements, you’re not going to get the ‘wow factor’
that many patients are hoping for.”
Dr Cliff highlights the importance of looking after the skin, not just
in the run-up to a treatment, but as a preventative measure from a
young age. This maximises the quality of the facial canvas should a
patient decide to undergo a procedure to improve or enhance their
appearance later in life.
PREPARATION IS PARAMOUNT
Practitioners employ different protocols to boost skin health in the
weeks and months leading up to an aesthetic treatment. Some less
intensive treatments, such as fillers, botulinum toxin and superficial
peels, require very little preparation at home according to Dr Cliff.
Although he sometimes recommends a topical solution six to
eight weeks before the planned treatment to even out the skin’s
34
Aesthetics Journal
Aesthetics
aestheticsjournal.com
texture. “I tend to use a range which includes antioxidant-containing
cleansers to improve texture. By using topical antioxidants in
combination with fillers and Botox, you’ll have the best of both
worlds, enhancing the deeper structures of the skin and its
superficial texture.”
Preparation for the application of chemicals, on the other hand, is
generally aimed at acclimatising the skin to the active ingredients,
says Dr Rabia Malik, a specialist in chemical peels. “There’s a
whole spectrum of different concentrations and various depths of
penetration depending on the type of treatment,” she comments.
“Anything more than a superficial peel requires a minimum of two
weeks’ preparation.” This typically involves patients using vitamins
A and C topically, as well as, in some cases, including a form of
alpha hydroxy acid in their homecare regime. “Using the peel in
the homecare regime conditions the skin for the stronger in-clinic
treatment,” says Dr Malik.
KNOWING YOUR PATIENTS
As the benefits of a holistic approach to medical aesthetics
are becoming more widely acknowledged, practitioners are
increasingly promoting a ‘whole-patient’ approach to treatment.
Rather than simply employing a quick-fix solution to an aesthetic
symptom, says consultant nurse practitioner Constance Campion,
the focus ought to be on delivering a “patient-orientated
symphony of care”, with the skin at its core. “The skin is the
mirror of the mind, body and soul,” Constance says, “so it’s a key
indicator to what’s going on with a patient.”
A thorough assessment, including an in-depth skin analysis and
comprehensive consultation, is therefore the first step in preparing
for a treatment. Not only does this process reveal whether
additional skin enhancement or skin health restoration is indicated,
it can also bring to the fore more fundamental issues in a patient’s
life, such as unhealthy diet, lack of sleep, and poor mental (and
sometimes physical) health – all of which need to be addressed
before a treatment can be undertaken. “As a nurse, I’m responsible
for the physical, spiritual and emotional needs of my patients,”
Constance adds. “Does care go out of the window because we’re
in aesthetics? I don’t think so.”
Getting to know your patients will also help guide the nature of the
skincare regime you recommend for them to carry out at home,
in the run-up to a treatment. Generally speaking, patients who
are spending a lot of money in clinic are keen to take on board
a practitioner’s advice and do whatever they can to optimise the
results of their procedure, however onerous the regime. For Dr
Cliff, keeping things simple is essential. “Gone are the days when
patients expect to apply one cream and then another; nobody
wants anything too complicated,” he says. “I advise patients to use
an emollient moisturiser that contains sun block in the morning,
and some sort of topical antioxidant with added retinoid in the
evening, to allow the skin to rehydrate and rejuvenate.”
Dr Charlene DeHaven, clinical director of California-based
Innovative Skincare, believes that aligning a patient’s regime with
their existing skincare preferences is crucial. “Some patients are
‘minimalists’ and will not take the time to apply a large number of
products. Multi-tasking products will be recommended for them,”
she says. “Others are ‘power users’ and are quite willing to spend
a great deal of time on skin regimes and are willing to use multiple
products.”
According to Dr DeHaven, reputable products with a proven
track record, the quality of which can be backed up by extensive
Aesthetics | August 2014
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Not for use in the U.S. market. © 2013. All rights reserved. eTwo, Sublative and CO2RE are trademarks of Syneron Medical, Ltd. Syneron and the Syneron logo, Candela and the Candela logo are registered trademarks. PB81281EN
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Not for use in the U.S. market. © 2013. All rights reserved. eTwo, Sublative and CO2RE are trademarks of Syneron Medical, Ltd. Syneron and the Syneron logo, Candela and the Candela logo are registered trademarks. PB81281EN
Clinical Practice
Clinical Focus
@aestheticsgroup
experience and
training, are essential.
Most notable is a
good, thorough yet
gentle cleanser to
exfoliate whilst also
cleaning pores,
alongside one or
more other topical
products such as
serums, gels and
creams that contain
various cosmeceutical
‘actives’. Dr DeHaven
adds that, in general,
“the regime should
address and
achieve optimising
epithelial turnover
to physiologically
more youthful values.
It should improve
Skin preparation with Innovative Skincare
skin cell metabolism,
internal hydration and
surface dryness. Improving fine lines and wrinkles as much as
possible is also important so that further gains may be achieved
via the procedure, lessening uneven pigmentation, decreasing
pore size, and improving skin texture.”
Equally important is making sure patients know what to avoid.
At the top of the list is excess sun exposure, which as well as
increasing the risk of skin cancer, will also thin the skin, causing
inflammation and discolouration – giving the skin a mottled and
rough texture. “Patients should also avoid abrasive treatments,
such as microdermabrasion and other types of peels,” says Dr
Malik. “Some patients use bleach to lighten the hair on their face,
but the chemicals in bleach can affect how the active ingredients
in their treatment penetrate the skin, increasing the risk of
interaction and side effects.”
FROM THE INSIDE OUT
Healthy skin relies not just on what we do to it on the outside, but
also how we treat it from the inside. “I believe the skin is an organ,
not a face, and it’s connected to every organ in the body, so every
organ in the body can affect how skin functions,” says Constance,
highlighting the importance of addressing the nutritional needs of
a patient in relation to their skin health, and the treatment they are
undertaking.
“Our dietary choices dramatically affect the health of our skin,
as well as ageing processes,” says nutritionist Kim Pearson.
“Optimising skin health through diet will mean getting the most
out of any aesthetic treatment and its results. It also potentially
helps with healing time and recovery.”
There is a great deal of focus on topical antioxidants to prevent
and combat premature ageing. But increasing the intake of
antioxidants in the diet – by eating more vegetables and lowsugar fruits – can also help to protect the skin’s cells from free
radical damage, noticeably improving skin health. “Fried, burnt
and processed foods, as well as sugars, create free radicals so
eliminating these in the diet in the first place is important,” Kim
says.
36
Aesthetics Journal
Aesthetics
aestheticsjournal.com
Patients seeking treatments to fill wrinkles and plump the skin
may be surprised to learn that collagen can be boosted through
diet too. “Collagen is protein, whether it’s from the skin, or from
chicken, eggs and tofu. Once in the digestive system it’s broken
down into amino acids and distributed throughout the body for
different uses, including maintaining a healthy skin structure,” Kim
explains. She adds that, despite the current trend for collagencontaining drinks to improve skin density and enhance the effects
of medical aesthetic treatments, she believes most people would
see equally good results by increasing their dietary intake of
protein.
Constance also highlights the role of advanced glycation endproducts (AGEs) in causing stiffening, weakening and noticeable
ageing of the skin. AGEs are created through a process called
glycation, whereby sugar molecules bind to the skin’s collagen.
Reducing sugar in the form of refined carbohydrates is thus
very important to skin health. Oily fish, particularly wild salmon,
according to Kim, is a good source of the essential nutrient omega
3, which has anti-inflammatory properties and can help combat
dry skin and maintain a supple complexion. “Supplementing
certain nutrients can also be beneficial,” says Kim. “There are
combinations available that boost a number of skin nutrients,
including vitamins A, C and E, B-vitamins and zinc. Patients should
also look out for supplementary sources of antioxidants, such
as green tea catechins, anthocyanins from dark berries, citrus
bioflavonoids, carotenoids such as lycopene and lutein from
tomatoes, resveratrol from red wine and genistein from soy – all
of which can offer potent protection to the skin.” Nutrition and
diet must be addressed up to several months before an aesthetic
procedure, in order for it to impact its success. In the shorter
term, practitioners should advise patients to maintain hydration
and ensure they are fully recovered from any illness or recent
surgery before placing the body through the stress of additional
treatments. “Rapid weight loss should also be avoided as this
But if you’re given
a poor canvas,
then while you
can make some
improvements,
you’re not going to
get the ‘wow factor’
that many patients
are hoping for.
Aesthetics | August 2014
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IN THE CLINIC
While the success of most procedures relies upon the patient
having adhered to the advice and prescribed regime in the
months and weeks beforehand, there is still room for some
eleventh-hour prepping in the clinic immediately prior to the
procedure. For the likes of botulinum toxin or a volumising
treatment, this usually involves applying a thorough yet gentle
cleanser. “My protocol also includes some light exfoliation,
and I use a device called a Foreo, which uses sonic pulsations
to lift debris from the surface of the skin,” says Dr Malik. “It’s
a similar concept to other cleansing devices, but it’s less
abrasive and more hygienic because it doesn’t use a brush.
With peels, preparation can involve using a degreasing
solution to remove any sebum from the skin.”
In the event that a patient has not been following a
practitioner’s advice, all is not necessarily lost. “Things can
still be done to help, such as extra cleansing, resurfacing or
applying antioxidant serums and anti-inflammatories, as well
as wound healers,” comments Dr DeHaven. “However, in all
medical disciplines, prevention is always better than attempts
at last-minute treatment.” Oral medication, though not typically
necessary except in the case of pre- or post-treatment
infection, is sometimes indicated. “Arnica in tablet form can
be given a few days before dermal fillers and volumisers, and
post-treatment, to prevent bruising,” says Dr Cliff. “I’d also tell
patients to avoid taking aspirin-containing products that are
more likely to make you bleed.”
Dr DeHaven adds that, since the outer layers of skin have
very few blood vessels, medication taken orally tends to
have difficulty reaching these areas. “There are no blood
vessels in the epithelial layer of skin and nutrients must reach
epithelium by the process of diffusion only. In the dermis,
capillaries become much less dense progressing up from
deep to superficial dermis. Orally ingested supplements
are delivered from the gastrointestinal tract to target organ
using the blood vessels. For these reasons, delivery of orally
ingested nutrients is quite small in skin’s outer layers, and so
topical products are essential in optimising results.” Similarly,
Constance takes the view that with the advancement of more
natural, biological solutions one should rarely need to resort
to medication to improve skin health. “For example if we didn’t
use antibiotics in the treatment of acne and instead used the
alternatives that are now available to us, we’d make a huge
contribution in the aesthetics and cosmetic dermatology
arena to reducing antibiotic resistance,” she says.
Skin is an integral part both of a medical aesthetic treatment
itself, and of its result. Adopting a multi-pronged approach
to skin health ultimately means patients will leave the clinic
looking and feeling their best, for as long as possible.
Skin Regeneration
Photographs Courtesy of
V. Gurvits, DO
impairs protein synthesis, which is required for good healing
and tissue regeneration,” comments Dr DeHaven. Skinpolluting agents such as those from traffic fumes and tobacco
smoke can negatively affect skin health. Kim points out that
smoke creates free radicals – unstable molecules that cause
damage to cells and catalyse ageing – and is one of the
main reasons that smokers’ skin ages significantly faster
than that of non-smokers. Patients should therefore consider
cutting down or stopping smoking to encourage healthier
skin, as well as for general well-being.
Clinical Practice
Treatment Focus
@aestheticsgroup
Aesthetics Journal
Cheek Fillers: Anti-Aging
All in One?
Dr Jenna Burton discusses the use of hyaluronic
acid malar enhancement in substituting direct
correction of deepened nasolabial folds, evening
out of jowl formation and lifting of the infra
orbital tear trough deformity through adoption
of the deep ‘bolus technique’.
Migration of Our Cheeks in Aging
As a child our cheeks were high and full of life, spawning “chubby cheek”
taunts, references to ‘puppy fat’ and squeezes from aunts. Gravity however
is unselective. The inverted, bright ‘triangle of youth’ becomes the weary, tired
‘triangle of old age.’ Increasing age brings about lipoatrophy, bone reabsorption
and laxity of ageing membranes. This, in turn, leads to a pseudo herniation of
facial fat over the zygoma and maxilla. As the fat pad migrates downwards and
more medially, skin loses its full supporting framework. It sags and collects, without
structure, around the eyes, cheeks, and mouth. It also gathers bilaterally in a mass
along the mandibular border in the form of jowls.
The tone, elasticity and hydration of the skin obviously plays a large part in
how dramatic the downward migration of facial fat is realised for each particular
individual. Despite this, there is little doubt as to its significant contribution to facial
ageing and attractiveness. 70% of women injected with 1.0cc of hyaluronic acid into
each cheek felt more attractive post-procedure than pre-procedure.1
Aesthetic practitioners appreciated this link between cheek fullness and perceived
attractiveness back in the 16th and 17th century. Artificial cheek implants were
adopted to lift and enhance a woman’s ogee curve in profile. Silver, gold, bone and
leather were trialled to produce crude implants, leading to much complication and
infection. Following many years of research, practitioners these days no longer
need to encourage patients to undergo surgery to create the same enhanced look
in their cheeks.2
Hyaluronic acid is now widely used in place of more artificial substances. This
glycosaminoglycan is distributed widely throughout connective, epithelial and
neural tissue within our anatomy. As a major component of the ground substance
within the reticular dermis, it adds like-for-like and allows for natural movement of
the face, post injection.
However in my experience, few practitioners presently choose to inject cheek
fillers into their patients as a first line treatment. If the loss of voluminous cheeks
Developing tear trough deformity and nasojugal groove, deepend
nasolabial fold, jowl formation and hollowing of the mid face.
38
Aesthetics | August 2014
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over the zygomatic arch plays such a significant role
in facial ageing, and injections of hyaluronic acid
are easy, safe and effective substitutes, this should
certainly be an area addressed more readily during
consultations.
Addressing The Cause, Not The Wrinkle
Patients often present complaining of specific
aesthetic concerns. They complain of their tear
trough deformities, their jowls, lines running along
the side of their cheeks and, most frequently, of their
nasolabial folds.
In order to please the patient, we reach for what they
are expecting. If they hate their nasolabial folds, we
want to ensure they are filled before they leave. If not,
we will have dissatisfied customers. We have stopped
thinking about why they have nasolabial folds and
what more we can do for the patient other than just fill
in the area they do not like.
Filling in the cheeks is an alternative solution to
filling in the nasolabial folds. Tackling the cause of
the problem itself should ensure longer lasting and
more natural results, and lifting of the overall face.
A randomised comparison of the efficacy of low
volume deep placement cheek injection versus mid
to deep dermal nasolabial fold injection technique
for the correction of nasolabial folds was carried out
and published in June 2014.3 The study, published
in Cosmetic Dermatology, concluded that neither
patients nor physicians involved noted a difference in
improvement between correction of nasolabial folds
with either method. Sadly, the study does not mention
whether there were any further benefits gained from
having cheek injections versus direct injection of the
nasolabial folds themselves.
Safety and Anatomy
Subcutaneous fat compartments have been studied
by Rorich and Pessa.4 They confirmed that deep
fat is compartmentalised into discrete anatomical
compartments which are not equally affected
by ageing. The malar fat pad is split into three
compartments; medial, middle and lateral. These
deep fat compartments show greater atrophy with
age than superficial fat, such as the nasolabial and
jowl fat compartments, which can actually increase in
volume as we get older.
Sagging of the arcus marginalis and the orbital
septum allows the aponeurotic fat to bulge. The
malar bag, nasojugal groove and tear trough
deformity that results is not considered aesthetically
pleasing and is associated with an ageing face.
Previous treatments have included cannula or needle
injections of permanent and semi-permanent fillers
in the infra-orbital region. Dr Riekie Smit, president
of the Aesthetic and Anti-Ageing Congress of South
Africa, has commented that filling of the deep cheek
compartments is not only more natural than direct
correction of tear trough deformities via infraorbital
injections, but can also be much safer.
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In Practice
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Dr Reikie Smit - injection of 0.5ml of hyaluronic acid to both cheeks to improve the nasolabial folds and beginning of tear trough deformity.
Tackling the cause of the
problem itself should ensure
longer lasting and more
natural results, and lifting of
the overall face.
Although there have been many instances of success, complications
for the semi-permanent filler range include risk of permanent oedema
and loss of sight5. Use of permanent fillers to this area has been
largely discontinued, and the FDA now only approves permanent
fillers made of polymethylmethacrylate beads, limited to correction of
the nasolabial fold5.
Intricate vasculature surrounding the eye increases the chance
of arterial occlusion and ECM (‘Embolia Cutis Medicamentosa’ or
full thickness necrosis).6 Further complications can be caused by
inadvertent injection of, even a tiny amount, of filler behind the
septum, according to Dr DeLorenzi, who has a private practice in
Kitchener-Waterloo, Ontario. She says, “this can cause persistent
oedema in the lower lids.” Although potentially corrected with
hyaluronase, it raises questions as to whether the same effect can be
had without such risks of vascular occlusion and infra-orbital oedema.
Again, the answer could lie within deep dermal cheek fillers. I believe
that the periosteal layer is a much safer region in which to inject as it
contains fewer arteries and veins, and when combined with aspiration
prior to injection, it reduces risk of arterial occlusion. Injecting a
bolus of hyaluronic acid deep to the zygoma stretches the skin from
below the orbital rim and pulls the tissues tight. Whilst previous fillers
over the malar eminence have concentrated on lateral injections to
highlight the cheekbones, practitioners may forget about injecting
the medial aspect of the cheek. This becomes more important in
later years, secondary to lipoatrophy and bone reabsorption of the
mid-face. Therefore, we should aim to fill the entire cheek. Doing so
should pull the excess skin from around the eyes outwards to look
much tighter and reduce sagging.
Technique
To achieve mid face enhancement for improvement of nasolabial
folds, jowls and tear trough deformity, along with improving the
overall general appearance of the face, there are many techniques
that can be adopted. Professor Alessio Redaelli, cosmetic medical
author7 and faculty member of the American Academy of Aesthetic
40
Medicine recommends the ‘deep bolus technique’.
His approach adopts the theory that your own tissue moves more
naturally than anything that is injected. He recommends injecting
deep, just above the periosteum of the zygoma. This will allow the
hyaluronic acid to sit below the muscle and hence the patient’s own
tissues. Smiling and laughing will recruit movement of their own
muscle and dermal layers without interruption from foreign products.
However, bruising can be common with this technique and it will
often require more hyaluronic acid to achieve noticeable results. If
the needle is inserted right to the depth of the bone, although not
painful, the sensation is not always well tolerated by patients. An
infra-orbital block may be used prior to injection for pain relief, but it
will have little to no effect on this needle to bone sensation.
Many practitioners still believe this is a minor trade off for a safer
procedure, as injections are below major vasculature which avoids
risk of the tyndall effect and gives a much more natural appearance.
Deep Bolus Injection
Important points to note when carrying out a deep bolus injection for
cheek enhancement:
• Counsel patients in how they will look following the procedure,
and manage expectations. To demonstrate how the cheeks will
look, push their current cheek pad upwards from underneath.
• As with all treatments, take oral and written consent.
• Apply local anaesthetic prior to the procedure. This can include
infra-orbital blocks/ice application/Emla cream or nothing at all.
Assess patients individually to determine tolerance.
• Redaelli8 recommends making three to six injections in the
cheek, depending on the patient’s needs.
• Draw a curved line along the malar eminence, approximately
2cm below the infraorbital rim. Along this line, mark three
appropriate points for injection.
• A second line can be drawn 1cm below and parallel to this,
again with three appropriate injection points (usually directly
below the points marked on the line above).
• Using high viscosity hyaluronic acid, inject at 90° to the bone,
just above the periosteum. ‘Grabbing’ and gently squeezing the
tissue to be injected can aid in pain relief as well as assisting
with the direction of the needle.
• Inject an appropriately sized bolus below the muscle layer and
withdraw the needle.
• Mould the material to create a gentle contour along the face.
• Approximately one syringe per cheek (1ml) of high viscosity
filler should be used (shared between the three to six marked
Aesthetics | August 2014
•
•
points.) This again will depend on the individual patient’s
needs.
Most filler is usually distributed over the most lateral point
of malar eminence, then secondly the most medial point
towards the nose. Use the least filler in between the two
extremities, as this area will include some overlap.
Remember that men’s faces have different contours, and
caution is needed not to feminise a male face (unless this
is the desired effect).
Conclusion
Use of the deep bolus technique for lifting of nasolabial
folds, tear trough deformity and overall improved, youthful
appearance is safe, effective and simple to perform.
Little research has been published regarding how jowls can
be affected by this mid-face enhancement. However, many
aesthetic practitioners are already marketing its use to help
even out the mandibular border, suggesting their success with
such a technique. Whilst there is little we can do about the
increasing volume of superficial facial fat as patients age, such
as for nasolabial folds and jowls without the use of cosmetic
surgery, we can consider how we can affect these areas by
correcting the loss of deeper, superior fat compartments In
the cheeks. As hyaluronic acid injections of the mid face are
also associated with an increased feeling of attractiveness1,
patients should not only look younger, but also experience an
increase in self-esteem. Overall it appears that the approach
to dermal fillers may slowly be changing. Practitioners are
attempting medical facelifts rather than simply filling in lines.
Yet it is important to remember that patients do have budgets,
and enhancing the mid-face contours successfully will usually
be a heavier financial burden compared to simply filling in
the infraorbital rim/nasolabial fold or premature jowls. Patient
education is needed to appreciate the cost-effectiveness of
enhancing the face in this way, and to communicate its virtues
as a safe and efficacious treatment.
REFERENCE
1. Amy Forman Taub, ‘Cheek Augmentation Improves Feelings of Facial Attractiveness,’ Journal of Drugs in Dermatology, Volume 11 issue 9 (2012)
2. Dr Neal Handel, Dr Steven Dresner, Dr Randal Howarth, ‘Online Surgery’ (California; www.onlinesurgery.com) <www.onlinesurgery.com/article/history-of-cheek-implants.
html>[accessed 26/6/14] (page 1)
3. Goodie M, Elm K, Wallander I, Zelickson B, Schram S, ‘A randomized Comparison of the efficacy of low volume deep placement cheek injection technique for the correction of nasolabial folds’, Journal of Cosmetic Dermatology, 13(2) (2014), pp. 91-8.
4. Rod J Rohrich, Joel E. Pessa, ‘The Individualised Compartments of the Face. Anatomy and Clinical Indications for Cosmetic Surgery.’ Plastic and Reconstructive Surgery. Volume 121 Issue 3 (2008)
5. FDA US Food and Drug Administration. ‘Wrinkle Fillers’ New Hampshire, Silver Spring MD, http://www.fda.gov/medicaldevices/productsandmedicalprocedures/
cosmeticdevices/wrinklefillers/default.htm> published 2014, [Accessed 15/07/15] (1)
6. Park SW, Woo SJ, Park KH, Huh JW, Jung C, Kwon OK, ‘Iatrogenic Retinal Artery Occlusion Caused by Cosmetic Facial Filler Injections.’ American Journal of Opthalmology, Volume 155 Issue 2, (2013)
7. Redaelli A.: Facial Aging: medical, surgical and odontostomatological solutions. OEO Firenze, Italy, 2012
8. Redaelli A.: medical Rhinoplasty: basic principles and clinical practice. OEO Firenze, Italy, 2010
Dr Jenna Burton is an aesthetic physician,
medical writer and is involved heavily with
the population health promotion (focusing
particularly on the promotion of chronic eating
disorder management.) Presently Dr Jenna works
between the United Kingdom and Dubai, UAE.
Dr Jenna has obtained a diploma from the American Academy
of Aesthetic Medicine, whilst working towards her American
Medical Board Specialist Status.
Clinincal Practice
Clinincal Focus
@aestheticsgroup
Peptide
Technology
Michael Q. Pugliese, L.E. explores the dynamic
role of peptides in cosmeceuticals
In nearly 15 years since making their introduction to the cosmetic market
place as effective clinical ingredients, peptides have gone from being
buzzwords to recognised as industry staples. While many practitioners and
patients have heard of them, few fully understand the dramatic benefits that
can be achieved by these high-performance ingredients, and what they hold
for the future of professional skincare. In this article we will review the structure
and function of cosmetic peptides, and take a look at some family
classifications. We will also highlight several proven commercially available
peptides for the practitioner to offer to the patient.
Figure 1
What are peptides? Peptides can be defined as short chains of amino acids
linked together in what’s known as the amine or peptide bond. Amino acids
are primarily composed of four elements: carbon, oxygen, nitrogen, and
hydrogen, with a few exceptions. There are 22 essential amino acids
playing various roles in skin health, which can be found functioning
throughout the many layers of the skin. These include lysine, proline, valine,
glycine, tyrosine, glutamine and several others. These individual amino
acids can be found in many cosmetic formulations serving their own unique
individual purposes. It is when we see these amino acids hooked together
in precise sequences, that we open up a new world of high-performance
ingredients with these very special bonds. When properly formulated,
42
Aesthetics Journal
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peptides have the ability to help us effectively address
almost every issue that we associate with skin irregularities
including wrinkles, hyperpigmentation, acne, rosacea,
cellulite and many more.
Each amino acid has a portion of its structure that is
positive (amine group) and a portion that is negative
(carboxyl group). This is the key to understanding how
peptides are made. In this case as in many others,
opposites attract. The positive of one amino acid will
conjoin with the negative of another, creating what is
referred to as the peptide bond. During this bond water is
produced as a byproduct. See Figure 1 which shows two
amino acids bonded together.
No matter how many amino acids are hooked together,
they will always link the positive of one to the negative of
another. Typically, the key difference between peptides
and proteins is the number of amino acids. Proteins are
recognised as 50 or more amino acids in a single chain,
but this is a relatively arbitrary classification as there are
many exceptions to this rule. Most commercial peptides
that are used as skincare ingredients are between two
and ten amino acids.
Where do peptides come from? Peptides are made by
the body in vast amounts every day. They help regulate
a variety of body functions in various systems. The
glycoprotein hormones are the most chemically complex
family of the peptide hormones. Three members of this
family include FSH (follicle stimulating hormone), LH
(luteinizing hormone) and HCG (human chorionic
gonadotropin). The synthesis of FSH and LH occurs in
the same cells of the anterior pituitary, but their secretion
is controlled by the hypothalamic portion of the brain
through a third peptide hormone called GnRH, or
gonadotropin releasing hormone. These hormones have
receptors on their target cells, which are mainly the
ovaries, and are used to regulate ovulation and the
menstrual cycle.
TSH or thyroid stimulating hormone, is stimulated by
thyrotropin-releasing hormone (TRH) from the
hypothalamus. TRH, a tripeptide, is synthesised by
neurons in the hypothalamus and is secreted in a
pulsatile manner, with peak secretion being exerted
between midnight and 4am, producing a biphasic
delivery of thyroid stimulating hormone. In turn, TSH
stimulates the thyroid gland to produce thyroid hormone,
which is essential for every cell in the body. The
Pro-Opiomelanocortin (POMC) family is a complex of
peptides having a wide range of function in the body.
Actually, it is a precursor of several other hormones,
including ACTH- like (adrenocorticotrophic hormone)
compounds that stimulate the adrenal gland to produce
cortisol type compounds. The major hormone produced
from POMC is Alpha MSH, which stimulates the
production of melanin in the melanocyte. Finally, this
versatile complex peptide also produces endorphins
which have a profound effect on the central nervous
system. With a basic understanding of these primary
hormones, it is important to clarify that the peptides we
use as skincare ingredients are very different from those
Aesthetics | August 2014
Clinincal Practice
Clinincal Focus
@aestheticsgroup
made and utilised by the body. Primarily, peptides used for
formulating topical products have been engineered. Specific
sequences of selected amino acids are designed to have an
influence on a particular cell or group of cells. There are a number
of ingredient supply companies which have made the technology
of engineering peptides big business and have reshaped the
skincare industry.
How do peptides work? Typically, cosmetic peptides are
designed to engage a particular cell, or group of cells, resulting in
a specific function that will vary, depending on the peptide and
the target cells. They do this by binding to various receptors on
the surface of these cells, and targeting messages to the nucleus
via transcription factors. Once the nucleus has received the
messages, they will be directed to produce the action that the
peptide dictates. Practitioners can communicate this action to
their patients by stating that peptides are meant to tell certain
cells what to do. Two notable properties of peptides are that they
are primarily water soluble, and they are relatively large
molecules. This combination makes it impossible for peptides to
penetrate cell membranes and affect cell activity. In contrast,
vitamin A, in its many forms, is lipid soluble and able to move
through the membrane and interact directly with cellular DNA. It is
for these reasons that commercial peptides are often formulated
with “built in” and/or additional delivery systems and penetration
enhancers, enabling them to reach targeted cells and receptors.
Carrier peptides. The first commercialised peptides were carrier
peptides. Introduced in the early 1990’s, these peptides were
designed to hook to another ingredient and facilitate
transportation of the agent to the active site. The first carrier
peptide was designed to deliver copper, a trace element
necessary for wound healing. From a wound healing application,
a peptide known as GHK-Cu was commercialised into a line of
skin care products to minimize the appearance of fine lines and
wrinkles. GHK-Cu is composed of glycine and histidyl and lysine
Signal Peptides
Preventhelia is a tetrapeptide, born from
preventive cosmetics, that protects skin
cells from UVA-induced DNA damage and
is able to promote the DNA repair system
capacity, providing skin protection of
intrinsic and extrinsic ageing.
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hooked to copper and was found to induce dermal keratinocyte
proliferation. GHK was originally isolated from human plasma and
then synthetically engineered. Copper peptides lost their
popularity mainly due to potentially harmful properties of copper
itself. While critical to collagen formation, copper is a transition
metal associated with free radical damage. Copper also has the
ability to create AGEs (advanced glycation endproducts) via the
Fenton reaction, which can damage collagen and other essential
dermal proteins. That said, however, everything old becomes new
again. Copper is now available once again in an ingredient
launched in 2013, under the trade name Neodermyl. The
manufacturer claims this new version of the ingredient, while not
technically a peptide, contains two amino acids, proline and
lysine, hooked to either end of the copper, ensuring a safe
delivery of the ingredient while virtually eliminating the risk of free
radical damage and glycation.
Signal peptides. The largest peptide family currently used in
marketed cosmeceuticals is made of the signal peptides. Signal
peptides provide a multitude of actions, most notably stimulating
collagen, elastin, fibronectin, proteoglycan and
glycosaminoglycans. The most popular signal peptide, palmitoyl
pentapeptide-4, was released in 1999, commercially known as
Matrixyl. Palmitoyl pentapeptide-4 is composed of the amino acids
lysine, threonine, lysine and serine. It is demonstrated to stimulate
the production of collagen I, III, and IV.1 Several newer, and
seemingly more effective, versions of this early technology have
been launched over the years by the ingredient manufacturer.
Matrixyl 3000 was introduced in 2003, and Matrixyl synthe’ 6 in
2010. Both achieved ready acceptance and exposure because of
their efficacy. Matrixyl sythe’ 6 has enjoyed a meteoric rise in use
in the industry, because of its ability to stimulate certain types of
collagen as well as fibronectin and lamanin-5, proteins
responsible for helping to strengthen the dermo-epidermal
junction. A few of the many signal peptides and their functions are
listed below.
encapsulated in a liposome vehicle. It
differentiates itself from other traditional
whitening agents with its unique inhibitory
action on the MITF cellular pathway to
decrease constitutive and facultative
pigmentation, allowing optimal whitening
and lightening effect with an excellent
safety profile.
dGlyage prevents DNA structure changes
triggered by transition metals. It chelates
such ion metals that catalyse different
reactions producing several DNA lesions.
Progeline is a 3 amino acids peptide
biomimetic of Elafin, an enzyme inhibitor
that regulates the integrity of the
extracellular matrix. Progeline decreases
progerin synthesis, a new ageing biomarker
involved in skin cellular senescence. By
acting directly on a senescence marker it
clinically improves the appearance of signs
associated with skin maturation: sagging,
slackness and wrinkles.
ß-White is a TGF-ß biomimetic peptide
Telangyn helps to decrease facial redness
Liporeductyl is a tripeptide and acts
as a scavenger for by-products of lipid
peroxidation, enhancing the effectiveness
of the other components to fight cellulite
and prevent adipocyte maturation.
44
Aesthetics Journal
Aesthetics | August 2014
and other skin disorders caused by LL-37
activation and subsequent release of
IL. It also provides a photo-protective
effect, lowering cell damage and skin
inflammation negative effects.
Bodyfensine, designed through a
combinatorial chemistry approach,
stimulates human-β-defensin -2 and -3,
enhancing the skin’s natural defence
system, therefore maintaining the balance
between commensal microbes and
pathogens in the skin.
Diffuporine enhances AQP3 expression
levels in keratinocytes, which are inherently
reduced due to chronologic ageing and
photo-ageing. In addition, this peptide
presents further properties that contribute
to maintaining skin barrier integrity and a
youthful appearance.
Neurotransmitter peptides Neurotransmitter peptides function
by inhibiting the release of acetylcholine at the neuromuscular
junction. They are similar to botulinum toxin in that they
both selectively modulate synaptosome-associated protein
of 25,000 Daltons, more commonly known as Snap-25.
Botulinum toxin A proteolytically degrades SNAP-25. Acetyl
hexapeptide-3, trade name Argireline, is a neurotransmitter
peptide, which mimics the N terminal end of the SNAP-25
protein that inhibits the SNARE (soluble N-ethyl-maleimidesensitive attachment protein receptor) complex formation.
Acetyl hexapeptide-3 functions topically to relax muscles by
inhibiting vesicle docking through prevention of the SNARE
complex formation. This muscle relaxation reduces the
appearance of facial wrinkles. Much like the Matrixyl family of
peptides, the manufacturer of Argireline has since improved
its initial technology. Snap-8, (Acetyl Octapeptide-3), a similar
functioning peptide, has been shown to reduce wrinkle depth
by 63% in 28 days.2 This provides nearly twice the wrinkle
reducing power of Argireline.
Enzyme modulating peptides. Enzyme modulating peptides
directly or indirectly inhibit the function of a key enzyme in some
metabolic processes. Many of the enzyme modulating peptides
are extracted from botanical sources rather than engineered
through chemistry. Soy proteins, already used in cosmeceuticals
for the reduction of pigmentation and the inhibition of hair
growth, possess another peptide that inhibits the formation of
proteases that break down collagen and elastin. Rice proteins
possess a peptide that inhibits MMP (matrix metalloproteinase)
activity. These naturally occurring peptides are used in
cosmeceutical facial moisturisers in combination with the
previously discussed synthesised peptides.3
The use of peptides in a skin treatment product is percentage
dependent, thus responsible manufacturers provide a formulary
range, low to high, of the effective dose concentration. Using a
higher concentration than recommended adds only to the cost,
not to the effectiveness, of a product. It follows that skimping
below the minimum percentage, when adding peptides
simply for labelling and advertising purposes, will do nothing
to contribute to the product, nor the patients’ results. Bear in
mind that the sophistication of peptide technology does not
require the professional to become a molecular biologist in
order to serve our patients. As in all new things, the goal is to
keep learning, and absorbing a little bit at a time. Be aware
that new discoveries in skin science allow us to address evermore specific skin care concerns with professional skin care
treatments and products, with the intention of safely effecting a
positive change in the health and appearance of human skin at
all stages.
Michael Pugliese is a skincare specialist and CEO of
skincare company, Circadia. He is a member of the
Society of Cosmetic Chemists and regularly attends
their education events to stay on the cutting edge of
new product development.
REFERENCES
1. Sederma, ‘The Messenger Peptide for Dermal Matrix Repair: An Alternative to Retinol and Vitamin C,’ (www.doctstoc.com, 2011) http://www.docstoc.com/docs/92616994/MatrixylTM
2. Lipotec Group, ‘Snap-8: An octapeptide to express yourself at ease’ (www.docstoc.com, 2011) http://www.docstoc.com/docs/84112127/An-octapeptide-to-express-yourself-at-ease
3. Physiology of the Skin, Third Edition, by Peter T. Pugliese, MD and Zoe Diana Draelos, MD (Allured Business Media, 2011) pp 233-234
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Spotlight On:
Mirvaso
Galderma’s Mirvaso gel for the treatment of the redness of rosacea was officially
launched in the UK in March this year. Here we ask leading dermatologists to discuss
patient selection, and to share their advice on prescribing.
Galderma’s Mirvaso 3 mg/g gel is an alpha-2adrenergic receptor agonist that acts rapidly to
reduce the persistent facial erythema (redness) of
rosacea in adult patients. The active ingredient is
brimonidine, an ingredient that has been used to treat
the eye disease glaucoma since 1997.
While not a cure, symptomatic relief can last for up
to 12 hours. The ability of Mirvaso to constrict blood
vessels in the skin was discovered by accident, when
patients with glaucoma and rosacea found the skin
underneath the eye developed pallor when they
spilled some of their glaucoma drops on the skin.
At the end of February 2014, Mirvaso was granted
marketing authorisation in Europe by the European
Commission. The EC authorisation is based on data
from 553 patients in two one-month phase 3 clinical
trials, showing that patients who used Mirvaso saw
significantly greater reduction of facial redness than
those who used the vehicle gel alone.
In a US, long-term, multi-centre study, 449 patients
with moderate-to-severe erythema of rosacea
applied Mirvaso once daily for up to 12 months.1
Mirvaso was shown to be effective in reducing
persistent facial erythema of rosacea from the first
day of treatment and throughout the 12-month
study. The study, published in the Journal of Drugs
in Dermatology, the study saw no evidence of
tachyphylaxis and so Mirvaso remained effective.
No new safety issues or side effects emerged.
The most common adverse reactions (incidence
≥ 1%) included erythema, flushing, skin burning
sensation, and contact dermatitis. In the long-term
study, the most common adverse events (≥ 2%
of subjects) included flushing (9.1%), worsening
of erythema (6.5%), worsening of rosacea (3.6%),
skin-burning sensation (3.3%), increased intraocular
pressure (4%), and headache (4%). Dr Anthony
Bewley, consultant dermatologist at Bart’s Health
NHS Trust in London, recently conducted UK
trials on Mirvaso with ten patients. He found they
all responded well to the treatment. “Rosacea
sufferers often find the facial redness very
disfiguring and even disabling,” he says. “Patients
often also suffer a burning sensation at the same
time. It makes them feel wretched and out of
control. Some become depressed and a few even
feel suicidal. Until now there hasn’t been much that
effectively treated the redness and flushing. Even
46
Before
After
if patients have expensive laser treatments, the redness tends to come back. To
have this is helpful not just for my patients’ skin, but their self-worth too.” A recent
awareness programme, launched in June 2014 by Galderma and fronted by
actress Cynthia Nixon, is working to urge rosacea sufferers to seek help for their
condition. New research data from the ‘Face Values: Global Perceptions Survey’
showed that facial redness affects sufferers emotionally (77%), socially (67%), at
work (63%) and in their relationships/dating behaviour (53%). The survey also
showed that respondents also formed judgements about sufferers’ personalities:
those with facial redness were less frequently perceived as intelligent, reliable,
successful and trustworthy compared to people without redness.2
Treatment
Dr Bewley says that although Mirvaso can take up to 30 minutes (or longer) to work,
he has found that redness cleared within a few minutes in some patients. “The
patients all liked it very much and told me how much better they felt when using it. It
made a big difference to their skin, taking away the redness. Redness and flushing
can lead to full blown rosacea with papules and pustules and even rhinophyma, or
skin thickening of the nose.
Treating the disease early could prevent progression.” However, as with all drugs,
Baseline
Aesthetics | August 2014
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Clinical Practice
Spotlight On
@aestheticsgroup
Aesthetics Journal
patient selection is vital. For grade 1 improvement, studies suggest Mirvaso may be
effective at reducing visible redness in 71% of patients.3 For a grade 2 improvement,
the result was 31.5%. The studies were rigorous: for a successful outcome both
patients and assessors had to agree that the patients had a two-grade reduction
in redness at each time point assessed. If Mirvaso is applied patchily, the face will
have red areas where the cream was missed. Consultant dermatologist Dr Nick
Lowe says, “I have been interested in brimonidine for some time now, and think
Mirvaso is going to be very helpful when treating rosacea. It seems it can be used in
conjunction with other medications such as antibiotics, for example metronidazole,
and devices such as IPL and lasers, such as the new Nd:YAG vascular lasers.
However, I would like to see more safety testing of Mirvaso in combination with
Baseline
3 Hours
9 Hours
other prescription drugs. I would be wary of prescribing it with tretinoin or isotretinoin
and in sensitive skin patients.” He adds, “It is vital to diagnose rosacea correctly in
the first place as there are other causes of rosacea-like redness, including facial
eczemas.” Dr Bewley advises that, as it constricts blood vessels, Mirvaso might not
be suitable for people who suffer from migraines. Dr Daron Seukeran, consultant
dermatologist and medical director of the sk:n laser unit, suggests caution in patients
with coronary or cerebral insufficiency, Reynaud’s phenomenon.
Alpha-2-adrenergic agents can lower blood pressure so patients with hypotension
may not be suitable. Galderma suggests Mirvaso should also be used with caution
in patients with depression, orthostatic hypotension, thromboangiitis obliterans,
scleroderma, or Sjögren’s syndrome or severe or unstable or uncontrolled
cardiovascular disease. Adverse reactions following accidental ingestion of Mirvaso
gel by children have been reported, though both children made a full recovery within
24 hours.4 Some contributors to internet sites have complained of side effects, of
which the worst seems to be worsening of redness that they believe is worse than
before they tried Mirvaso.5
And Dr Lowe says, “Some of my patients who have used Mirvaso in the US
say they have experienced stinging and increased redness. However, the
complaints may also arise because the contrast with their new pallor could make
patients believe that when the redness returns after 12 hours, it is worse than
they remembered. They may find that papules, which are disguised by diffuse
redness, become more obvious when the redness fades, as Mirvaso does not
reduce these.”
Dr Alison Layton, consultant dermatologist at Harrogate District Hospital, agrees.
“It is important to warn patients that Mirvaso does not treat lesions. In addition,
some patients note that some of the small red vessels on their skin are more
prominent. Again it is important to inform patients that any dilated vessels which
we call telangiectasia (sometimes referred to as small thread veins) will not
clear with the Mirvaso and may look more prominent. These telangiectasia are
amenable to laser treatment.”
Patients may also be less vigilant about avoiding triggers such as alcohol, spicy
food, extreme temperatures and stress while the Mirvaso is active, and, warns Dr
Bewley, the skin may show a delayed reaction to these triggers when the effect
of Mirvaso wears off. Dermatologist and medical therapeutic area specialist for
Galderma, Dr Gregor Schäfer, says, “The vast majority of patients have been very
satisfied with Mirvaso. But it’s important to set clear expectations: Mirvaso is a
symptomatic treatment for facial erythema of rosacea and the patients’ erythema
48
Aesthetics | August 2014
Aesthetics
aestheticsjournal.com
will return as the effect of the drug/brimonidine
wears off. Therefore it is of crucial importance to set
the patients expectations right, to ensure they have
a good knowledge of the potential side effects and
understand the limitations of the treatment. The term
rebound, as defined in the clinical development
programme, refers to worsening of erythema after
the end of a 29 day study (at week two and four
visits following cessation of treatment) as compared
to baseline assessment.
However, no substantial numerical difference
in ‘rebound’ was observed between Mirvaso
(brimonidine) and vehicle groups, in either of
the two pivotal Phase III trials. However, in these
studies, during the treatment period, some patients
reported a flare of their redness, sometimes worse
than baseline, occurring a few hours after Mirvaso
application. This was reflected in the US PI in the
‘warning and precaution’ section as worsening of
erythema and in the European Label as worsening
of rosacea and skin redness. Intermittent flushing
is also reported. These adverse events occurred
intermittently in some patients or on a daily basis in
others, but were not defined as rebound in these
studies.”3
Good clinical photography and counselling is of
crucial importance when prescribing Mirvaso. Dr
Lowe adds, “As patients can be allergic or irritated
by any ingredient, I would suggest patients first
apply a small amount of Mirvaso in an inconspicuous
area of skin before applying it to their entire face.”
Health trusts will now have to decide whether to
offer Mirvaso to patients in their area – it is expected
to cost the NHS as little as 50p a day per patient.
However, Mirvaso will also be available privately.
Galderma originally assumed patients would use
around 1g a day which contains 5mg of brimonidine
tartrate, but in studies they found participants used
an average of .53g meaning a 30g tube will last up
to 60 days and will cost less than £35.
Baseline
3 Hours
REFERENCES
1. Moore A, Kemper S, Murakawa G et al. ‘Long-term safety and efficacy of once-daily topical brimonidine tartrate gel 0.5% for the treatment of moderate to severe facial erythema of rosacea: results of a 1-year open-
label study’, J Drugs Dermatol, 13 (1) (2014), pp. 56–61.
2. Galderma S.A. Face Values: Global Perceptions Survey. 2013.
3. Fowler J, Jackson JM, Moore A et al. ‘Efficacy and safety of once-daily topical brimonidine tartrate gel 0.5% for the treatment of moderate to severe facial erythema of rosacea: results of two randomized, double-blind, vehicle-controlled pivotal studies’, J Drugs Dermatol, 12 (2013), pp. 650–656.
4. Galderma, Mivaso 3mg/g SPC (www.medicines.org.uk, 2014) <www.
medicines.org.uk/emc/medicine/28682/SPC/Mirvaso+3mg+g+Gel>
5. David Pascoe, Mirvaso User Reviews (http://rosacea-support.org, 2013) <http://rosacea-support.org/mirvaso-user-reviews.html>
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Clinical Practice
Abstracts
@aestheticsgroup
Aesthetics Journal
Aesthetics
aestheticsjournal.com
A summary of the latest
clinical studies
Title: Diet and acne update: carbohydrates emerge as the main
culprit
Authors: SN Mahmood, WP Bowe
Published: Journal of Drugs in Dermatology, 2014 April
Keywords: Acne, Carbohydrates, Diet, Dermatology
Abstract: ‘The prevalence of adult acne in the US appears to be
increasing over the last few decades. But what’s behind the rise: is
it nature or nurture? We are well aware that genetics can strongly
influence a patient’s risk of developing acne. However, significant
changes in germline genetic variants are unlikely to have occurred
over the last 20 years. Consequently, we are forced to examine
environmental variables, including diet. This review article presents
the most updated evidence supporting a link between refined
carbohydrates and acne. Based on the data summarized here,
dermatologists should encourage their acne patients to minimize
their intake of high glycemic index foods.’
Title: Influence of skin ageing features on Chinese women’s
perception of facial age and attractiveness
Authors: A Porcheron, J Latreille, R Jdid, E Tschachler, F Morizot
Published: International Journal of Cosmetic Science, 2014 May
Keywords: Ageing, Wrinkles, Chinese, Caucasian
Abstract: ‘Ageing leads to characteristic changes in the
appearance of facial skin. Among these changes, we can distinguish
the skin topographic cues (skin sagging and wrinkles), the dark
spots and the dark circles around the eyes. Although skin changes
are similar in Caucasian and Chinese faces, the age of occurrence
and the severity of age-related features differ between the two
populations. The aim of this study is to evaluate the contribution
of the different age-related skin features to the perception of age
and attractiveness in Chinese women. Facial images of Caucasian
women and Chinese women in their 60s were manipulated
separately to reduce the following skin features: skin sagging and
wrinkles, dark spots and dark circles. Finally, all signs were reduced
simultaneously. Female Chinese participants were asked to estimate
the age difference between the modified and original images
and evaluate the attractiveness of modified and original faces.
Chinese women perceived the Chinese faces as younger after the
manipulation of dark spots than after the reduction in wrinkles/
sagging, whereas they perceived the Caucasian faces as the
youngest after the manipulation of wrinkles/sagging. Interestingly,
Chinese women evaluated faces with reduced dark spots as being
the most attractive whatever the origin of the face.’
Title: Severe androgenetic alopecia as a proxy of metabolic
syndrome in male psoriatic patients older than 59 years
Authors: V Descamps, E Mahé, F Maccari et al
Published: European Journal of Dermatology, 2014 June
Keywords: Androgenetic alopecia, Psoriasis, Hypertension
Abstract: ‘Whereas several studies have underlined the
association between severe psoriasis and metabolic syndrome
(MetS), the association of androgenetic alopecia (AGA) and MetS
have yielded inconsistent results. We investigated the relationship
between AGA and the components of MetS in psoriatic male
50
patients. A non-interventional, cross-sectional, multicenter
study was conducted in France. A standardized questionnaire
was completed, including information on components of MetS
and other possible risk factors. MetS was defined in this study
as a combination of three or more of the four components of
MetS: waist circumference, hyperlipidemia, diabetes mellitus and
hypertension. A standardized simplified Norwood classification
limited into 5 grades (0-4) was used. In a total of 1073 male
patients, hypertension, high waist circumference, diabetes mellitus
and hyperlipidemia were observed in 28%, 59%, 11%, and 31%,
respectively. In age-adjusted multivariate analysis, severe AGA
(grade 3-4 versus grade 0) was associated with the presence of
at least one component of MetS. By groups of age, a statistically
significant association of severe AGA and MetS was demonstrated
in patients over 59 years. Severe AGA was also associated with
a first-degree familial history of major cardiovascular event in
patients older than 59. Our study, based on a simplified but
stringent definition of MetS, confirmed the link between severe
AGA and individual components of MetS in psoriatic patients.
This argues for careful follow-up with regular screening in
male psoriatic patients with severe AGA in order to early detect
determinants of MetS.’
Title: Complications after facial injections with permanent fillers:
Important limitations and considerations of MRI evaluation
Authors: J Kadouch, C Tutein Nolthenius, D Kadouch et al
Published: The Aesthetic Surgery Journal, 2014 June
Keywords: Filler migration, Filler complication, Magnetic
resonance imaging
Abstract: ‘Soft-tissue fillers have become more prevalent
for facial augmentation in the last 2 decades, even though
complications of permanent fillers can be challenging to treat.
An investigative imaging tool could aid in assessing the nature
and extent of these complications when clinical findings
are ambiguous. The authors analyzed the value of magnetic
resonance imaging (MRI) in the assessment of delayed-onset
complications. Thirty-two patients with complications related
to facial fillers were evaluated in this prospective cohort study.
Their medical history was documented, and MRI was conducted
before treatment. Radiologists were informed of the injection
sites but were blinded to the results of other clinical evaluations.
Levels of agreement between clinical and radiologic findings
were calculated with the Jaccard similarity coefficient. A total of
107 site-specific clinicoradiologic evaluations were analyzed. The
level of agreement was assessed as strong for deposits without
complications and noninflammatory nodules (combined 85%),
moderate for abscesses (60%), fair for low-grade inflammations
(32%), and slight for migrations (9%). Results from the MRI
examinations aided in subsequent treatment decisions in 11%
of cases. Results show that MRI may be useful for diagnosing
complications associated with fillers that have migratory
potential, for depiction of the extent of deposits before
treatment, and for follow-up of low-grade inflammation and
abscesses after surgery.’
Aesthetics | August 2014
@aestheticsgroup
Aesthetics Journal
Aesthetics
Don’t miss your
chance to attend
The Aesthetics Awards 2014,
book your ticket today!
With entry closed and the finalists being
chosen, plans are coming together for the most
prestigious celebration in medical aesthetics.
The Aesthetics Awards 2014 will be held on
Saturday 6th December at the Park Plaza
Westminster Bridge Hotel in Central London
and will play host to the best in the profession.
Alongside the presentations honouring winners
and highly commended finalists, the evening will
also feature fantastic entertainment, a formal sit
down dinner and a great opportunity to network
with colleagues and peers.
Individual ticket: £200 plus VAT
Table of 10: £1,900 plus VAT
To book your tickets visit
www.aestheticsawards.com, call 0203 096 1228
or email bookings@aestheticsawards.com
This year the Janeé Parsons Award for Sales
Representative of the Year is sponsored by
Healthxchange Pharmacy
aestheticsjournal.com
Aesthetics Awards
Special Focus
Finalists will be announced in next month’s issue of Aesthetics journal
on 1st September whereby voting/judging will commence.
How will winners be selected?
Once the finalists have been selected and announced in September,
voting and judging will take place to select the winners.
Via the Aesthetics Awards website you will be able to vote for the winner
in the following categories:
• Cosmeceutical Range/Product of the Year
• Injectable Product of the Year
• Treatment of the Year
• Equipment Supplier of the Year
• The Janeé Parsons Award for Sales Representative of the Year,
supported by Healthxchange Pharmacy
• Best Customer Service by a Manufacturer/Supplier
• Distributor of the Year
• The Neocosmedix Award for Association/Industry Body of the Year
An expert judging panel will consider the nomination forms submitted
by the finalists for the following categories:
• The Pinnell Award for Product Innovation
• Training Initiative of the Year
• The 3D-lipomed Award for Best New Clinic, UK and Ireland
• The Syneron Candela Award for Best Clinic Scotland
• The Rosmetics Award forBest Clinic North England
• The Dermalux Award for Best Clinic South England
• The Oxygenetix Award for Best Clinic London
• The Sinclair IS Pharma Award for Best Clinic Wales
• Best Clinic Ireland
• The Institute Hyalual Award for Aesthetic Nurse Practitioner of the Year
• The Merz Aesthetics Award for Aesthetic Medical Practitioner of the Year
• The Church Pharmacy Award for Clinic Reception Team of the Year
The winner for The Aesthetic Source Award for Lifetime Achievement
will be selected by the Aesthetics team and announced on the night.
Winners in all categories will be announced at The Aesthetics Awards on
Saturday 6 December 2014. Where appropriate, judges may also choose to
commend or highly commend particular finalists. These commendations will
also be announced at The Aesthetics Awards.
Gemma Knowler, voted winner of the Janeé Parsons Award for Sales Representative
of the Year, shares her experience of being honoured at The Aesthetics Awards 2013.
“Winning Sales Rep of the Year at The Aesthetics Awards was the biggest achievement
of my career to date. I had set myself a personal goal two years ago to make the shortlist
in 2013 or 2014 so to win went beyond my goals and made me feel very proud of all my
hard work since joining the industry seven years ago. I am thankful to all of my customers
and colleagues that both nominated and voted for me. It was a wonderful feeling to win
and know my work was recognised and that all those who voted for me care for me as
much as I do them. Knowing all this is a lovely feeling!”
Aesthetics | August 2014
51
In Practice
Design
@aestheticsgroup
Aesthetics Journal
Clinic design
Dr Tapan Patel details his journey from construction
site to design excellence, recounting his clinic
development project, which began in March 2013
Essentially, my practice had outgrown my
clinic in North London and we decided
that it was time to find something in Harley
Street. The site I chose was an empty
shell that would need to be built up almost
entirely from scratch. In my first clinic, the
facial aesthetic procedures on offer were
purely non-surgical, and with the new
clinic I decided that I wanted to provide a
wider range of aesthetic treatments for my
patients. The first steps were to consider
the name and concept for the clinic, and
what I wanted to do architecturally with the
space. The name I decided upon was the
Greek letter PHI, the 21st letter of the Greek
alphabet, pronounced ‘Fy’. The clinic takes
its inspiration from Ancient Greek scholars,
artisans and the notion of the golden ratio
with its aesthetically pleasing proportions.
The design for the clinic wasn’t based on
any practice that I had previously seen. I
wanted to reinvent how cosmetic-based
practices were presented and perceived.
The idea was to make it a combination
of traditional but modern, clinical and
professional. Initially, this seemed to be a
mass of conflicting themes but I felt that
there was a way for me to bring all these
disparate notions together.
I met with an architectural design specialist,
Roger Gullidge, and very early on he was
able to explain to me what could be done
with the space. I already had some design
concepts that I had been working on, and
when I shared my ideas and vision for
52
the clinic these began to be transposed
into the foundations of a plan. During the
development I was on site a lot; I wanted
to be there as often possible, and it meant
that I could be involved in all of the day-today decisions. I also employed a project
manager and a building company, which
meant that I didn’t have to carry out the
actual running of the site myself.
Considering the rebranding of the practice
was a very different process to the
construction of the site, it was carried out
through working with a specialist website
and graphic design team who were able to
come up with specifically tailored branding
Aesthetics | August 2014
Aesthetics
aestheticsjournal.com
that suited the new clinic. In the new clinic,
patients are offered both non-surgical and
surgical solutions for all indications, and I
wanted this to be reflected in the image of
the practice, especially as previously the
clinic’s provision was purely non-surgical.
Amazingly, we didn’t come across any
significant obstacles or problems during
the build or design; in fact we were very
lucky throughout the entire project. When
I originally selected the site I was aware
that it was a listed building and knew about
the relevant controls and regulations, but I
wasn’t overly concerned about these issues.
Fortunately, having a specialist architectural
design company on board able to deal with
these factors, and who had experience
managing this kind of build previously, meant
that this was not a problem.
Now that the project is complete and has
become a fully working practice, I am
particularly pleased with the clinic’s overall
impression. For me, it really does create that
kind of wow-factor that we had intended,
and simply managing to get it all up and
running in such a short space of time is a
proud achievement.. The whole team here
at PHI Clinic are able to share my excitement
and pride everyday when we walk in to our
gleaming new clinic – it really brings a smile
to all our faces.
The advice I would give to other practice
owners going into a similar project is to allow
plenty of time from conception to conclusion,
and not to be too unrealistic as to the
amount of your own time that a project like
this will take up. You can budget for a build
or for equipment, but there will always be
unforeseen factors that can add to a project,
and you have to make sure that you have the
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In Practice
Design
right timescale to accomplish what you want.
I was fortunate in that respect. Beforehand,
I had made some provisions for hidden
surprises but luckily I was able to avoid any
major problems. It would have only taken an
issue with the wiring or the plumbing, or for
the builders to find damage somewhere, to
add a considerable unexpected expense.
It is also worth noting what a big task it
actually is to rebuild and rebrand a clinic.
It requires coordinating building work with
all aspects of the business; you will have to
organize everything from the equipment to
the staffing, the branding and the marketing
strategies, as well as all of the legalities. It is
very important to be under no illusion as to
@aestheticsgroup
Aesthetics Journal
the huge amount of work that will be involved.
Whether you are looking to rebuild or
rebrand your practice to expand or improve
the services you offer, I would suggest
that you meet with a project manager as
early into the conceptualisation of the
project as possible. They will be able
to use their experience to help identify
what the limitations or possibilities of your
project might be; if you’re not already in the
field yourself you don’t always realise the
potential that a building might have. From my
own personal experience, I would certainly
recommend getting that advice early on
and working with a design service that will
help you establish your artistic concepts and
budgets to ensure the long term success of
your business.
Looking back at the project, from start to
finish, there isn’t anything I would have done
differently. For me, it was very important to
get this project right the first time, and I think
we achieved that through detailed plans and
a clear vision from the start. The new clinic
is just as I had envisaged it, and now I don’t
anticipate myself having to go through this
process again.
The project began in March 2013 and took
us right into January 2014. It’s difficult to say
for certain so soon after its completion what
affect this project has had on the success
of the overall business, but it has certainly
started with a bang. I have received masses
of positive feedback about the clinic and its
design, and I hope that patients and visitors
Aesthetics
aestheticsjournal.com
alike will continue to be pleased with the
outcome, and that this momentum will carry
on for many years to come.
Dr Tapan Patel is the founder
and medical director of VIVA
and PHI Clinic. He has over 14
years of clinical experience and
has been performing aesthetic
treatments for ten years. Dr Patel is passionate
about standards in aesthetic medicine and still
participates in active learning. Dr Patel gives
presentations at conferences worldwide.
The power of any clinic design lies in its function for everyday practice. How your patients respond
to your tailored space is key to its success. We take a look at three compelling clinic designs:
Riverbanks Clinic
Dr Ravi Jain, owner
“As soon as I saw the building, I knew I
wanted it for my clinic. It was previously a pub
called the Leather Bottle and had to be totally
gutted and rewired before any of the interior
design could begin. The secluded location
of the clinic allows patients privacy, with no
stressful parking. We even grew the hedges
around the car park so people can’t be
recognised by their cars. The clinic gardens
back on to a river, providing a beautiful view
and constantly reaffirming the clinic’s ‘natural’
ethos. With the river running by, we came up
with the name: Riverbanks. Designed by my
wife, Rosalind Jain, she chose a blue-green
colour scheme, as it is calming and tranquil.
Getting the correct balance between clinical and homeliness was our challenge.
We kept a few of the original features such as the fireplace and ceiling beams. Natural
54
Aesthetics | August 2014
In Practice
Design
@aestheticsgroup
Aesthetics Journal
Aesthetics
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wood floor was laid, and our white shutters are a great success, letting light in but
providing privacy for the patient. The same colours were used in furnishings, vases and
ornaments to create a calming continuity.
We have rooms to accommodate all our treatment options, as well as a room dedicated
purely to consultation, with no treatment chairs in sight. We wanted to make it homely
and let patients feel at ease straight away. Our natural and timeless interior design
reflects the treatment outcomes that we offer.
We wanted our clinic to be reassuringly traditional and discreet; there are no big signs
outside saying, ‘Botox here!’ Patients quite simply love our clinic. Comments include, ‘I
wish I lived here’, ‘The view is beautiful’, and ‘It’s so relaxing’.”
Cosmex Clinic
John Culbert, Business Director
Our patients respond
very well to our clinic
design, they love the
light, airy feel and tell
us it is a comfortable
place to come to.
“Our clinic was originally a gatehouse,
and is part of a grade I building called
Anstey Hall. With vaulted ceilings and
hardwood flooring, we wanted to keep
the original features, whilst incorporating
a contemporary, modern feel.
Although our colour scheme is neutral,
our walls are decorated with pieces
by the artist Richard Snowden, that
are also for sale. When patients enter
the reception they are greeted with glass and stainless steel features – a minimalist feel
which lets the building speak for itself. Based in Cambridge, in the middle of a burgeoning
upmarket area and adjacent to Waitrose, we are just three minutes from the M11. Being so
close to the motorway has definitely increased our catchment area. Our patients can come
to our clinic, have their treatment, and pop to Waitrose to do their shopping on their way
home. We are also only 150 yards from a bus stop.
Our patients respond very well to our clinic design, they love the light, airy feel and tell
us it is a comfortable place to come to. They appreciate the space and the fact that there
are no parking restrictions. The building was previously used as a laser clinic, an area we
are hoping to expand into, so has already received CQC approval. In anticipation of future
laser use, the clinic is already fitted with blackout blinds.”
Medikas
Dr Beatriz Molina, medical director
“In Spanish ‘Medica’ means female doctor and ‘Kas’ means calm: I combined the two to
create the name of my clinics: Medikas. I chose the locations as I had been working in the
local area as a GP, so I was already well known. We now cover large areas of Somerset,
forming a triangle of clinics in Bristol, Bath and Street.
Our Bristol clinic incorporates a minimalistic, modern design, which is in line with how I like
treating my patients. I normally like my patients to look very natural, only treating what is
absolutely necessary and adding treatment only where it gives the best results.
The building itself inspired the design of the interior, as it offered bright and spacious
rooms. I took into account what would be required in each treatment room and how much
space would be needed to treat our patients with the latest technology and commodities.
We have a waiting room with comfortable sofas for our patients to relax on, along with a
recovery room for patients to rest in after more invasive treatments.
Our photography room gives a comprehensive skin analysis with sophisticated photos
that use the latest 3D technology, and we have a room dedicated to laser treatments.
Patients love the clinic, we always get lots of compliments – my daughter thinks we
should live there!”
56
Aesthetics | August 2014
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Royal College of Nursing?
As of the 1st of July, The Royal College of Nursing will no longer be providing
indemnity cover for aesthetics to their members.
Don’t worry…
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In Practice
Business process
@aestheticsgroup
Aesthetics Journal
Aesthetics
aestheticsjournal.com
clients, within your competency, that your
competition is not offering and that is in line
with what the client is willing to pay. If you
are not sure, one of the best ways to find out
is try out some treatments at various clinics
yourself, and speak to friends and family to
find out their needs.
Opening a clinic
Annalouise Kenny offers helpful advice on how
to successfully build a medical aesthetics clinic
Although the result can be highly
rewarding, opening an aesthetic practice
does take a lot of hard work and careful
planning. Here are some simple tips to help
you with the process of launching a clinic:
Location – Whether this is on a high street
or in a more discreet area, location is so
important. If you are looking at off-high street
locations you need to take into consideration
that you will have to put more effort into
marketing, which then needs to be included
in your budget. Clients like the privacy of an
off-high street clinic, but they need to know
about it first; if you advertise your services
sufficiently then you will encourage patients
to move away from the high street. If the
clinic is on the high street there will be higher
overheads, but this is countered by the walkin business. Whatever location you choose,
just be aware of any extra considerations
you need to make and allow for these in your
planning.
Competition – Before you make a
decision on equipment or services, ensure
that you look at what your competitors
are offering; what kind of clientele they are
attracting; and of course their price range.
This is not to undercut them, but rather to find
your own demographic. If another clinic is
offering low cost services and deals, it might
be preferable to offer better equipment at
a higher price – otherwise it’s a race to the
bottom.
Equipment – Do the training FIRST.
Training not only supplies you with
invaluable skills but also gives you the
information to know what questions to
ask suppliers regarding service contracts
58
and consumables. All machines have their
benefits and drawbacks. You need to find
one that will suit your demographic, price,
location and your business as a whole.
Website – A well designed, aesthetically
pleasing and functional website is one of the
most important factors for any new business.
It is true that you get what you pay for, so
with this in mind your website needs to be
built on a good platform. I have never paid
for SEO for the Advance website, but we
always remain at the top of the results for the
search term “training courses”. If someone
else builds your website, make sure they give
you access to it so you can update it yourself
regularly. I have seen too many cases where
owners are held to ransom by their website
developer because they have no control
over their own site.
Staff – If you are going to hire staff, develop
a staff manual that includes all aspects of
how you want the business to be run on
a daily basis. This ensures that once they
commence employment they are aware of
how things should be done. It also makes
hiring staff much easier. The manual needs
to be as in-depth as possible and include
specifics such as how to answer the phone
and how to greet the clients. This ensures
consistency within the business. If you are
sending staff on training courses, make sure
the costs are built into their contract; if they
leave within a certain period of time they will
have to pay back anything owed for training.
Treatments – So many students I meet
want to know what the best treatment is.
There is no single best treatment; it is the
treatment that is most suitable for your
Aesthetics | August 2014
Suppliers – Nowadays, clients have
researched the different treatments;
they are knowledgeable so you must be
knowledgeable too. When asking suppliers
about machines do not be afraid to ask
questions. Do not just take their word for
how it works – ask them to explain why it
works. All reputable suppliers will offer follow
up support and this is why it is so important
that the supplier is UK based. If, for example,
the machine breaks down and you have a
lengthy appointment list, most suppliers will
be willing to make necessary repairs within
a day.
Training – I would advise finding someone
that has extensive experience in the field.
Life experience is invaluable, as well as being
hugely beneficial to students. Ensure that the
training company you use is accredited by an
official awarding body such as BTEC VTCT or
ITEC. These awarding bodies ensure that the
centres are of a high standard.
Social Media – Google looks for people
who are Google+ account holders. If you
have a Google+ account you will be ranked
higher in Google searches. Clients love free
advice – posting hints and tips on Facebook
and Twitter on how to improve your skin and
body is a good example. If you don’t have
time, schedule posts to go out at a certain
time every week. Competitions are also
worthwhile and can be run at a low cost.
When I last ran a competition, the Facebook
page for Advance increased in views by
500%.
Targets – Decide what your targets are
for the next three years. If you do not have
stringent targets, you have nothing to
measure yourself against. It gives you more
drive. Have a treat if you reach your target,
something that drives you to reach your
goals.
Annalouise Kenny is managing
director of Advance and
company director of Fitzwilliam
Transformation clinic. She has
worked in the industry for 12
years, working specifically with
Advanced skin treatments and laser for the last
seven years in America, Europe and Africa.
INTRODUCING LASER
TREATMENTS INTO YOUR CLINIC
Laser courses available with Advance
3 day, BABTAC course.
This course is for medical practitioners who do not need NVQ level
4, potential clinic owners who are looking to have an overview of
information or previously experienced laser therapists who do not
have NVQ level 4 qualifications.
6 day, NVQ level 4 certificate in Laser and IPL treatments.
This course is suited to the person who has an NVQ level 2
qualification and experience within the beauty industry.
9 day, NVQ level 4 certificate in laser and light treatments.
This course has been designed for students who have no previous
requisites. Upon completing this course you will receive a certificate
in anatomy & physiology NVQ level 3, core of knowledge certificate
and NVQ level 4 certificate in laser and light treatments.
For more information or to book contact Advance
on info@advanceclinictrainingandconsultancy.com
UK: 0845 261 3714 / +44 (0) 7885 215025
IRE: +353 (0) 860640595
Conference 2014 - Saturday 20th September 2014
Autumn Conference 2012
Royal Institute of British Architects, 66 Portland Place, London W1B 1AD
Purchase a ticket to the British
College
of Aesthetic
Medicine
Main conference
takes
place on:
Conference 2014 from just £199.
•
Saturday 15th September 2012
•
The conference will be held at the Royal Institute
of British Architects, London and will comprise
a mixture of lectures and live demonstrations
•
from fantastic international speakers in the
main conference room. This year BCAM are also
delighted to feature a parallel business programme
•
for practice
managers.
Main conference
speakers
include Dr Russell Emerson,
9am - 5pm followed by a gala dinner
£199perticketforBCAMmembers,
(includesafabulouslunchand
coffeebreaks)
Ticketsforguestattendingbusiness
lectures£149(includeslunchand
coffeebreaks)
TicketsfornonBCAMmembers
are£249
Venue: Celtic Manor Resort, Newport, Wales
Professor Alex
Drfeature
Raj Acquilla
and
more...
TheAnstey,
evening will
a superb gala
dinner
on
the River Thames boat restaurant. Tickets for this
event are just £99 perPharmacy,
ticket and will include
7 x workshopsevening
by Healthxchange
a welcome drink, four course meal and live music.
Wigmore Medical Ltd, Merz Aesthetics and more...
Don’tmissoutonthisyear’sBCAM
Autumnevent,Saturday20th
September2014...Register Now!
Visit www.bcam.ac.uk
and from the membership
tab click on ‘events’
Invitation open to all.
Visit
www.bcam.ac.uk
andSaturday
from the evening
Drinks reception & gala dinner on the
membership tab click on ‘events’
£390 (conference fee , Saturday dinner & accommodation)
£250 (conference fee & Saturday dinner)
£30
per pers
per works
In Practice
Marketing
@aestheticsgroup
Aesthetics Journal
Aesthetics
aestheticsjournal.com
2. Identify who is about to buy
Mastering
Mailchimp
Marketing consultant Dan Travis
explains how using email marketing
effectively can help your business
For me, clinics are split into two groups
when it comes to their approach to
marketing. There are those who use
mailchimp and those who don’t. Those
who are not using the email campaign
service are being left behind and, in my
opinion, will lose out to their competition.
In terms of raising new business I find
mailchimp to be measurably superior to
Google as your main marketing activity and
urge all my clients to dedicate time and
resource to utilising it as a tool. In this article
I will outline four very powerful strategies
that could make an immediate contribution
to your clinic’s profits. The strategies are
based upon close study and the online
course that I run for the aesthetics industry.
By starting with these basic strategies in
mailchimp, the clinic owners and staff that
I have worked with are always surprised
and fascinated by the results of their
efforts. They are even more interested in
turning these results into a process for their
business that will generate profit.
1. Formulate a process
As a clinic owner and/or manager, I have
little doubt that you are under extreme
time pressure. This is why you must invest
time in creating and maintaining business
processes that allow your clinic to run as
efficiently as possible and will ultimately
save you time and unnecessary stress. By
carefully forward planning your marketing
strategy, you can ensure that you are
making the most of any opportunities
to promote your business rather than
60
The subscribers in your mailchimp account
who are most likely to buy products or
services are those who have opened
the most emails. You can see who these
subscribers are after you have sent an
email campaign. Go to the report of your
campaign and click ‘Opened’. Then click
‘opens’ above the numbers until the arrow
points up. The important recipients are
those who have opened the same email
more than twice. From the close studies
that the Marketing clinic has made of this
strategy, we know that those who have
opened three or more times are far closer
to purchase than any other group. You
need to contact these individuals quickly
(preferably within 12 hours) and this is what
you should say:
By carefully forward planning
your marketing strategy, you
can ensure that you are making
the most of any opportunities
to promote your business
missing out due to time constraints. Please
remember to make time in your clinic
diary to take action on the strategies I am
about to outline at least once a month,
even better, once a week. The sooner and
more frequently you take action, the better
and quicker the response. A successful
campaign should have long term and short
term goals and you will need to think about
all aspects including the optimum dates
and times to send emails to your database.
When do you think they will receive the
best response? Do you have a launch or
specific promotions planned that need
to be factored in? Although it is important
to keep content fresh and current, you
can draft, or at least outline, a lot of this in
advance to avoid a last minute rush during
a busy clinic week. Whether it is yourself
or your front of house staff who will be
taking day to day responsibility for sending
client emails, make sure that several
team members are well trained in using
mailchimp to ensure that momentum does
not falter due to planned or unplanned staff
absence.
Aesthetics | August 2014
“Hi, this is XXX from the XXX Clinic. Thanks
for showing an interest in the XXX product/
service, is there anything I can do to help or
any more information that you require?”
This message can be sent by email, SMS
or you can phone them. Some will say “No
thanks, I was just looking.” But some will
say “Yes, can I book an appointment”. The
message may seem brief and simple but
it is highly effective when aimed at this
particular group of potential clients.
3. Find out who is not opening
You need to know who is not opening
because 75% of subscribers who do not
open our mailchimp emails are not aware
that they have received the email. Gmail,
Yahoo and hotmail have all introduced
a “Promotional” inbox. This means that
Google is deciding on your behalf what are
“Promotional” emails and putting them into
another inbox. This can include mailchimp
emails and to prevent this from happening
again, you need to identify the non-openers.
There are two ways to identify your non-
@aestheticsgroup
Aesthetics Journal
openers. Both give you different types of
information about your non-opener’s activity.
The first way of identifying this group is
after you have sent four emails in different
campaigns. Go to ‘Lists’ then single click
‘Member Rating’ to give you the list of one
and two star subscribers in ascending order.
You then need to run the Export process.
The other way of identifying your nonopeners is to go to “Reports” and click on
“View Report” for the last campaign. Below
where it says “Email Subject Lines” you will
see “Activity”. Click here and click “Didn’t
Open”. You need to Export this group using
the Export process. You then need to create
a group in Gmail called ‘non-openers’ and
send them a group email (using BCC) with
an interesting and non-commercial headline.
You need to find ways of reaching your
non-openers after every email that you send
out. Just by sending your email directly
via Gmail, you will bypass the promotional
inbox and end up in the ‘Priority’ inbox. This
means that your email stands a much better
chance of being read. Unfortunately there
will be a percentage of people who ignore
(deliberately or otherwise) your mailchimp
Aesthetics
aestheticsjournal.com
emails. You need to grab their attention by
writing compelling headlines – think about
what they would be interested in hearing
about. You can send them an SMS saying
that you have sent them an email (this
improves the open rate dramatically for any
section of your subscribers).
4. Dysfunctional Emails
Surprisingly to most clinics, identifying and
communicating with the group of email
addresses that failed to reach the recipient
is the most productive of the four strategies.
It produces an immediate result and I urge
you to do this on at least a monthly basis.
Start by going to your first campaign and
looking at your bounced emails (it will show
you this next to the ‘opens’). Export these to
Gmail and label them in a new group called
‘Dysfunctional Emails’. Check which of these
emails you have a mobile phone number
for and send them an SMS on your phone
or via txt local. Most of this group will not
respond but between 10% and 20% will reply.
Of these, some will book an appointment
with you. Those who do reply will be highly
All Things Bright ‘n’ Beautiful
“All Things Bright
‘n’ Beautiful”
BACN Conference
and Exhibition
Friday 3rd October
BACN
Conference
2014
Workshops
and Exhibition
Saturday
4th October
Hilton Brighton Metropole
Join the BACN in BRIGHTON for the not-to-be-missed event of the year!
Highlights:
• Impressive
Friprogramme
3rd of speakers
• Friday evening Dinner/Dance with tribute band
October
• Fantastic
location
Sat 4th
October
See BACN website for Programme, Exhibitors, Accommodation and more.
Hilton Brighton Metropole
Open to ALL professionals within the Aesthetic Industry
t: 01749 836328 e: info@cosmeticnurses.org w: www.cosmeticnurses.org
Impressive Programme of Speakers on Friday - Hot Topics • Presentations &
Demonstrations on Saturday • Friday Evening Dinner/Dance with Band • Fantastic
Location • Beachfront • Shopping • Nightlife • and BRIGHTON COMEDY FESTIVAL
In Practice
Marketing
responsive to your communications (including
email campaigns). This is for two reasons:
first, they have not received an email from
you before. Second, they have expressed
a direct and very recent interest in receiving
information about your clinic.
I hope the information above is as valuable
to you as it has been to many other clinics
that I have been working with in the last
eighteen months. This is only part of the
mailchimp strategy you need to employ to
make an effective process in your business.
There is much more that you can do and
implement in mailchimp and your clinic’s
marketing as a whole, but by learning more
about the benefits that mailchimp can offer
with comparatively little effort, you can make
a strong start on improving your customer
communication marketing.
Dan Travis is director of the
Marketing clinic and provides
business services to clinic
owners. Dan specialises in
providing business education
programmes for the aesthetics
industry. He writes and speaks on how
clinics can overcome the challenges they face
and thrive in the new economy.
In Practice
In Profile
@aestheticsgroup
Aesthetics Journal
Aesthetics
aestheticsjournal.com
“I would like to be
known for being
able to help people”
Karen Betts shares her experience as
a leading permanent cosmetic artist,
medical tattooist and trainer
Karen Betts began her training aged 16.
Ten years later she had opened her own
salon, specialising in colour analysis and
wig making. Designing and styling wigs for
cancer patients was always something Karen
thrived on. Providing her customers with what
Karen calls the “gift of confidence,” is hugely
rewarding, she says.
Soon after Karen opened her salon, a close
friend developed cancer and confided that
one of her biggest fears was losing her
eyebrows. With a tattoo parlour based in the
same building, Karen had an idea.
“After watching the tattooist at work, my
belief was that tattooing eyebrows couldn’t
be much different to drawing eyebrows
on with a pencil,” she explains. Knowing
that conventional tattooing wouldn’t be
appropriate for creating facial features, Karen
began researching alternative methods. Soon
she discovered micro-pigmentation and,
keen to learn more, she embarked on an
educational journey to the US.
“I went to San Francisco on my own,
absolutely scared to death,” she says. “I
went to most of the states, gaining as much
knowledge as possible because at the time
there was no education here in the UK.”
She decided there was a gap in the market
and after six months of hard work, developing
techniques and writing manuals — Karen
opened her first training school, Nouveau
Contour, in 2001.
She began training people in permanent
cosmetic techniques for eyebrows, lips
and eyes and later expanded into medical
tattooing.
Karen now works alongside numerous
charities, specialising in treating cancer
patients, patients with alopecia, cleft lips,
burns and scarring.
“I see a couple of patients a week through
the Katie Piper Foundation, which I really
enjoy,” she says. “As much as I’m giving back
people something they’ve lost, it really makes
me appreciate what I’ve got in my own life.”
62
Making her work look as natural as possible
is Karen’s aim. “If it is good permanent
cosmetics, people don’t even realise you’ve
had it,” she explains.
“Having an artistic eye is extremely important,”
she says. “At Noveau Couture we have a
strong educational programme where we
teach trainees to be more artistic. We look at
face shapes; we look at bone structure; how
to create and draw eyebrows for each face.
As long as they’ve been trained really well
you can teach people to be more artistic.”
Initial consultations with patients are vital
for Karen — each patient has to complete
medical consent forms. “When they come into
the clinic we go through all the forms again,
all the treatments available, and really get to
know the person and what their expectations
are,” she explains. “If we don’t feel that we can
reach their expectations then we definitely
don’t advise the procedure.”
If she knows another specialist can achieve
better results then Karen would have
no qualms referring them. She explains
that a patient may need laser treatment
before she treats them. “I don’t ever think
about doing the laser treatment myself,”
she says. “I send patients to practitioners
who specialise in laser. I would never take
anybody’s money just because they’ve
walked through my door.”
Strategy, planning and structure — these are
the key ingredients for running a successful
business says Karen. “I go home every
evening making sure I’ve planned the
structure for the next day, organising what
the priorities of the business are and what I
need to be working on.”
At the moment, there is no official body
governing the regulation of medical
tattooing and permanent cosmetics. Instead,
Karen offers her trainees Nouveau Contour
qualifications, recognised in more than
twenty countries. Trainees can take a range
of different courses, which all involve case
studies and four levels of exams.
Aesthetics | August 2014
In the future Karen hopes that she can raise
awareness of how permanent make-up and
medical tattooing can appear very natural.
“Now I’m trying to make sure people know
it’s a safe procedure, carried out by safe
technicians who have been trained well.”
After recently winning the Beauty Guild
award for best eyelashes, designed with
alopecia patients in mind, Karen says, “I
see myself as a business entrepreneur and
would like to be known for being able to
help people, and most importantly give them
back the gift of confidence.”
Q&A
What is your proudest moment yet?
When I tattooed eyebrows on a woman
I met through the Katie Piper foundation,
she burst into tears as soon as I showed
her the results. She was crying with joy.
What treatment do you enjoy carrying
out the most?
Breasts for medical tattooing. Giving my
clients back areolas and nipples after
they’ve gone through breast cancer is just
like the final end to their journey.
What’s the most difficult procedure
you do?
Treating vitiligo. The results are not as
successful as you’d like them to be
because the skin type can change. In
bigger areas on Caucasian skin it’s not
always as effective as I’d want it to be.
What advice would you give to
practitioners in this field?
Practice, practice, practice; that’s the only
way they’re going to stay ahead of the
game and gain more confidence. They
need to continue training and professional
development — don’t ever just think
that you’re good enough or the best,
things change constantly. I change my
techniques yearly, there is always scope
to learn.
TRAINING WORKSHOPS
TRAINING WORKSHOPS WILL BE
RUNNING THROUGHOUT
SEPTEMBER & OCTOBER 2014
BOOK YOUR PLACE TODAY AT
silhouettetraininguk@sinclairpharma.com
FOR MORE INFORMATION
CONTACT US AT
+44 (0) 207 467 6920
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M 00
J6
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pantone 2985 C
C 100
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SINCLAIR PHARMACEUTICALS
WHITFIELD COURT
30-32 WHITFIELD STREET
LONDON
W1T 2RQ
+44 (0) 207 467 6920
In Practice
The Last Word
@aestheticsgroup
Aesthetics Journal
The last word
How traceable is the product you are injecting
into your patient? Roseanne Aitken argues the
accountability of practitioners in dealing with
product traceability
At the heart of the 2013 Keogh report
lies the person who chooses to have a
cosmetic procedure. While the vast majority
of non-surgical treatment providers care
deeply for the safety of their patients, are
a small minority overlooking an important
aspect of patient care?
As Dr Patrick Bowler wrote in the Huffington
Post, following the release of the Keogh
report, “The entire review is about putting
the patient at the heart of cosmetic
treatments. Every patient has the right to be
protected by legislation that makes them
feel confident that they will be well looked
after and safe.”1
Injectable non-surgical treatments fall under
the Medical Devices regulatory product
group. To provide guidance, the Medicines
and Healthcare products Regulatory Agency
(MHRA) recently released Managing Medical
Devices (April 2014), and Devices in Practice
(June 2014). The latter contains checklists for
using medical devices. The Record Keeping
checklist emphasises the need for recording
where the medical device is from, it’s serial
or batch number, and expiry date. This
product traceability is a critical requirement
for distributors and manufacturers as well.
Regular audits by Notified Bodies on ISO
certified distributors and manufacturers
always include a detailed check on product
traceability. Product traceability however,
may well be the Achilles heel of the
excellent work carried out by bodies and
practitioners striving to protect the patient.
When your patients give signed consent for
their treatment, they do so trusting that their
clinician has covered all aspects necessary
for their safe care.
Reputable practitioners keep accurate
64
records of product LOT or serial numbers
injected into patients. This information
becomes meaningless if, further back
in the chain of supply, there has been a
break in traceability. If an adverse event
occurs, if a product recall is needed, or if
the manufacturer needs to highlight safety
aspects of the product, there must be no
break in traceability from manufacturer to
patients. The patient has no protection if
such a break occurs.
How could such a patient-risk
situation develop?
It develops hand-in-hand with a so-called
‘grey market’ of product. A grey market (or
parallel market) is the trade of a product
through distribution channels which, while
legal, are unofficial, unauthorised, or
unintended by the original manufacturer. The
most common type of grey market is the sale
of imported goods brought in by small import
companies or individuals not authorised by
the manufacturer, and who have obtained
these goods from third parties.
The sale of grey market goods is of concern
across diverse industries, ranging from
snacks and drinks to clothing and cosmetics.
The concern is especially acute with medical
devices. Suppliers of grey market goods
sold outside authorised distribution channels
have no relationship with the producer of
the medical device. The manufacturer is
completely unaware of where their product
has ended up. For the patient, there is
no traceability and no protection. The
medical device grey market is substantial.
Sellers of grey market goods are smart and
determined, and substantial money is at
stake for them. They often use the EU “free
Aesthetics | August 2014
Aesthetics
aestheticsjournal.com
movement” of goods rationale to support
their unauthorised sales. Anything that it is
legal to sell in the EU can be sold anywhere
in the EU. When it comes to injectable
medical devices however, this blithe free
movement argument shouldn’t be applied
in the same way as in the grey market of
chocolates, cars and other products. Often
grey market suppliers tempt clinicians
with an offer of a lower priced product.
If clinicians take up this offer, appearing
unaware of, or even not caring about the
implications of a grey market product for
their patients, then who does care?
Apart from the patient, it is the authorised
country suppliers of the product as well
as the manufacturers who care. These
suppliers and manufactures ensure that all
medical devices they provide to you are
fully traceable. Authorised country suppliers
have the clinical and sales support of the
manufacturer and hold product liability
insurance. Grey market suppliers have
none of these and are seeking to get a free
ride on the manufacturer’s good name and
reputation. The waters are further muddied
for the clinician by the existence of private
labellers. Checking whether traceability
exists may not be a simple case of looking
for the name of the manufacturer on the
product label. How can you, as a reputable
clinician or clinic, ensure you are not
purchasing grey market products and that
all your treatments are fully traceable and
supported by the manufacturer?
The answer is to ask your local supplier for
a supporting letter from the manufacturer.
The letter should confirm that the individual
or company from whom you are purchasing
is indeed the authorised distributor of the
product, and that you and your patients can
be assured that the product you are using
is fully traceable from source. Not only will
you have the full sales and clinical support
of the manufacturer, but if there is ever any
potential risk to your patient you will be the
first to know.
Roseanne Aitken is the
managing director of Medira
Ltd, a company specialising
in biomaterials for the skin
regeneration and rejuvenation
market. Roseanne has more
than two decades experience in the medical
device industry, working closely with
Regulatory Bodies, Quality Assurance and
Clinical Management in the wound healing
and reconstruction segments.
REFERENCES
1. Dr Patrick Bowler, Huffpost Lifestyle, UK (The Huffington Post, 24/04/2013, <http://www.huffingtonpost.co.uk/dr-pat
rick-bowler/cosmetic-surgery-report_b_3145470.html> [date accessed: 14/07/2014]
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LONDON SALES REPRESENTATIVE
OPPORTUNITY
Join a dynamic company rapidly expanding in the UK medical
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Please send your CV and covering letter to
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Not all HA dermal fillers
are created equal.
Intelligent manufacturing
technology creates a variable
density gel1 resulting in...
Optimal tissue integration2
Greater dermal compatibility3
Superior cosmetic results4
High patient satisfaction5
Contact Merz Aesthetics
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OPTIMAL
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INTEGRATION
Injectable Product
of the Year 2013
1. BEL-DOF3-001_01. 2. Tran C et al. in vivo bio-integration of three Hyaluronic Acid fillers
in human skin: a histological study. Dermatology DOI:10.1159/000354384. 3. Taufig A.Z. et
al., J Ästhet Chir 2009 2:29 – 36. 4. Prager W et al. A Prospective, Split-Face, Randomized,
Comparative Study of safety and 12-Month Longevity of Three Formulations of Hyaluronic
Acid Dermal Filler for Treatment of Nasolabial Folds. Dermatol Surg 2012, 38: 1143 – 1150.
5. Buntrock H, Reuther T, Prager W, Kerscher M. Efficacy, safety, and patient satisfaction of a
monophasic cohesive polydensified matrix versus a biphasic nonanimal stabilized hyaluronic acid
filler after single injection in nasolabial folds. Dermatol Surg. 2013; 39(7):1097-105.
BEL092/0314/FS Date of preparation: April 2014