Results Without Compromise

Transcription

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VOLUME 3/ISSUE 1 - DECEMBER 2015
Results
Without
Compromise
New For January 2016
Marini Luminate Eye Gel
Marini Luminate Face Mask
The ABC
of Moles CPD
Mrs Barbara Jemec explains how
to recognise a malignant melanoma
Vaginal
Rejuvenation
Treating the
Brow Area
Marketing
to Men
Practitioners discuss
patient concerns and
options for successful
treatment
Dr Victoria Dobbie
details her techniques
for treating eyebrow
aesthetic concerns
Charlotte Moreso
highlights the best
ways to attract male
patients to your clinic
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Contents • December 2015
06 News
The latest product and industry news
14 On the Scene
Out and about in the industry this month
16 News Special: Reflection on 2015
Practitioners discuss developments in the industry this year
19 Aesthetics Conference and Exhibition 2016
A look at the latest additions to the ACE 2016 Conference agenda
CLINICAL PRACTICE
Special Feature
Evolution of Vaginal
Rejuvenation
Page 21
21 Special Feature: Vaginal Rejuvenation
Practitioners highlight patient concerns and treatments for the vagina
Clinical Contributors
26 CPD: The ABC of Moles
Consultant plastic surgeon Mrs Barbara Jemec explains how to recognise and treat a malignant melanoma
31 Treating the Brow Area
Dr Victoria Dobbie details her technique for addressing eyebrow concerns
35 Copper in Skincare
Dr Charlene DeHaven explores the use of copper in advanced skincare
38 Body Dysmorphic Disorder in Aesthetic Practice
Dr Dimitre Dimitrov and Dr Anthony Bewley discuss how to manage patients with BDD
42 Treating Birthmarks with Laser
Dr Salinda Johnson outlines the types of birthmark and how to treat them
44 Assessing the Lips for Successful Rejuvenation
Dr Souphiyeh Samizadeh gives insight and advice for lip-treatment trends
47 Managing Acne
Dr Terry Loong shares her aproach to treating acne and managing patients
51 Spotlight On: Radara
Aesthetics examines the new micro-channelling skincare system 53 Abstracts
A round-up and summary of useful clinical papers
IN PRACTICE
54 Team Motivation
Victoria Vilas describes ways to motivate your team and boost trade
57 Finding the Funding Key to Business Growth
Peter Nolan explains clinic financing options
59 Introducing Laser and IPL Hair Removal to Clinics
Christine Clarke discusses why it can be beneficial to introduce hair
removal treatments to your clinic
63 Patient Cancellations
Professor Bob Khanna shares his methods of managing late or cancelled clinic appointments
Mrs Barbara Jemec is a consultant plastic surgeon
at the Royal Free Hospital with a special interest in skin
cancer, as well as a member of its Multidisciplinary Team
(MDT). The MDT works together to discuss both NHS
and private patients with skin cancer.
Dr Victoria Dobbie has 13 years experience in
aesthetics and has carried out more than 20,000
treatments. She is the director of the Face and Body
clinic in Edinburgh, and previously ran her own dental
clinic with the Royal Army Dental Corps.
Dr Charlene DeHaven is a certified physician in
Internal and Emergency Medicine emphasising on age
management and health maintenance. She is currently
serving on the lecture faculty for the University of
Washington Department of Family Medicine.
Dr Dimitre Dimitrov graduated medical school
and specialised in dermatology and venereology
in Bulgaria. He received full registration with the
GMC in 2011 and is currently an honorary consultant
at Whipps Cross Hospital and London Royal Hospital.
Dr Anthony Bewley is a consultant dermatologist
at Whipps Cross University Hospital and the Royal
London Hospital and lectures at the Universities of
London and Hertfordshire. He is trained in all aspects
of adult and child dermatology.
Dr Salinda Johnson is an aesthetic practitioner
and has completed a specialist fellowship programme
in cosmetic dermatology. She has lectured and trained
in the specialty for many years, incorporating up-todate procedures and best practice as they develop.
Dr Souphiyeh Samizadeh is a dental surgeon with a
special interest in medical aesthetics. She is an honorary
clinical teacher at King’s College London and the clinical
director of the Revivify London clinic. Dr Samizadeh also
speaks at both national and international conferences.
Dr Terry Loong graduated from Guy’s and
St. Thomas’ Hospital and completed her postgraduate
qualifications with the Royal College of Surgeons.
Her earlier training was in general and plastic surgery
before she began specialising as an anti-ageing doctor.
64 Marketing to Men
Charlotte Moreso provides advice on how to attract men to your clinic
67 In Profile: Nigel Mercer
Mr Nigel Mercer reflects on his career in plastic surgery and aesthetics 69 The Last Word
Dr Asim Shahmelak argues why we should put an end to the hard sell in aesthetic practice
NEXT MONTH
• IN FOCUS: Weight-loss • CPD: Treating Scars in Asian Skin
• Radiofrequency • Choosing Insurance
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Editor’s letter
Welcome to the December issue of the
Aesthetics journal; I can’t quite believe it’s the
end of the year already – where has the time
gone? As we prepare to send this issue to the
printers, we are in the final weeks of preparation
for the Aesthetics Awards and it really does
Amanda Cameron
not seem like 12 months ago that it last took
Editor
place! We are delighted that this year’s Awards
finalists include newcomers as well as more established names, who
each have a capacity for hard work and all presented the judges
with a challenge when deciding the winners. The last 12 months in
the aesthetics industry has been interesting as always, and it is no
surprise that the market continues to grow significantly.
Turn to p.16 to read our review of the year, where we talk to
practitioners about the advances, challenges and highlights of 2015.
We’d also love to hear your thoughts on the year and find out what
you’re looking forward to in 2016, so get in touch with us using the
contact details listed below.
One of the growing treatment sectors in 2015 has most certainly
been vaginal rejuvenation. More and more practitioners are
starting to offer procedures that can potentially enhance both the
appearance and function of the vagina, which, according to reports,
is becoming increasingly popular with women in the UK. For our
Special Feature, we speak to five practitioners, offering different
types of treatments, about patient concerns, techniques and the
results of vaginal rejuvenation – read their views on p.21. As we treat
our patients’ aesthetic concerns, it is also important to remember the
serious side of dermatology. As such, this month’s CPD article on
the ABC of Moles (p.26), written by consultant plastic surgeon Mrs
Barbara Jemec, shares advice on recognising suspicious lesions.
Please do read it carefully to ensure that your patients are given
appropriate treatment when necessary.
On a lighter note, I am sure you are all seeing increased footfall in
your clinics as the Christmas party season is upon us. And while it is
usually women seeking aesthetic treatment, there is the chance that
more men will be inclined to consider our services during the festive
period. To help you pique their interest, public relations director
Charlotte Moreso has written a fantastic article with lots of practical
tips on Marketing to Men, featured on p.64.
Finally, on behalf of the Aesthetics team, I’d like to say that
we’re all looking forward to seeing you at the Awards and wish you
a wonderful Christmas!
Let us know how your year has gone by tweeting us
@aestheticsgroup or emailing editorial@aestheticsjournal.com
Editorial advisory board
We are honoured that a number of leading figures from the medical aesthetic community have joined Aesthetics journal’s
editorial advisory board to help steer the direction of our educational, clinical and business content
Mr Dalvi Humzah is a consultant plastic, reconstructive and
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.
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.
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).
Dr Tapan Patel is the founder and medical director of VIVA
and PHI Clinic. He has more than 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 and gives presentations
at conferences worldwide.
Dr Christopher Rowland Payne is a consultant
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.
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 Sarah Tonks is a cosmetic doctor, holding dual
Dr Maria Gonzalez has worked in the field of dermatology
qualifications in medicine and dentistry. Based in Knightsbridge,
London she practices a variety of aesthetic treatments. Dr Tonks
has appeared on several television programmes and regularly
speaks at industry conferences on the subject of aesthetic
medicine and skin health.
for the past 22 years, dividing her time between academic work
at Cardiff University and clinical work at the University Hospital
of Wales. Dr Gonzalez’s areas of special interest include acne,
dermatologic and laser surgery, pigmentary disorders and the
treatment of skin cancers.
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mandy@aestheticsjournal.com
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chloe@aestheticsjournal.com
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Aesthetics Journal
Aesthetics aestheticsjournal.com
Submental fat
Talk #Aesthetics
Follow us on Twitter @aestheticsgroup
#OpenDay
Simons Vitiligo Blog @SiVitilgoBlog
@DrAnjaliMahto Great talk today on current #Vitiligo
treatment and exciting research at @VitilgoSociety Open Day.
#Advice
Dr Mark Hamilton @CosmeticDrMark
Before injecting a simple wipe isn’t enough. If the pad
still has traces of makeup on it its not clean. Then use
antiseptic. Biofilm exists!
#Skin
Dr Emma Wedgeworth @DrEmWedgeworth
Good talk to the team @BBCRadioLondon this morning
about impact of skin conditions on young people.
A subject I’m passionate about.
#Clinic
Dr Stefanie Williams @DrStefanieW
Most exciting Friday – just signed the lease to our new
clinic premises! Should get some champagne out…
#LiveShow
Dr Raj Acquilla
@RajAcquilla
Rammed live show here
in #Egypt today with
my friend and mentor
#KeonDeBoulle @Allergan
#Botox #Juvederm
#Dermatology
Wendy Lewis & CO LTD @WendyLewisCO
At the @Syneron #ConfluenceOfPower event in Wash DC
– top #dermatologists sharing their expertise @DrTanzi
@DrTKeaney @ClarusDerm
#Collaboration
Dr Johanna Ward @DrJohannaWard
Delighted to be working alongside Mr Taimur Shoaib to
deliver first class cosmetic surgery @skinandbodyclin
#Sevenoaks #CosmeticSurgery
Study suggests Kybella
is effective in men
A study has indicated a reduction in submental fat in men using
deoxycholic acid. The research comes from two identical phase III
trials of 1,022 patients with moderate to severe submental fat. Patients
received either six treatments of deoxycholic acid (Kybella) or a
placebo, over the course of a month.
Researchers then analysed the results of 156 men; 80 of whom
received deoxycholic acid and 76 who received a placebo, 12 weeks
after the final treatment. A composite 1-grade and 2-grade response,
based on investigator and patient assessment, was then measured.
Men receiving deoxycholic acid had a composite 1-grade response of
64.4% compared with 8.6% in the placebo treatment group and 9.6%
compared with 0% in the composite grade-2 response. The majority
of patients using the Subject Self Rating Scale reported being happy
with their appearance after treatment with deoxycholic acid (79.2%)
compared with those in the placebo group (22.9%). “The post-hoc
analysis of the Refine-1 and Refine-2 trials showed that men got very
good results, just like women did,” said researcher Dr Vince Bertucci.
Acquisition
Lumenis acquires Pollogen
Global laser manufacturer Lumenis has completed the acquisition
of Israeli-based medical aesthetics company Pollogen.
Tzipi Ozer-Armon, CEO of Lumenis said, “We are excited to
welcome the Pollogen team into the Lumenis family. This transaction
complements our aesthetic product portfolio and positions Lumenis
well in the dynamic beauty market.” She added, “The addition
of Pollogen’s extensive portfolio is key to continuing to provide
tailored and innovative beauty solutions to all of our existing and
future aesthetic customers.”
Zion Azar, co-founder and chairman of Pollogen said, “This transaction
is a positive outcome for our shareholders, employees and customers.
We are thrilled to join the Lumenis team and further develop our
products and presence in this rapidly developing market.”
Laser
FDA expands indications
for Syneron Candela
C02RE device
The Food and Drug Administration (FDA) has granted its
approval for Syneron Candela’s C02 laser to be used for multiple
indications. A total of 90 specific indications have now been
approved for the system, including, scars, wrinkles, a wide array of
dermatology indications and gynecology applications. Amit Meridor,
chief executive officer of Syneron Candela, said, “This broad range
of newly FDA cleared clinical indication of the CO2RE will enable
Syneron Candela to address new physician markets with very high
patient demand and creates a significant business opportunity for
the company.”
Reproduced from Aesthetics | Volume 3/Issue 1 - December 2015
aestheticsjournal.com
@aestheticsgroup
Aesthetics Journal
Aesthetics
Botulinum toxin
Study indicates botulinum
toxin may be effective to treat
posterior cheek enlargement
in HIV patients
According to the results of a pilot study led by Dr Alastair Carruthers,
botulinum toxin injections could be an effective, long-lasting treatment for HIV
patients suffering from posterior cheek enlargement. Five HIV-positive men,
all with posterior cheek enlargement, took part in the study and were treated
with a total of 100 units per patient, divided into 50 units per side, injected into
five points on each side directly within the area of enlargement. Improvement
was measured through clinical, photographical and radiological evaluations.
According to the research team, 100% of test patients had good results, with
a 21.4% mean decrease in masseter muscle volume and a 11.2% decrease in
the volume of the parotid gland. Adverse effects, though short-lived with an
approximate duration of one to four weeks post injection, included decrease in
bite force, sunken cheeks and change in facial expression. The researchers claim
that all patients continued to be satisfied with the results at six-month follow-ups,
and although one patient did not follow-up at 12 months, the remaining four were
reported to be either “satisfied” or “very satisfied”. The researchers concluded,
“Botulinum toxin A was found to be effective for posterior cheek enlargement
and could represent a novel treatment for this condition.” They continued, “This
was easy to administer, generally well tolerated with no downtime and provided
long-lasting results. However, it is a temporary treatment, and injections need to
be repeated to maintain the desired result.”
Laser
Naturastudios launches the
Forma Magma Diode
Aesthetic equipment supplier Naturastudios
has introduced a new platform offering a
diode laser, Nd:YAG and IPL.
The Forma Magma Diode aims to treat
unwanted hair, pigmented lesions, vascular
lesions, active acne and nail fungus, as well as
offering skin lightening and photo rejuvenation
treatments. A cooling system is also included
which aims to make treatments more
comfortable.
A clinical study – Comparison of Long Pulsed
Diode and Long Pulsed Lasers for Hair
Removal: A Long Term Clinical and Histologic
Study – carried out by the Washington Institute
of Dermatologic Laser Surgery and Georgetown
University Medical Center, found an 86%
reduction in hair after just three sessions using
the device. The device also claims to treat
skin types 1-6 quickly and efficiently and can
be used on patients during summer months,
when they are likely to have an active tan. The key features of the device include;
diode laser 808nm, 1064nm Nd:YAG laser, a choice of 10 IPL applicators and an
electrical melaninometer.
Countdown to ACE 2016
Latest programme updates
Dr Daron Seukeran is set to run
an Expert Clinic session exploring
the benefits of different laser
treatments for problem-skin patients.
Dr Sotirios Foutsizoglou will
be presenting on hair transplant
techniques with an anatomy and
physiology analysis at an Expert
Clinic session on Saturday 16.
Insight
Aesthetic nurse, BACN Chair
and ACE Steering Committee
member Sharon Bennett says:
“The Aesthetics Conference and
Exhibition is a great opportunity to
learn about the latest products and treatments
and share experiences with colleagues. ACE
sessions are always full of practical content
that professionals can bring to their clinics the
next day. I’m honoured to be part of the ACE
team and to be among next year’s Conference
speakers at the session dedicated to perioral
rejuvenation treatments. Practitioners attending
the Conference will have the opportunity
to perfect their skills and gain in-depth
knowledge on consultation, treatment options,
complication management and best practice
for each anatomical area. The ACE 2016
Conference programme, as well as the other
clinical and business content, is extremely
well-designed to guarantee all delegates an
outstanding learning experience.”
What delegates say
“Now with nurses needing
revalidation, it is important
to get a certificate and
CPD points. I think that the live
demonstrations, the masterclass
sessions, the exhibition and all of the
programme content is good for the
professional development and ACE is
the best conference to attend.”
Aesthetic Nurse, Gloucestershire
HEADLINE SPONSOR
@aestheticsgroup
Radiofrequency
Aesthetics Journal
Industry
Alma Lasers
introduces new
handpiece for Alma
Accent
A new ultrasound handpiece has been launched
for use with the radiofrequency-based device
Alma Accent. The body contouring handpiece
aims to make treatments quicker, more comfortable
and cost effective by targeting 60cm squared in
a single session. The handpiece aims to work by
utilising patented ultrasound selective resonance,
which uses cold and hot ultrasonic waves that
selectively resonate with and destroy fat cells, while
leaving surrounding tissue unharmed. The company
claims that selective sound waves disrupt fat cell
membranes, which leads to the gradual breakdown
and release of stored fat through the lymphatic
system. Alma Accent is approved by the FDA for use
on the face and body.
Skincare
Elizabeth Arden
PRO releases two
new products
Skincare brand Elizabeth Arden PRO has released
two products that aim to provide an instant boost
of skin hydration and refreshment. The Hydrating
Antioxidant Spray, which has been designed as
an ‘on-the-go’ product, includes a range of key
antioxidants such as; ferulic acid, resveratrol, white
tea, ergothioneine and carnosine, and sodium
hyaluronate. The company claims that the spray
provides lightweight moisture and is beneficial for
all skin types. The Intense Hydrating Cream aims to
strengthen the skin’s natural defences by working
to reduce the appearance of fine lines and wrinkles,
and includes essential ingredients including; lactic
acid (AHA), sodium hyaluronate, flaxseed extract,
ceramides, caprylic/capric triglyceride, salicornia
herbacea extract, sodium PCA and marimoist.
Allergan to acquire earFold
Allergan is to acquire Northwood Medical Innovation, the developer of
earFold. Implant technology earFold is a medical device for the correction of
prominent ears in patients aged seven or older. Allergan hopes the technology
will add to its medical aesthetics product portfolio and provide patients with an
alternative to corrective surgery. The small implantable device is made from a
short strip of nitinol metal alloy, which is designed to retain a pre-set shape. It
is inserted under the skin and works by gripping onto the cartilage of the ear,
enhancing or creating the shape of the anti-helical fold – thereby reducing the
prominence of the ear. Mr Norbert Kang, consultant plastic surgeon and creator
of the earFold, said, “In my clinical practice, there are a significant number of
patients who are reluctant to undergo surgery and so put up with accepting the
social hindrance of prominent ears. The beauty of the earFold treatment system
is that it offers an evidenced-based alternative to standard otoplasty surgery
that may meet the needs of a wider range of patients, by delivering immediate
and predictable results, without the risks associated with general anaesthetic.”
Allergan hopes earFold will provide patients with a rapid and more predictable
alternative to surgery. Paul Navarre, president and EVP of international brands
at Allergan said, “Allergan is constantly searching to partner with or acquire
companies with disruptive technologies that offer substantive value to our
customers, often opening up new categories or setting new trends within our
specialist segments. Many of Allergan’s plastic surgery customers currently
perform otoplasty (pinnaplasty) procedures, emphasising our commitment to
serving the unmet needs and practice of plastic surgery.”
Weight loss
Obesity to be referenced
in advertising
The Committee of Advertising Practice (CAP) has announced that for the first time,
advertisers of responsible lifestyle weight loss programmes can make reference
to obesity in their advertising. The change in advertising rules comes among wider
public policy initiatives to try and tackle the issue, and now means advertising can
be targeted at people who are classed as obese. “These new rules strike a sensible
balance,” said Shahriar Coupal, director of the CAP. He continued, “Providing weight
loss management programmes that meet necessary criteria allows advertisers the
freedom to target their advertising at people who are obese while ensuring the
right level of protections for consumers are in place.” The new rule will come into
immediate effect and be reviewed by the CAP in 12 months’ time.
Industry
Lifestyle Aesthetics becomes
Teoxane UK
After more than ten years of partnership with distribution company Lifestyle
Aesthetics in the UK, Teoxane Laboratories has announced the two companies
are to merge together as one. Teoxane Laboratories hopes the new UK subsidiary
will help to further the global expansion of the company’s hyaluronic acid filler
products. Lifestyle Aesthetics founders Sandra Fishlock and Sue Wales, who
will lead Teoxane UK, said, “After a strong ten year partnership with Teoxane
International, we feel this latest business transition allows us to expand and improve
both awareness and product innovation into the UK market. We are delighted to
have joined forces and become Teoxane UK.”
@aestheticsgroup
Aesthetics Journal
Aesthetics
Conference
ACE Business Track
sponsor announced
Aesthetic distributor Church Pharmacy has announced its sponsorship
for the Aesthetics Conference and Exhibition (ACE) 2016 Business Track
sessions. This is the second year Church Pharmacy has chosen to support
the ACE 2016 Business Track sessions, which provides expert guidance
on building, sustaining and growing a practice in medical aesthetics. “Last
year the response of the Business Track attendees was great, it was nice
to know the delegates found it so useful and were able to take things away
to improve their businesses from industry experts,” said Zain Bhojani, codirector of Church Pharmacy. He added, “ACE is one of my favourite shows
and we have exhibited there more than any other show so far. Most of the
delegates at ACE are customers and as Church Pharmacy is primarily an
online business it’s a great opportunity to meet them face to face, which is
why I am excited to sponsor and contribute to the success of the Business
Track again in 2016.” Speaking in regards to 2015’s Business Track, Bhojani
said there was a good response from those attending and people really
benefited from the quality and diversity of the speakers. “I think everybody
recognises the speakers, they are all faces within the industry and always
have something new, innovative and useful to say. Church Pharmacy are
delighted to be the proud sponsors of the ACE 2016 Business Track and
look forward to discussing the success and new features of DigitRx which
continues to lead the industry.” he said. The Business Track has a particular
focus on supporting small businesses; providing sales, marketing and
regulation advice and ideas on how to enhance their practice.
To find out more and to register for ACE 2016 visit
Melanoma
Vital Statistics
In a survey of 2,006
respondents, 40% said they
would undergo aesthetic
treatment to satisfy their partners
(Intraline Medical Aesthetics)
At least two 15-34 year
olds are being diagnosed
with malignant
melanoma every day in the UK
(British Skin Foundation)
More than 480,271 laser
skin-resurfacing treatments were
performed in 2014 globally
(International Society of Aesthetic Plastic Surgery)
Research in
2014 suggested
that there was a
109% rise in the number of people
undergoing cosmetic treatment
abroad over a two-year period
(WhatClinic.com)
Skin cancer risk could
increase with more than
11 arm moles
New research published in the British Journal of Dermatology suggests
people with more than 11 moles on their right arm are at a higher risk
of developing skin cancer. Researchers claim that counting moles on the
right arm is the best indicator to how many moles someone has altogether.
Having more than 100 moles on the body is thought to be a ‘strong
indicator’ of a higher risk of melanoma.
The study examined data from 3,594 female Caucasian twins. Specially
trained nurses from St Thomas’ Hospital in London performed a mole
count on 17 areas of the twins’ bodies. Researchers found that the number
of moles on the right arm was the most reliable predictor of total mole
count than any other area. Further information on skin type, hair and eye
colour, and freckles were also recorded.
“The findings could have a significant impact for primary care, allowing
GPs to more accurately estimate the total number of moles in a patient
extremely quickly via an easily accessible body part,” said Simon Ribero
from the department of twin research and genetic epidemiology.
He added, “This would mean that more patients at risk of melanoma can
be identified and monitored.” Malignant melanoma is now the fifth most
common cancer in the UK, with more than 2,000 people dying from the
disease each year.
1 in 3 facial surgeons
in the US claim that they saw an
increase of patients requesting
cosmetic surgery in 2014 due to
the popularity of ‘selﬁes’
(American Academy of Facial Plastic and Reconstructive Surgery)
In a survey of 500 females,
38% said that they would consider
cosmetic surgery procedures
(OnePoll)
Approximately 85%
of people between the ages of 12 and
24 experience minor acne
(British Journal of Dermatology)
@aestheticsgroup
Events diary
3rd – 4th December 2015
B.A.D Research Techniques Course, London
www.bad.org.uk/events
5th December 2015
The Aesthetics Awards 2015, London
www.aestheticsawards.com
22nd January 2016
RSM Aesthetics 8, London
www.rsm.ac.uk/aesthetics8
28th – 31st January 2016
IMCAS World Congress 2016, Paris
www.imcas.com/en/attend/imcas-worldcongress-2016
4th – 8th March 2016
American Academy of Dermatology Annual
Meeting, Washington D.C.
www.aad.org/meetings/2016-annual-meeting
30th March – 2nd April 2016
AMWC World Congress 2016, Monte Carlo
www.euromedicom.com
15th – 16th April 2016
Aesthetics Conference & Exhibition, London
Aesthetics Journal
Conference
New speakers announced
for ACE 2016
New speakers for the Expert Clinic agenda at next year’s Aesthetics Conference
and Exhibition (ACE) have been announced. A host of new presenters will join the
established team of industry leaders at ACE 2016, providing informative discussions
on the latest aesthetic topics and performing live treatments using the most up-todate techniques and products. April 15 will include talks from aesthetic practitioner
Dr Victoria Dobbie, who will present on botulinum toxin off-label indications;
plastic and cosmetic surgeon, Mr Adrian Richards, who will compare surgical
and non-surgical options for the face; dental surgeon and aesthetic practitioner,
Dr Souphiyeh Samizadeh, who will discuss different facial skeletal patterns and
how to optimise facial aesthetics; aesthetic practitioner Miss Sherina Balaratnam,
who will present the three-dimensional approach to injectables as well as a talk
by nurse prescriber and director of AestheticSource, Lorna Bowes. The day will
also have an international presence, with Serbian plastic surgeon Dr Vladislav
Ribnikar to go through treatments using PDO threads. April 16 will include sessions
led by aesthetic practitioner Dr Lee Walker, who will explain lip augmentation;
dermatologist Dr Daron Seukeran, who will examine the range of laser treatments
available for the skin; aesthetic practitioner, Dr Sangita Singh, who will explain ‘the
red flag patient’; cosmetic surgeon, Dr Sotirios Foutsizoglou, who will share hair
transplant techniques, anatomy and physiology, and dental surgeon Dr Kishan
Raichura together with aesthetic doctors Dr Sarah Tonks and Dr David Jack, who
will lead the session on different approaches to lower face treatments.
To book your place at ACE 2016 and to find out more about the speakers visit
Surgery
Aquisition
Med-fx bought
by The Dental
Directory
The Dental Directory has acquired Med-fx as part
of its growth strategy.
Facial aesthetics and skin rejuvenation provider
Med-fx has a long history of working with The
Dental Directory, which claims to be the largest
purchaser of dental products in the UK. The
addition of Med-fx to the company opens up a
new segment of the medical sector, as well as
expanding its product offering. Chief operating
officer at The Dental Directory, Mark Stephenson,
said, “Med-fx is a great brand and a natural fit
for The Dental Directory. We are delighted to be
expanding our facial aesthetics expertise for our
existing dental clients as well as providing Medfx customers with a superior choice of medical
supplies partner.”
The deal formalises the relationship between the
two companies and it is hoped the partnership will
deliver enhanced value and service for customers
of both organisations.
RCS calls on surgeons to prepare
for changes in standards
The Royal College of Surgeons (RCS) is requesting that hospitals and cosmetic
and aesthetic surgeons prepare for changes that will improve standards of care
in the industry. From spring 2016, surgeons will be able to apply for certification
that will show they are qualified and competent to perform specific procedures.
It is hoped this will allow surgeons working in the private sector to demonstrate
that they have reached a high standard of training and experience to perform
cosmetic surgical procedures. Mr Stephen Cannon, chair of the Cosmetic Surgery
Interspecialty Committee (CSIC), which was set up to oversee the changes said,
“We are calling on all surgeons who perform cosmetic surgery to prepare for these
very important changes. This new system of certification will raise standards of care
for patients and enhance the reputation of the profession as a whole.”
Currently, cosmetic surgery is not defined as a specialty, but from spring next year,
surgeons will be able to demonstrate their skills and expertise upon certification.
“It will make cosmetic surgery safer for patients, who for the first time, will be able
to identify a highly qualified, experienced surgeon to perform a procedure through
a register of surgeons,” said Mr Cannon. He continued, “It will also make it simpler
for hospitals to check the qualifications, experience and training of the doctors who
work there. All eligible surgeons should apply for certification.”
Surgeons will be able to obtain certification in one or more groups of closely
related procedures, as long as they are on the General Medical Council’s specialist
register, in a specialty that demonstrates training and experience in the chosen
area of practice, and they can demonstrate they meet certification requirements.
These changes come in response to the PIP breast implant scandal, which led to
the Keogh report in April 2013.
@aestheticsgroup
Aesthetics Journal
Aesthetics
Laser
Syneron Candela releases
PicoWay Resolve
Aesthetic medical device company Syneron Candela has launched a new dual
wavelength fractional modality for the PicoWay picosecond laser.
The Resolve fractional picosecond modality features both 532nm and 1064nm
wavelengths. The device employs a holographic fractionator, which aims to
deliver precise, consistent energy to the entire treatment area. The two different
wavelengths aim to allow treatment of shallow lesions with the 532nm wavelength
and deeper lesions with 1064nm.
“PicoWay continues to exceed expectations and delight customers,” said Amit
Meridor, chief executive officer of Syneron Candela. “We are thrilled to introduce
to the market the next step in the PicoWay story, Resolve, the fractional modality
that uniquely includes two wavelengths. Our PicoWay customers know that we
have a robust road map for PicoWay which includes expanded applications and
new capabilities enabled by outstanding technology. It is energising to witness the
excitement that this product is experiencing in the marketplace as we introduce
appealing new ways to utilise the technology to treat patients.”
Clinic
Mr Dalvi Humzah opens
clinic in Oxfordshire
The AMP (Aesthetic Medical Practitioners)
Clinic has opened in Greatworth, near
Banbury in Oxfordshire. The new clinic,
launched by consultant plastic, reconstructive
and aesthetic surgeon Mr Dalvi Humzah and
cosmetic and dermatology nurse practitioner
Anna Baker, aims to be a multidisciplinary clinic,
incorporating treating patients, and teaching
and training practitioners. It offers a variety of
treatments including non-surgical injectables, skin peels, dermatology and laser hair
removal. Baker said, “We are delighted to have opened a new site due to recent
expansion and have had a fantastic response so far. We look forward to developing
the service in the future.”
Award
Skin to Love Clinic receives award
Aesthetic manufacturer Teoxane UK
awarded The Skin to Love Clinic in St Albans
the ‘Teosyal Outstanding Clinic’ award. The
award, presented quarterly, is judged upon
performance in areas such as customer
service, patient safety, treatment results
and commitment to training and product
knowledge, as well as recognising the
standard of Teosyal-certified practitioners and
clinics throughout the UK. Kerri Lewis, clinic
manager, said “We are so thrilled to have won
the Teosyal Outstanding Clinic award. At the clinic we strive for excellence in our
customer service, patient safety and treatment results so it’s fantastic that Teoxane
UK has recognised us in this way.”
60
Gary Conroy, co-founder of 5 Squirrels
Why did you decide to start 5
Squirrels?
Having developed strong
partnerships with medical
aesthetic practitioners, the issue
of mainstream skincare brand
manufacturers selling skincare products directly
to patients was causing real issues with patient
trust and retention. Essentially, many practitioners
were being used to endorse and recommend
mainstream brands, only to find the manufacturers
selling the products at discounts directly to
patients. Being faced with an angry patient who
has bought a brand from a practitioner at a
reasonable price and then finds it at a bargain
price on Amazon does not evoke trust!
How does 5 Squirrels solve this problem?
We are the silent partner of concerned
practitioners, supporting them in the
development of their own skincare brands.
They are then able to recommend their own
brand products; re-establishing trust and loyalty
with patients. Our research revealed that there
is a relatively small number of molecules used
in skincare with robust clinical evidence; the
majority of mainstream brands essentially all
have the same generic ingredients, L-ascorbic
acid, retinol, alpha hydroxy acids, humectants,
emollients, metallic oxides, etc. Practitioners
who work with us can offer the same clinicallyproven ingredients to their patients at an
affordable price.
What success have you had?
Some brands have appeared on national
television and been recommended by celebrities
in the national press. Others are now sold in
high-end retail outlets. This has really disrupted
the current skincare trends and successful clinics
are able to recruit new patients for treatments
following exposure to their brands.
Is the process complicated?
Launching a new brand can be very expensive
and time consuming, without the guarantee of
success. We remove most of the risk by allowing
our partners to order low quantities of products.
We have streamlined the process and have a
network of suppliers who are able to handle all
of the brand artwork, regulatory requirements,
production, supply and batch traceability, without
individual practitioners having to start from scratch
every time.
This column is written
and supported by
@aestheticsgroup
Aesthetics Journal
Launch
Skyncare releases Biocare-one
UK-based aesthetic technology provider Skyncare has launched a new
multifunctional device to deliver a range of aesthetic treatments.
Biocare-one is an all-in-one system that encompasses laser, IPL and radiofrequency
technologies. The system supports eight interchangeable handpieces and aims to
offer a combined capability of more than 20 different aesthetic treatments, including
stretch-mark reduction, hair removal and skin rejuvenation.
Skyncare director Rob Knowles said, “It gives you the flexibility to provide a range
of aesthetic treatments suited to your clientele, and all from just one device.” He
continued, “Platform devices are the future of aesthetic technology. With such
versatility in its application, the ability to expand a growing business, or streamline an
established one, the Biocare-one embodies the progressive direction of the industry.”
Research
Nearly a third of visibly scarred
men feel compelled to change
their behaviour
A survey conducted by OnePoll has suggested that 31% of men with visible scars
feel pressured to adhere to the ‘tough guy’ image associated with facial scarring.
The survey indicated that 10% of visibly scarred men have felt negatively judged as a
result of their scars and 15% feel the need to joke or explain about their scars on first
meeting people, to ‘get it out of the way’.
The founders of Science of Skin, clinician scientist Dr Ardeshir Bayat and cosmetic
surgeon and British Association of Aesthetic Plastic Surgeons (BAAPS) member Mr
Douglas McGeorge, commissioned the study after formulating their Solution for Scars
cream. The cream, which aims to treat scars that are still symptomatic, contains a form
of green tea extract that Dr Bayat and Mr McGeorge claim has been proven to be
particularly effective in actively shrinking scars.
Light therapy
Skinbrands launches Lightfusion
Aesthetic product supplier
Skinbrands has released a new
non-invasive light therapy device.
The company explains that
Lightfusion aims to rejuvenate the
skin by delivering 10 minutes of
optimised red and near-infrared (NIR)
light simultaneously.
The product uses wavelengths of
light that energises cellular functions
within the body and aims to help the
absorption of skincare. It is claimed
that phototherapy creates a cascade
of biochemical reactions, which continue after the treatment is finished, and aim to
stimulate collagen, improve skin laxity and reduce pigmentation. Skinbrands claim
that Lightfusion has a simple user interface and includes an inbuilt timer and three
treatment heads that overlap the cheeks, forehead, hairline, chin and periorbital
region, or alternatively the chest area. The heads are designed to help reduce light
scattering – which in turn improves treatment efficiency by maximising the light
dose. Lightfusion is available now.
News in Brief
AestheticSource launches Xxtralash
Medical aesthetics distributor
AestheticSource has launched eyelash
growth serum, Xxtralash. The product,
which is formulated using hydrolysed soy
protein, myristoyl pentapeptide-17 and
lysophosphatidic acid, amongst other
ingredients, aims to improve length and
volume of eyelashes. The product, designed
to be used daily, is brushed onto the base
of the eyelashes at night. AestheticSource
claims the serum can stimulate new growth,
repair weak and thinning lashes, nourish the
eyelash and prevent lash loss.
Active Gold Collagen re-released with
new ingredient
Minerva Research Labs has reformulated its
Active Gold Collagen drink and remarketed
the supplement to both men and women.
The liquid collagen drink, which aims to
promote younger and healthier looking skin,
has a new flavour of apple and mango and
now contains chondroitin, which, according
to Minerva, aims to give extra support to skin
health, joints and muscles.
Fotona launches new app and touchscreen interfaces
Fotona Lasers has re-designed its range
to incorporate new technology. The new
touch-screen interface aims to make the
lasers easier to use for practitioners. The
company has also created an iPad app, which
allows Fotona users from around the world to
communicate with each other and review the
latest clinical studies and procedures.
In addition, the laser company has
incorporated a customer relationship
management (CRM) system with an integrated
camera. Fotona Lasers also aims to enhance
the safety and accuracy of treatments by
introducing the MatrixView Thermal Detection
System in the laser hand piece.
HA-Derma appoints new sales and
marketing manager
Aesthetic distributor HA-Derma has
appointed a new sales and marketing
manager. Iveta Vinklerova, who graduated
with a master’s degree in Economics from
the University of London, has more than five
years of experience in the medical sales
field, previously working with Boston Medical
Group. Vinklerova said, “I am delighted to
join the team.”
@aestheticsgroup
Aesthetics Journal
Conference
IMCAS Annual World Congress 2016, Paris
Thousands of aesthetic practitioners, plastic surgeons and
dermatologists from across the world are set to attend the 18th
International Master Course on Aging Science (IMCAS) Annual
World Congress on January 28-31 at the Palais des Congrès, Paris.
As well as hosting 200 exhibiting companies, the Continued Medical
Education (CME)-accredited programme will provide practitioners
with more than 150 learning hours. The sessions will be available
throughout eight rooms over four days and will allow practitioners to
build and develop their knowledge of aesthetic procedures, alongside
practice management skills, market analysis and industry insights.
IMCAS will host an array of speakers from across the world, including,
Dr Arthur Swift, Dr Marina Landau, Dr Raj Acquilla, Dr Uliana Gout, Mr
Dalvi Humzah, Mr Christopher Inglefield and Dr Tapan Patel. Topics
covered in the conference will include, amongst others: skin ageing:
basic and applied research, genital treatments using laser, clinical
dermatology, business strategy: branding and planning, and managing
your reputation. There will also be cadaver workshops on threads and
injectables, as well as live demonstrations of best practice methods.
A brand new e-learning platform, IMCAS academy, will also launch at
On the Scene
the upcoming congress. The online platform will allow practitioners
to catch-up on lectures after the meeting or view missed sessions
from the comfort of their own home. At the end of the conference,
delegates can obtain a Certificate of Attendance as well as CME
credits, by filling out an evaluation form. Additionally, there will be lots
of opportunities for networking with like-minded peers. Attendees
can meet with companies from around the world in the large
exhibition hall and develop new collaborations or partnerships during
the Networking Cocktail session. On the Saturday evening IMCAS
will host the Gala Dinner where attendees can socialise, relax and
dance with fellow delegates. Dr Benjamin Ascher, plastic surgeon
and IMCAS scientific director said, “IMCAS Annual World Congress
2016 promises to be the most exciting and innovative medical
aesthetic event of the year. We’re looking forward to welcoming
more participants, speakers and exhibitors than ever before and
to providing a fantastic platform for the exchange of knowledge of
experts from around the world.”
Practitioners can register online now for a full or partial access badge.
Early Bird rates are available until Wednesday December 16.
On the Scene
Meet The Face
Surgeons, London
Female-only led clinic The Face Surgeons (TFS)
launched its new practice on Wimpole Street in
London on October 28.
The five specialist surgeons, Miss Sarah Osborne,
Miss Caroline Mills, Miss Katherine George, Miss Helen
Witherow and Miss Sarah Little, welcomed friends,
colleagues, patients and practitioners to the event.
TFS is a multidisciplinary team, with surgeons having
expertise in different areas of the face. Miss Osborne
performs eyelid surgery; Miss Mills, Miss George and
Miss Witherow provide maxillofacial surgery and Miss
Little, ear, nose and throat surgery.
Whether patients are seeking anti-ageing treatments,
facial feminisation, ear, nose and throat procedures,
maxillofacial or ophthalmic surgery, the surgeons aim
to tailor treatment plans to each individual. Miss Mills
explained she recognised a gap in the market in 2014
for a clinic that patients could go to seeking facial
surgery that had a specialised surgeon for each part
of the face. ‘For anybody contemplating facial surgery,
this is often a daunting prospect,” said Miss Mills. “Some
people are told they have to have surgery; others
choose to have surgery for aesthetic reasons. Either
way, who you choose as your surgeon is of paramount
importance.” Miss Little added, “The mission of our clinic
is to provide anyone who requests surgery the best
possible advice from a true UK specialist in their field of
care. We are a multi-skilled team and the first female-led
clinic in the country which is very special.”
Mrs Sabrina Shah-Desai Eye
Boost Launch, London
Consultant ophthalmologist and
aesthetic oculoplastic surgeon Mrs
Sabrina Shah-Desai presented her new
‘Eye-Boost’ procedure in a private room
at Chutney Mary restaurant in London
on November 4. Friends, practitioners
and members of the press were treated to
breakfast at the Indian restaurant before
Mrs Shah-Desai presented her new
procedure, which aims to diminish eye
bags and dark circles. She spoke about
the anatomy of the eye, before explaining
how she came to create her new eye treatment. The Eye-Boost treats the tear
trough – the area between the eyelid and the cheek – by placing a hyaluronic acidbased dermal filler into the thin skin of the lower eyelid and medial tear trough; not
deeply in the inner corner under the eyes, which Mrs Shah-Desai believes is the
more common procedure.
“As we get older, the eye area can age in a number of ways,” said Mrs Shah-Desai.
“One of the biggest problems is the tear trough area – the hollow between the eye
and the upper cheek, which can deepen, creating a tired look. It can also make
dark circles and eye bags appear more prominent.” Mrs Shah-Desai explained that
the filler aims to strengthen the skin’s inner matrix and add volume to pronounced
tear troughs, plumping hollows and rejuvenating the area. She also claims to be the
first practitioner in the country to use this technique and commented that she has
been thrilled by the results seen from her patients so far.
“I am hoping to educate patients and the industry as the tear trough is a complex
area and should only be treated by practitioners who are highly experienced.”
said Mrs Shah-Desai. “I was really pleased at the interest generated by the Eye
Boost treatment launch on November 4.”
@aestheticsgroup
A Reflection on 2015
Aesthetics looks back at the
industry over the past year and asks
practitioners what they think have
been the biggest and most significant
changes to occur in 2015
Patients
This year has brought about a significant change in patients’ attitude
toward aesthetic procedures, according to aesthetic nurse prescriber
Adrian Baker. He believes patients are becoming more wary and
careful than ever before. “What I have seen from my patients this year
is a lot more caution and a lot more questions being asked – which
I think is a good thing. Usually I would have to try and encourage my
patients to ask questions or simply hand them the information I think
they should know; now they are asking themselves. It’s nice to see
patients coming in more informed and probing me as practitioner.
Patients ask, ‘Who are you?’ ‘What do you do?’ ‘Is that safe?’ ‘How long
has that been used?’ – It’s great.”
Aesthetic practitioner Dr Beatriz Molina has also seen a change in
her patients’ this year, as she says they now want to be able to get
everything they want from one clinic or practitioner. “We are noticing
a huge difference in our clinic; patients are coming in and wanting us
to provide them with everything they require. Not only do they want
the treatment, but they want the aftercare products, the moisturisers,
and the supplements.” Dr Molina has tried to cater for this demand
by offering a bespoke skincare range, which she believes has been
another big development in 2015. “In the patient consultations, we
would work hard to recommend the branded products that we sold
in the clinic, but then the patients would go away and find it cheaper
online, and it’s not necessarily the same quality.” Dr Molina decided
to adopt the recent move of launching her our own branded skincare
range, “Its been really popular and people have been coming back
and buying it because they can’t get it anywhere else and it’s a really
good price. I’ve seen other clinics starting to do this too and I think we
are going to see a lot more of this in 2016.”
Treatments
There has also been an increase in patients wanting minimally
invasive treatments this year. Aesthetic practitioner Dr Preema Vig
says her patients are now requesting a more natural-looking outcome
to their treatments. “This year has been all about the ‘tweakment’ –
Aesthetics Journal
little treatments that tweak rather than tuck. My patients’ want subtle
treatments, to look rested, uplifted and refreshed – not like they’ve
just had a procedure done.” Plastic and cosmetic surgeon Mr Adrian
Richards agrees the natural-look is back, “It has become almost
fashionable to look natural – less is now more.”
Looking at developments in treatments and techniques, Dr Molina
believes that the advance in thread lift treatments has been a big
achievement in the industry. “I know they have been around for
a long time but there has been a big boom in threads this year –
they’re huge. There is more competition now with more brands of
threads available, which does means it’s a little bit costly, so I would
like to see the prices revised.”
Although the mainstay of most aesthetic clinics still tends to be
dermal fillers and botulinum toxin, Dr Vig believes that aesthetic
body treatments have proved very popular this year, especially fat
freezing treatments. “There has been a number of cryolipolysis
devices launched in 2015 and I’ve definitely seen an influx of
patients wanting these procedures.” Mr Richards has also noticed
the patient demand for fat freezing treatments, “These treatments
weren’t big last year but this year they certainly are. Lots of
colleagues have told me how popular these treatments are and
commented on the amount of enquiries they have had.”
Challenges
Reflecting on the issues faced by the aesthetics industry in 2015,
Dr Vig suggests that the ‘selfie culture’ on social media is causing
patients to over-analyse their appearance and leads them to seeking
out treatments they don’t necessarily need. “I’ve seen an increase
in requests from younger patients for aesthetic treatments,” Dr Vig
explains. “Whereas normally I might not see a patient until their late
30s, 40s or older, I have now seen women in their 20s wanting
procedures. I think there is a fixation on looking perfect and it’s
causing people to hone in on tiny imperfections just because of
a certain angle on a photograph or ‘selfie’, when in real life, it isn’t
obvious.” Many practitioners also worry that the industry still is not
being taken seriously. Dr Molina says “I want recognition for aesthetic
medicine, for it to be seen as a real, serious specialty. It’s very sad
because, for practitioners who are passionate about aesthetics like
me, we have felt that our industry is being vandalised by the bad
practitioners – and unfortunately it has still been an issue in 2015.”
Regulation has remained a concern for most practitioners this year.
“It is the same old argument that has been carrying on since the
Keogh Report,” says Baker. “I think sometimes we are considered by
some professionals and members of the public as a bit of a cowboy
industry. I do think some patients are almost playing Russian roulette
when they choose a practitioner because there is currently no way
for them to know who they are or how competent they are to do
the procedure. Although it has been a slow process, I am confident
regulation is going to happen.”
Competency
In September this year, Health Education England (HEE) released the
final publication of its 2015 guidelines, giving its recommendations
regarding the safe practice of non-surgical aesthetic treatments.1 This
was in response to the 2013 Keogh Report, which called for greater
regulation of the industry and labeled the lack of regulation with
dermal fillers a ‘crisis waiting to happen’.2 Some practitioners have
viewed these guidelines as a big step in the move towards tighter
regulation of the aesthetic industry in 2015.
“Practitioners have been striving for regulation in the aesthetic and
@aestheticsgroup
Aesthetics Journal
cosmetic sector for years – and often when policy has tried to be
implemented, it has failed,” says Dr Tristan Mehta, managing director at
the Harley Academy. “Off the back of the Keogh report, HEE created
the first real framework for how qualifications in non-invasive cosmetic
medicine can be achieved. This comes at a time when the General
Medical Council (GMC) is opening up the possibility of credentialing;
which will allow for doctors to gain formal acknowledgement for their
competencies in this field.”
‘Credentialing’ would provide official recognition of practitioners’
capabilities in a particular area.3 Dr Molina also believes the possibility
of credentialing and the HEE guidelines are an important move in
the right direction this year. “We’re all working really hard to bring
in better training and exams so that the profession is taken more
seriously. Hopefully it will stop people being able to do a day course
and start injecting straight away. The guidelines are another step
forward towards this.” Similarly, the Nursing and Midwifery Council
(NMC) has announced that from April 2016, they will be revalidating
nurses and midwives to ensure they practice safely and effectively.
This is something Baker is particularly excited about, “As a nurse,
this has been something very exciting to happen this year. The
revalidation that’s coming will allow nurses to feel empowered and it
will encourage better learning and better practice. It’s going to give us
confidence and ensure we are competent.”
What does the future hold?
Looking ahead to 2016, Dr Mehta believes this year’s HEE
guidelines, along with the hard work industry bodies are putting in,
Aesthetics
will ensure positive changes for next year. He says, “Expect to see
a wave of higher-education options for aesthetic training in 2016. As
practitioners we should aspire to best-practice guidelines. We can
ultimately pave the way to improved patient safety.”
Dr Molina hopes next year will bring more cohesion between
the different specialties. “I would love to see more unity between
aesthetic practitioners, surgeons, nurses, dentists and more. I believe
together we can move forward and make the standards in this
industry much better – working as a team and helping each other
to minimise the risks, as well as push out the rogue practitioners.
I know the different bodies, such as the BACN (British Association
of Cosmetic Nurses), BAAPS (British Association of Aesthetic
Plastic Surgeons) and BAPRAS (British Association of Plastic and
Reconstructive Aesthetic Surgeons) are working hard independently
to make this industry safer and better, but it would be good to see us
all join forces next year.”
Mr Richards concludes, “The aesthetics industry has got a lot bigger
this year and treatments are better than ever before, but what we
need is regulation. It’s still a bit of a jungle out there, however I am
hopeful we will see improvement next year.”
REFERENCES
1. Harley Academy, Health Education England 2015 Guidelines, Are you ready? (2015) <http://www.
harleyacademy.com/hee-guidelines/>
2. Department of Health, Review of the Regulation of Cosmetic Interventions, (2013) p.5 <https://
www.gov.uk/government/uploads/system/uploads/attachment_data/file/192028/Review_of_the_
Regulation_of_Cosmetic_Interventions.pdf>
3. General Medical Council, Introducing regulated credentials, (2015) <http://www.gmc-uk.org/
Introducing_Regulated_Credentials_Consultation_W_form_FINAL_distributed.pdf_61589419.pdf>
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Aesthetics Journal
ACE 2016:
The Conference
Agenda
With a 10% early booking discount
running until December 31, we look
at the comprehensive Conference
agenda and detail what’s in store
for delegates at the Aesthetics
Conference and Exhibition 2016
Featuring expert speakers and high-quality educational content,
the Aesthetics Conference and Exhibition (ACE) 2016 is not to be
missed. Hundreds of aesthetic practitioners have already registered
for the two-day event and delegates are still able to benefit from a
special early booking discount for the first-class Conference.
This premium programme will comprise eight sessions presented
by a team of more than 20 world-leading speakers, sharing their
extensive knowledge and expertise on treating aesthetic patient
concerns. Focused on key facial and body anatomical areas, each
session will include anatomical explanation and discussion, a range of
treatment options with live demonstrations, presentation of case study
results, and vital complication management guidance.
The sessions, which will run for either 1 or 1.5 hours each, will cover
aesthetic treatments for the forehead, temple and brow, perioral,
chin and submental area, periorbital region, mid-face, lower face,
neck, décolletage and breast, buttock and thighs, and vaginal
rejuvenation. Each will provide an in-depth and thorough learning
experience, enabling delegates to enhance their skillset, develop
greater aesthetic results and improve patient satisfaction. Delegates
can also share their opinions and participate in peer discussions
with interactive voting pads, which will be utilised throughout the
Conference agenda. All sessions will feature the latest audio-visual
congress technology to allow maximum effect and optimise learning.
Mr Dalvi Humzah, Dr Tapan Patel and Dr Raj Acquilla will once again
provide attendees with exclusive insights into their anatomy and
injectables expertise during multiple sessions.
Aesthetics
Other popular ACE speakers returning for 2016 include
Dr Simon Ravichandran and Dr Maria Gonzalez who will share their
advice on treating the mid-face for volumisation and pigmentation,
respectively. Dr Firas Al-Niaimi and Mr Taimur Shoaib will join the
panel for the lower body session; Dr Kate Goldie will perform a
periorbital live demonstration in Friday’s ‘Enhancing the Eye’ and
Mr Adrian Richards and Dr Aamer Khan will draw on their experience
to guide delegates in the neck and breast session. In the upperface module, specialist dermatologist Dr Stefanie Williams and
aesthetic nurse prescriber Anna Baker will form key members of the
esteemed panel, while Dr Sherif Wakil and Dr Kannan Athreya will
look at treatment options for vaginal rejuvenation in their Saturday
session. For the lower face, aesthetic nurse prescriber Sharon
Bennett will perform a live demonstration of perioral rejuvenation,
while consultant dermatologist Dr Sandeep Cliff will detail how to
treat this area with active ingredients.
Joining the faculty will be new additions to the ACE team, including
cosmetic practitioner Dr Uliana Gout, who will present on medical
skincare and chemical peels; clinical lecturer and practitioner
Dr Kieren Bong, who will give a presentation on the ‘Two-Point Eye
Lift’, and GP and aesthetic practitioner Dr Shirin Lakhani, who will
present the latest O-shot case studies. Also new to the agenda will
be aesthetic nurse prescriber Frances Turner Traill who will highlight
common pitfalls of treating the mid-face, Mr Sultan Hassan who will
outline key anatomy and treatments for the buttock and thigh, and
board certified ophthalmologist Dr Maryam Zamani who will discuss
complications associated with treating the periorbital area with fillers.
To attend the Conference, delegates can choose to book either
a one-day pass for the Friday or Saturday, or a two-day pass to
experience the entire Conference agenda. The Conference Pass
will also give visitors access to all the practical free content on
the educational programme that includes; Masterclasses, where
delegates can learn how to achieve the best results with the leading
products from aesthetic suppliers; the Expert Clinic agenda, which
will offer invaluable advice through live demonstrations of the most
up-to-date techniques from the UK’s most successful practitioners;
Business Track sessions providing essential advice on how to
develop a thriving aesthetic practice, and a new addition to this
year’s agenda, Treatments on Trial, where delegates can directly
compare products with similar indications and join debates with
company representatives on their use and success in aesthetic
practice. A networking event, sponsored by 3D-lipo, will take place
on Friday 15 from 5.30-7pm, offering delegates the opportunity
to build new business contacts and liaise with peers and industry
suppliers. For every ACE session attended, delegates will be
awarded CPD points, with a total of 50 points available over the full
education programme.
Aesthetic professionals can book Conference attendance on the
new ACE website, where they are also able to view the full agenda
timetable and search speaker biographies and exhibitor profiles.
Once logged in, delegates can create their own programme for ACE
by saving the sessions that they particularly don’t want to miss to a
personalised agenda in order to plan out their visit before arrival.
Early booking discount ends December 31. To book your place at
ACE 2016 and find out more visit www.aestheticsconference.com
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Aesthetics Journal
Aesthetics
Vaginal ageing
The vagina ages in much the same way as the skin covering the rest
of the body. It loosens and sags, taking on a droopy and wrinkled
appearance. Women often notice differences after pregnancy
and childbirth,1 but are particularly susceptible to vaginal changes
following menopause. These include vaginal atrophy, whereby
the vagina’s lining becomes thinner, drier and less elastic, due to
declining levels of the hormone oestrogen.2 As well as being less
attractive and appealing, an atrophic vagina is often the source of
great discomfort, owing to the lack of lubrication, causing general
itching and dyspareunia (pain during sex).3 What’s more, symptoms
are likely to continue or worsen if left untreated.3
Treatment Options
Dermal fillers
At her Real You Clinics in Richmond and Godalming, Dr Taylor-Barnes
offers a number of vaginal rejuvenation treatments. These include:
Vaginal
Rejuvenation
Allie Anderson talks to practitioners
about the demand, concerns
and treatment approaches used
to enhance the function and
appearance of the vagina
Vaginal rejuvenation is a rapidly expanding treatment area
offering solutions to complaints that, just a few years ago, those
seeking such treatment would have been reluctant to even talk
about. Now, however, treatments that aim to improve the form
and/or function of the vagina are gaining recognition in the
industry and among the public.
Why do women seek treatment?
Once restricted to invasive surgery and perhaps considered
the most extreme form of vanity, the perception of the ‘designer
vagina’ is now being challenged. According to the practitioners
interviewed for this article, women of all ages are undergoing a
range of minimally and non-invasive procedures to not only boost
the appearance of their vaginas, but also – crucially – to overcome
conditions that could seriously impinge on their quality of life.
“As a GP with more than 20 years of clinical experience, I have
had a significant amount of exposure to intimate women’s health
problems,” says aesthetic practitioner Dr Kathryn Taylor-Barnes. “I
have realised that there is a need among women to have better
solutions to problems of the genital skin, which they have previously
just put up with because there hasn’t been treatments readily
available that give a superior result.” And while many patients seek
treatment primarily for medical reasons, the resulting cosmetic
enhancement can have a positive effect, too. “There can be a
great improvement in a woman’s confidence following treatment
of her genital skin problem,” Dr Taylor-Barnes adds, explaining,
“An aesthetic uplift can lead to a psychological uplift. This is what
motivates me to offer these specific options in my clinics.”
• Non-ablative ‘soft surgery’ lifting, for episiotomy scar treatment
and skin resurfacing, treatment of Bartholin’s cysts, ingrown hairs
and follicular hypertrophy.
• Hyfrecator electrocautery for removal of labial and vulval warts
and skin tags.
• Botulinum toxin to treat vaginismus and vulvodynia, caused by
vaginal muscle tension or scarring.
• Dermal fillers for labial enhancement.
One of the most popular treatments is the use of dermal fillers
containing hyaluronic acid (HA) gel. The benefits of HA as a
panacea for anti-ageing have been well documented, and indeed
HA-based fillers have been commonly and successfully used to
rejuvenate facial skin for many years. The science behind HA is
fairly simple: it is a naturally occurring substance found in cell and
tissue fluids, and is a key component of well-moisturised skin.4
The skin’s high water content helps to keep it plump and pliable
– properties associated with youthful skin – and therefore, HA
fillers are a very effective tool for lip and cheek augmentation and
correcting lines, wrinkles and folds.5
Dr Taylor-Barnes explains that since 2014, however, aesthetic
practitioners in the UK have been offering a revolutionary
procedure – injecting HA gel in the vagina – to treat vaginal
atrophy. The filler contains HA gel that has an interpenetrated
cross-linked structure to increase its longevity. The formula used
by Dr Taylor-Barnes also contains mannitol, a naturally occurring
antioxidant that significantly slows down the breakdown of the filler
by free radicals.6 First, local anaesthetic is applied superficially,
followed by delivery of the filler through a 25-gauge cannula (to
minimise the risk of haematoma) into the labia majora. “I massage
the area post treatment to improve the filler-tissue integration
and aesthetic contour,” explains Dr Taylor-Barnes, adding, “Most
importantly, I conduct thorough disinfection with chlorhexidine pre
and post treatment and prescribe oral acyclovir if there is a history
of genital herpes.”
The effect of the filler – known as ‘labial puff’ treatment – is to
volumise the labia majora, thereby concealing the labia minora in
order to give a more proportioned appearance. It aims to restore
tone and elasticity, strengthen the intra-vaginal muscles, and
improve sensitivity, while also reducing mucosal dryness.7 This can
have a significant impact on the patient’s day-to-day life, making
simple things like sitting, exercising and wearing tighter trousers
THE BUSINESS DESIGN CENTRE / LONDON / 15-16 APR 2016
The UK’s biggest and best
medical aesthetics
conference and exhibition
Focused Conference sessions
Everything you need to perfect your skills from consultation guidance,
treatment options, case studies and complication management advice
on key facial and body anatomical areas
• What to do with the Mid-face
• Treating the Buttock and Thigh Area
• From Neck to Breast
• Enhancing the Eye
• Forehead, Temple and Brow
• Vaginal Rejuvenation
• Perioral, Chin and Submental Area
• Lower Facial Contouring
World-leading speakers at the ACE 2016 Conference
Mr Dalvi Humzah, Dr Raj Acquilla, Dr Tapan Patel, Sharon Bennett,
Dr Simon Ravichandran, Dr Maria Gonzalez, Dr Stefanie Williams, Anna Baker,
Mr Adrian Richards, Dr Aamer Khan, Dr Uliana Gout, Dr Sherif Wakil,
Dr Shirin Lakhani, Dr Kannan Athreya, Dr Sandeep Cliff, Dr Kate Goldie,
Dr Kieren Bong, Dr Maryam Zamani, Mr Sultan Hassan,
Follow us:
Dr Firas Al-Niaimi, Mr Taimur Shoaib and Frances Turner Traill
Aesthetics
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Aesthetics Journal
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Aesthetics Journal
Book before December 31 to receive a 10% discount on your Conference Pass
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Aesthetics Journal
more comfortable. “The psychological benefits of a woman feeling
happier in herself, and with her partner when naked or in an
intimate situation, is priceless and can have a positive knock-on
effect in other areas of her life,” Dr Taylor-Barnes says.
HA fillers for vaginal rejuvenation are not without their
disadvantages, though. One of the main problems Dr TaylorBarnes reports is that the initial post-treatment swelling gives the
patient the experience of much plumper labia majora than will
be achieved in the long term, leading to disappointment when
the swelling dissipates and the labia deflate. Aligning patients’
expectations with their budget and the treatment’s limitations can
also be challenging. Infection, haematoma and labial asymmetry
caused by lumping and drifting of the product are among the
complications she has encountered. More worrying risks have
been highlighted in the media, including pain, nerve paralysis,
bleeding and loss of sensation during sex, due to the abundance
of nerves and blood vessels around the clitoris, labia and urethral
opening.8 However, research studies have concluded that
high-molecular weight HA can be effective in improving postmenopausal vaginal atrophy with no adverse events,9 and that HA
gel could be safely used more widely in women presenting with
vaginal dryness of any cause.10
Laser resurfacing
Just as dermal fillers have been adapted for use in genital
rejuvenation, so have lasers. Lasers are commonplace in medical
aesthetics, used to effectively treat the likes of unwanted hair,
vascular lesions, scars and acne, pigmented lesions, tattoo
removal, skin rejuvenation of the face and décolletage, and
varicose veins.11 A more recent development is the fractional laser,
in which the laser beam is optically split into thousands of tiny
dots, each targeting a minuscule area at a time and leaving the
surrounding tissue undamaged.12 Whereas HA fillers specifically
target the outside of the vagina (as they are injected into the labia
majora), the fractional laser is directed at the vagina’s inside wall.
Plastic surgeon Mr Christopher Inglefield explains that the
practitioner inserts a probe into the vagina, through which the
laser beam is directed. At the end of the probe is a small mirror
angled at 45 degrees, which allows the beam to be reflected to hit
the required spot of the interior wall of the vagina with precision.
The probe can be rotated at right angles, thereby enabling the
practitioner to target the whole area through 360 degrees. “This
gives a much more reliable, reproducible treatment,” comments
Mr Inglefield, who uses a fractional CO2 laser. “It aims to improve
the tone of the vaginal wall, thereby improving sexual function and
pleasure for both the patient and her partner,” he comments. “By
treating the anterior wall of the vagina, it also has very significant
effects in treating stress urinary incontinence.13”
How does it work? The laser uses light that transfers into heat
energy, which penetrates to a depth that stimulates and promotes
the regeneration of collagen and elastin fibres in the vaginal
tissue.14 This newly synthesised collagen and elastin causes the
vaginal skin to thicken – in the same way as the facial skin plumps
when collagen production is boosted. The outcome is rejuvenated
and toned vaginal skin, which increases sensitivity and has the
added benefit of reducing symptoms of vaginal atrophy, such as
dryness, burning and itching, dyspareunia and dysuria.15 Laser
treatment has also been demonstrated to have a therapeutic effect
on stress urinary incontinence, and is associated with a high level
of safety and short recovery period.13
Aesthetics
Research studies have
concluded that
high-molecular weight
HA can be effective in
improving postmenopausal vaginal atrophy
with no adverse events
As dermatologist Dr Harryono Judodihardjo explains, successful
treatment can have a major impact on a patient’s life. “It can be
particularly helpful for women who have dyspareunia, which
can be due to a lack of lubrication in the vaginal wall,” he says.
“After treatment, because the cells are renewed, they are able
to produce more mucous, and lubricate during sex, therefore
reducing friction and pain.16” According to aesthetic practitioner Dr
Kannan Athreya, the psychological effect in older women is even
more profound. “Some ladies in their 60s will come to see me and
after the first treatment, they tell me they are getting a physiological
discharge again, when the last time they experienced that was in
their 40s or even their 30s,” he says. “It can be a very emotional
thing for them, because it reminds them of an earlier time, and
things are beginning to work once more.”
Practitioners report that vaginal laser treatment is relatively painless
and problem-free. Dr Judodihardjo recommends that, following
treatment with the CO2 laser, patients should refrain from sex
for five to seven days, and with the erbium YAG laser, for three
days. Side effects are limited to mild bleeding or spotting, and the
procedure lasts around 20-25 minutes. “The main disadvantage
is that because it’s a non-invasive treatment, it offers gradual
improvement,” Mr Inglefield comments. “Most patients need two or
three treatments to achieve good results, which can take several
months to come about and can last approximately two years.”
According to Mr Inglefield, it is suitable for most women, with the
exception of those suffering severe vagina laxity or severe urinary
incontinence; in such cases he suggests that surgery would be
more appropriate.
Platelet-rich plasma (PRP)
A string of celebrity endorsements has plunged the ‘vampire facelift’
firmly into the spotlight in the last few years. But now, this treatment
– which involves withdrawing the patient’s own blood, processing
it to create platelet-rich plasma (PRP), and then re-injecting it to
smooth wrinkles and regenerate collagen – has applications in
other, more intimate areas. As well as the ‘vampire breast lift’, some
women are beginning to opt for vaginal rejuvenation using PRP.
Blood is taken from the patient (usually their arm), and is spun
@aestheticsgroup
Although some side effects
have been reported, all
the treatments discussed
have anecdotally yielded
impressive results
through a centrifuge machine to separate out plasma containing
a high concentration of platelets – at least four to eight times
normal levels.17 This PRP is rich in growth factors, naturally occurring
substances that stimulate cell growth and proliferation, and thereby
promote tissue regeneration.18 Aesthetic practitioner Dr Sherif Wakil
pioneered the use of one vaginal PRP system in the UK just last year,
but therapeutic properties of PRP have been used for many years in
orthopaedics, dentistry, maxillofacial surgery and wound healing.19
“The point of this treatment is that when you inject platelets into
one place, it regenerates the area that is injected, whether it is
bone, muscle or skin,” explains Dr Wakil. “In the vagina, the skin
becomes thicker and firmer, giving it a glow and making it look
much more youthful. You also increase vascularisation into the
area, which in turn means sensitivity is dramatically increased.”
In addition, the newly plumped skin of the vaginal wall provides
a supporting structure for the urethra, making PRP an effective
treatment for urinary incontinence.20 A third indication is a condition
called lichen sclerosus, a chronic disorder affecting the skin around
the genitals, causing very itchy and sore white spots.21 “Patients
with this disease are often brushed off by their GPs because
there is no treatment for it, other than topical steroid cream that
also makes the skin thinner, causes other side effects and cannot
improve sexual function,22” Dr Wakil adds. PRP injections, however,
have been shown in a small number of early studies to result in
regeneration of normal skin.23
While other types of PRP system take around 10 to 20ml of blood
and centrifuge it to produce 8ml of platelet-rich plasma, the
machine Dr Wakil uses takes 60ml and breaks it down to 8ml of
PRP, resulting in a far higher concentration which yields superior
results, he claims. “The procedure is safe and effective, it takes
about 40 minutes and patients can go back to work straight
afterwards, and can even have sex the same day,” he adds.
The ease and lack of down time associated with PRP injections
may explain why they are rapidly becoming so popular. Recent
figures predict the global market will reach US $0.35 billion by
2020.19 Dr Athreya postulates that the increasing numbers of
women seeking these types of treatments for post-menopausal
vaginal symptoms reflects the decline in take-up of hormone
replacement therapy (HRT). This was typically prescribed for
many women going through menopause until 2002, when the US
Women’s Health Initiative study suggested that women using HRT
were at a higher risk of breast cancer.24 A UK study the following
year corroborated these findings.24 “There is still a lot of concern
and anxiety over HRT (since the reports) and many women have
stopped taking HRT at the time of menopause,” Dr Athreya
comments. “This leads to vaginal atrophy, and in the end, these
ladies develop the problems associated with it, such as irritation,
dryness and painful intercourse. It’s great that we can now address
this for ladies who don’t want to try HRT.”
Aesthetics Journal
Conclusion
It’s clear that numerous benefits can be derived from all the
treatments on offer, both aesthetically and clinically. Although some
side effects have been reported, all the treatments discussed
have anecdotally yielded impressive results. At the very least, the
growth in this area of medical aesthetics is generating more open
discussion among women about common intimate problems that,
left untreated, can drastically impinge on their quality of life. And
that can only be a good thing.
Dr Sherif Wakil and Dr Kannan Athreya will share their
techniques for vaginal rejuvenation at the Saturday afternoon
Conference programme session of the Aesthetics Conference
and Exhibition 2016, taking place on April 15 and 16. To find out
more visit www.aestheticsconference.com/programme
REFERENCES
1. NHS Choices, Vagina changes after childbirth (UK: NHS, 2013) <http://www.nhs.uk/Livewell/vagina-health/Pages/vagina-after-childbirth.aspx>
2. The North American Menopause Society, Changes in the vagina and vulva, (US: North American
Menopause Society, 2015) <http://www.menopause.org/for-women/sexual-health-menopause-online/changes-at-midlife/changes-in-the-vagina-and-vulva.>
3. NHS Choices, Menopause – symptoms, (UK, NHS, 2014) <http://www.nhs.uk/Conditions/Menopause/Pages/Symptoms.aspx.>
4. Papakonstantinou E et al., ‘Hyaluronic acid: A key molecule in skin aging’, Dermatoendocrinol, 4
(2012) pp.253-258.
5. Lupo MP, ‘Hyaluronic acid fillers in facial rejuvenation’, Semin Cutan Med Surg, 25 (2006), pp.122-6
and Sundaram H et al., ‘Biophysical characteristics of hyaluronic acid soft-tissue fillers and their
relevance to aesthetic applications’, Plast Reconstr Surg, 132 (2013)Clinical introduction to the hyaluronic acid dermal filler using cohesive polydensified matrix technology):5S-21S, cited in: Robert
S Bader MD, ‘Dermal Fillers: Hyaluronic acid’, Medscape, 2015 <http://emedicine.medscape.com/
article/1125066-overview#a3.>
6. Ramos-e Silva M, ‘STYLAGE: a range of hyaluronic acid dermal fillers containing mannitol. Physical
properties and review of the literature’, Clin Cosmet Investig Dermatol, 6 (2013) pp.257-261. <http://
www.ncbi.nlm.nih.gov/pmc/articles/PMC3810198/>
7. Consulting Room, Desirial – product summary (UK: Consulting Room, 2015) <http://www.consultingroom.com/treatments/desirial-vaginal-rejuvenation>
8. Ruth Styles, Would you plump up your vagina with fillers? Top cosmetic doctor warns of risky new
trend... after being inundated with clients looking for ‘genital enhancements’, (UK: Daily Mail, 2015)
<http://www.dailymail.co.uk/femail/article-3114937/Top-cosmetic-doctor-warns-risky-new-trend-genital-filler-jabs.html>
9. Grimaldi EF, Restaino S, Inglese S, Foltran L, Sorz A, Di Lorenzo G, Guaschino S., ‘Role of high molecular weight hyaluronic acid in postmenopausal vaginal discomfort’, Minerva Ginecol. 64 (2012)
pp.321-9. <http://www.ncbi.nlm.nih.gov/pubmed/22728576>
10. Stute, P., ‘Is vaginal hyaluronic acid as effective as vaginal estriol for vaginal dryness relief?’, Arch
Gynecol Obstet, 288 (2013) pp.1199-201.
11. Patil, UA and Dhami, LD., ‘Overview of lasers’, Indian Journal of Plastic Surgery, 41 (2008) S101-S113.
12. Ngan, V., ‘Fractional laser treatment’, DermNet New Zealand Trust, 2015. <http://www.dermnetnz.
org/procedures/fractional.html.>
13. Ivan, F et al, ‘Minimally invasive laser procedure for early stages of stress urinary incontinence’,
Journal of the Laser and Health Academy, 1 (2012) <http://www.laserandhealthacademy.com/
media/objave/academy/priponke/67_74_laha_journal_2012_1.pdf>
14. Salvatore S, Leone Roberti Maggiore U, Athanasiou S, Origoni M, Candiani M, Calligaro A, Zerbinati
N. ‘Histological study on the effects of microablative fractional CO2 laser on atrophic vaginal tissue:
an ex vivo study’, Menopause, 22 (2015) pp.845-9.
15. Salvatore S, Nappi RE, Zerbinati N, Calligaro A, Ferrero S, Origoni M, Candiani M, Leone Roberti
Maggiore U., ‘A 12-week treatment with fractional CO2 laser for vulvovaginal atrophy: a pilot study’,
Climacteric, 17 (2014) pp.363-9. <http://www.ncbi.nlm.nih.gov/pubmed/24605832>
16. Perino A, et al, ‘Vulvo-vaginal atrophy: A new treatment modality using themo-ablative fractional
CO2 laser’, Elsevier, 2015 <http://www.happyhooha.com.au/files/5514/3037/8480/V2LR_Perino_et_
al_Maturitas_2015.eng_IN_PRESS.pdf>
17. MedGadget, Platelet Rich Plasma Market Set to Reach US$0.35 billion by 2020 (US: MedGadget,
2015) <http://www.medgadget.com/2015/11/platelet-rich-plasma-market-set-to-reach-us0-35-billionby-2020.html>
18. El-Sharkawy H, Kantarci A, Deady J, Hasturk H, Liu H, Alshahat M, Van Dyke TE., ‘Platelet-rich plasma: growth factors and pro- and anti-inflammatory properties’, J Periodontol, 78 (2007) pp.661-9.
<http://www.ncbi.nlm.nih.gov/pubmed/17397313>
19. Ashish Jain, Ravneet Kaur Bedi, and Kshitija Mittal., ‘Platelet-rich plasma therapy: A novel application in regenerative medicine’, Asian J Transfus Sci, 9 (2015) pp.113–114. <http://www.ncbi.nlm.nih.
gov/pmc/articles/PMC4562126/>
20. ‘Urinary incontinence: Novel nonsurgical method to treat vesicovaginal fistula’, Nature Reviews
Urology 10, 125 (2013) <http://www.nature.com/nrurol/journal/v10/n3/full/nrurol.2013.5.html>
21. NHS Choices, Lichen sclerosus – introduction (UK: NHS, 2014) <http://www.nhs.uk/conditions/
lichen-sclerosus/Pages/Introduction.aspx.>
22. NHS Choice, Topical cortocosteriods – side effects (UK, nhs, 2015) <http://www.nhs.uk/Conditions/
Corticosteroid-preparations-(topical)/Pages/Side-effects.aspx>
23. Casabona F, Priano V, Vallerino V, Cogliandro A, Lavagnino G., ‘New Surgical Approach to Lichen
Sclerosus of the Vulva: The Role of Adipose-Derived Mesenchymal Cells and Platelet-Rich Plasma
in Tissue Regeneration’, Plastic & Reconstructive Surgery, 126(4) (2010). <http://www.dermnetnz.org/
immune/lichen-sclerosus.html.>
24. NHS Choices, Health scare ‘clouded views on HRT’, (UK: NHS, 2012) <http://www.nhs.uk/
news/2012/05may/Pages/hrt-risk-examined-after-health-scare.aspx>
one
point
@aestheticsgroup
Aesthetics Journal
The ABC of Moles
Consultant plastic surgeon Mrs Barbara Jemec shares
advice on recognising a malignant melanoma
Skin cancer is increasing, and the incidence of Malignant Melanoma
(MM) has been rising by 3-7% every year since 1989.1 MM accounts
for only 2% of all skin cancers worldwide, however it causes the
majority of skin cancer related deaths.2 The occurrence is highest in
New Zealand and Australia, while, in Europe, the incidence for men
is highest in Switzerland and for women in Denmark.2 Caucasian
people now have a 2.4% (1 in 40) chance of developing MM in their
lifetime, while Hispanics have a 0.5% (1 in 200) chance and Africans a
0.1% (1 in 1,000) chance of developing the disease.3 According to the
American Cancer Society, an estimated 9,940 people in the US will
die of melanoma in 2015.3
Most MMs arise in previously normal skin, though having more than
100 moles increases the chances of having a MM fourfold, as do
atypical or very large moles.4 Any changes in asymmetry, border,
colour, diameter and evolution of a pigmented lesion, including the
‘Ugly Duckling’ sign – which refers to a mole that doesn’t look like the
others – should also be treated as suspicious. The main treatment
remains removal through surgery, though recent advances in
immunotherapy has improved survival in advanced disease.5
While it is not the duty of aesthetic practitioners to treat an MM, they
can play a role in identifying any suspicious lesions early and alerting
patients of when to seek specialist help. Working closely with patients
to treat age-related and aesthetic concerns means practitioners
have direct and regular access to patients’ skin, allowing them the
opportunity to monitor any changes in the appearance of moles
and provide valuable advice on appropriate sun care to reduce the
chance of developing a malignant melanoma. This article aims to offer
comprehensive advice on what changes to be aware of, and how to
best manage them.
Occurrence of MM
MM arises de novo in about 75% of cases and in 25% from preexisting moles.4 Having numerous moles (100+) or Dysplastic Naevus
Syndrome increases your lifetime risk of developing MM 4-10 times.4
Atypical Naevus Syndrome is associated with a melanoma called
Familial atypical multiple mole melanoma (FAMMM) which is a
syndrome (autosomal dominant) genodermatosis, characterised by
multiple melanocytic nevi, usually more than 50 moles, and a family
history of melanoma.6
Figure 1
Figure 2
Unevenly pigmented melanoma with irregular border
Red melanoma
86% of MMs can be attributed to UV radiation7 and the risk of a MM
doubles if a person has experienced more than five sunburns in their
lifetime.8 The regular use of SPF 15 reduces the risk of MM by 50%,9,10
and using a higher SPF will likely give even more protection, but
people who use a tanning bed before the age of 35 increase their risk
by 75%.11 A single indoor tanning session increases a person’s chance
of developing MM by 20%, and every subsequent tanning session in
the same year by 2%.12
Learning the ABC
Of course, a normal mole does not become a MM overnight; it will
undergo a gradual change that can usually be identified using what
we call the ‘ABCDE of moles’. The ABCDE details five changes that
could occur within a mole, providing practitioners and patients alike
with information on what factors to be aware of.
A is for Asymmetry: Any mole that is not symmetrical if halved is
suspicious, so an oblong mole is acceptable, but a mole which has
a bizarre shape should be looked at by an expert. I have excised
a perfectly round MM, but this is a rarity and other features (such
as growth, change in colour etc.) in a round mole should make you
suspicious.
B is for Border: A benign mole usually has a smooth border, whilst
the border of a MM might be indistinct, irregular, notched and uneven
(Figure 1). A specific and very visible difference is when moles become
Halo Naevi, which is discussed in more detail later in the article.
C is for Colour: A normal mole is evenly pigmented, while a MM is
usually not (Figure 1), however an evenly pigmented mole, which
suddenly starts growing, or ulcerating, or is asymmetrical should
be treated as suspicious. MMs usually become darker, and can
sometimes appear black unevenly within the previous pigmented
area of the mole. 4% of MMs are, however, red (Figure 2), and are now
recognised as a separate entity.13 The red colour is most likely present
because the pigment is missing.
D is for Diameter: Small moles are rarely dangerous, but larger moles
carry a 4-10 times greater risk of becoming a MM,14 which is why
doctors sometimes recommend large moles are excised, even if they
do not exhibit any of the warning signs that they have turned bad. A
mole is classified as large when it has a diameter larger than 6mm.
E is for Evolution: As we become older, we develop more moles.
Figure 3
‘Ugly Duckling’ sign
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Aesthetics Journal
Aesthetics
BAD advice
The British Association of Dermatologists (BAD) guideline from 201018
outlines the required minimal histological dataset for a MM. The guidance
offers a broad overview of what dermatologists should be aware of
when examining skin, hence, I advocate aesthetic practitioners familiarise
themselves with the guidance and follow it in their own practice. Noteworthy
points include:
Presence or absence of ulceration: Ulceration has prognostic value as it
changes the overall thickness of the tumour.
Thickness: Found to be the single most predictive marker of outcome.
Mitotic count: The number of mitoses has prognostic value, it also tips very
thin tumours under 1 mm into the Sentinel Lymph Node Biopsy group (see
SLNB section).
Histological subtypes: Desmoplastic melanoma in particular
behaves differently, and the subtypes: superficial spreading, nodular,
Lentigo Maligna and acral lentiginous melanomas all have good
clinicopathological correlation.
Margins of excision: To determine whether the excision is complete.
Pathological staging: For prognosis and further treatment.
Growth phase: MM has horizontal and vertical growth phases.
Regression: Has not been shown to affect long-term outcome.
Tumour-infiltrating lymphocytes: It is still unclear whether this has
prognostic value.
Lymphatic or vascular invasion: Vascular or lymphatic infiltration has
prognostic value.
and disappears, while the paler skin surrounding
it gradually re-pigments.17 These moles are usually
benign, at worst atypical, but the process can be
triggered by a MM somewhere else, so a careful skin
examination is required.17 The formation of a halo
surrounding a naevi occurs when white blood cells
(CD8+ T lymphocytes) destroy the melanocytes. This
is presumably because the body recognises them as
abnormal, something that a MM might have sensitised
the immune system to. A Halo Naevi is mostly found in
children and young adults.17
Excision
The width of the primary excision is determined by the
thickness of the tumour: in situ tumours are excised with
a 5mm margin, 1mm tumours with 1cm, between 1 and
2 with 1-2cm, between 2 and 4mm by 2-3cm and more
than 4mm by 3cm.18 Bearing this in mind, the primary
excision biopsy, to determine the thickness and the
exact histology, is done with a 2mm margin, though it
must be complete and must take into account a later
re-excision, so orientation is paramount.18
Defects resulting from excision of MM can be quite
extensive, but can be reconstructed with flaps to
make the aesthetic result more acceptable, without
compromising detection of local recurrence. The MM is
not suitable for excision with Mohs’ surgery as Mohs’ is
used for for lesions that are not well circumscribed and
an MM is a well-circumscribed lesion.19
Sentinel lymph node biopsies
The next step is to determine whether to offer the
Perineural infiltration: Correlates with increased local recurrence and is
patient a Sentinel Lymph Node Biopsy (SLNB), which
most commonly associated with desmoplastic melanoma.
is also mostly determined by the thickness of the
Microsatellites: These are defined as islands of tumour outside the main
tumour. Any MM that is thicker than 1mm is offered a
tumour and are predictive of regional lymph node metastases.
SLNB, and, in the presence of mitoses, even thinner
MMs are too.20 The mitotic count is taken as a measure
Precursor naevus: The presence of a contiguous melanocytic naevus.
of activity in the tumour. There is some controversy
Clark level of dermal invasion: This is less reliable for prognosis than
regarding SLNBs, as some practitioners feel a fine
thickness.
needle aspiration is enough.20 There are also concerns
that a biopsy could result in a false negative and that
it could be an unnecessary operation, as the disease
wouldn’t necessarily progress.20 The decision to offer patients
Whilst most moles appear before the age of 20, sun exposure
increases the incidence of moles later in life,15 however any mole
this option is taken by the Multi-Disciplinary Team (MDT). The MDT
consists of all parties involved in the care of MM patients and
or previously normal skin that changes colour, grows or bleeds
includes members from the oncology, dermatology, plastic surgery,
spontaneously is better looked at by an expert and potentially
pathology and radiology departments.
removed. For people with many moles, doctors look for the ‘Ugly
Duckling’ sign (Figure 3) – a mole that is the odd one out.16 For
The SLNB is the hypothetical first lymph node or group of nodes
people with many moles, most are usually of similar size and
draining a cancer, and identifying and examining this lymph node
colouration, those that look different are an easy indicator of what
is an effective staging tool. If the SLNB is negative, the patient
could be malignant. Examination of the lesion by dermatoscope,
is followed up on a regular basis: three months for the first two
which is a hand-held skin microscope with a bright light source that
years, then every six months for another three years. If the SLNB
magnifies the skin 10 times, can give more certainty to determine
is positive, then the patient undergoes imaging in the form of a
whether a lesion is benign or malignant. The dermatoscope
CT scan for staging, and if this scan does not show widespread
contains polarised filters, which remove the glare of the bright light
metastatic disease, the patient is offered a clearance of the
and allow the user to examine the mole in much more detail and
affected lymph node basin. The lymph node basins cleared include
to a deeper layer in the skin. A Halo Naevus deserves a special
the groin, the popliteal fossa, axilla and neck. Further staging
mention. It is a mole which presents with a lighter (un-pigmented)
area of skin around it, which gradually changes colour in the middle depends on the number of further involved lymph nodes.21,22
@aestheticsgroup
Local recurrences can be treated with surgery or
electrochemotherapy (ECT). ECT refers to the combination of
electroporation and administration of anticancer drugs for local
treatment of solid neoplasms. Electroporation uses short and
intense electric pulses to induce a transient permeabilisation
of the cell membrane by creation of pores, which allows
chemotherapeutic agents to freely diffuse into the cytosol.
The chemotherapeutic agent, for instance bleomycin, is given
systemically.23 Regional recurrences are treated surgically, but
when a MM is disseminated the treatment becomes oncological.
Recently, the development of immunotherapy for disseminated MM
has brought new hope for patients.24
Immunotherapy
Immunotherapy drugs used in MM treatment work by targeting
molecules that serve as checks and balances in the regulation
of immune responses. By blocking inhibitory molecules, these
treatments are designed to unleash or enhance pre-existing anticancer immune responses.25
Almost 50% of MMs harbour mutations in the human gene (BRAF),
which makes a protein (B-raf) that helps transmit chemical signals
from outside the cell to the cell’s nucleus.26 B-raf is part of a
signaling pathway, which controls several important cell functions
such as proliferation, differentiation, migration, and apoptosis. BRAF
is an oncogene, which when mutated, has the potential to cause
normal cells to become cancerous.
Vemurafenib was approved in 2011 and is a BRAF inhibitor, which
can induce the growth of cutaneous squamous-cell carcinomas – a
unique side effect. Unfortunately, most responses to Vemurafenib
are partial and disease progression is typically seen at a median of
five to seven months.27
Ipilumumab is a mono-clonal antibody, which targets cytotoxic
T-lymphocyte associated antigen 4 (CTLA-4), a protein found on
the surface of T-cells which act as a brake for the cell’s cytotoxic
activity. Ipilumumab removes this block and consists of four
injections over three months.28
Pembrolizumab is also a monoclonal antibody, which binds to the
programmed cell death 1 receptor (PD-1), in order for the T-cells to
discover and kill the MM cells.29
All immunotherapy has the potential side effect of attacking the
patients’ own normal tissues, and the process, therefore, has to be
monitored closely.
Conclusion
At present the overall five year survival for localised MM is 98%, with
lymphatic spread 63% and distant spread 16%.3 Melanoma accounts
for less than 2% of skin cancer cases, but the vast majority of skin
cancer deaths.3 All practitioners dealing with skin can help early
detection by being vigilant and using the ABCDE of moles and the
‘Ugly Duckling’ sign to recognise any abnormalities. Early detection
is paramount to long-term survival and the changes can be subtle.
Although surgical removal remains the mainstay of treatment, and
the outlook for patient with very thin melanomas remains very
good, immunotherapy has brought some hope for patients with
disseminated disease.
Aesthetics Journal
Acknowledgement: I would like to thank Tina Rasmussen and Kristine
Saad for the photographs.
Mrs Barbara Jemec is a consultant plastic surgeon at
the Royal Free Hospital with a special interest in skin
cancer, as well as a member of its Multidisciplinary
Team (MDT). The MDT works together to discuss
both NHS and private patients with skin cancer, and
recommend the best treatment available.
FURTHER READING
Skin Cancer Facts (New York: Skin Cancer Foundation, 2015)
<http://www.skincancer.org/skin-cancer-information/skin-cancer-facts#melanoma>
Skin cancer risk factors (UK: Cancer Research UK, 2015) <http://www.cancerresearchuk.org/healthprofessional/cancer-statistics/statistics-by-cancer-type/skin-cancer/risk-factors#heading-Two>
REFERENCES
1. Parkin DM, Bray F, Ferlay J, Pisani P, ‘Estimating the world cancer burden: Globocan 2000’, Int J
Cancer, 94 (2001) pp.153-156.
2. Ferlay J, Soerjomataram I, Ervik M, et al, ‘GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality
Worldwide: IARC CancerBase No. 11’, International Agency for Research on Cancer (2013) <http://
globocan.iarc.fr>
3. American Cancer Society, Cancer Facts & Figures 2015 (American Cancer Society, 2015) <http://
www.cancer.org/acs/groups/content/@editorial/documents/document/acspc-044552.pdf>
4. Olsen CM, Carroll HJ, Whiteman DC, ‘Estimating the attributable fraction for cancer: A meta-analysis
of nevi and melanoma’, Cancer Prev Res 3 (2010) pp.233-45.
5. C Fellner, ‘Ipilimumab Prolongs Survival In Advanced Melanoma Serious Side Effects and a Hefty
Price Tag May Limit Its Use’, Yervoy, 37 (2012) pp.503-511.
6. Atypical Mole (Dysplastic Nevus) (US, Medscape, 2015) <http://emedicine.medscape.com/
article/1056283-overview>
7. Parkin DM, Mesher D, P Sasieni, ‘Cancers attributable to solar (ultraviolet) radiation exposure in the
UK in 2010’, Br J Cancer, 105 (2011), S66-S69.
8. Pfahlberg A, Kolmel KF, Gefeller O, ‘Timing of excessive ultraviolet radiation and melanoma:
epidemiology does not support the existence of a critical period of high susceptibility to solar
ultraviolet radiation-induced melanoma’, Brit J Dermatol, 144 (2001) p.471.
9. Green A, Williams G, Neale R, et al., ‘Daily sunscreen application and betacarotene supplementation
in prevention of basal-cell and squamous-cell carcinoma of the skin: a randomized controlled trial’,
Lancet, 354 (1999) pp.723-729.
10. Green A, Williams G, Logan V, Strutton G., ‘Reduced melanoma after regular sunscreen use:
randomized trial follow-up’, J Clin Oncol, 29(2011) pp.257-263.
11. Lazovich D, Vogel RI, Berwick M, Weinstock MA, Anderson KE, Warshaw EM., ‘Indoor tanning and
risk of melanoma: a case-control study in a highly-exposed population’, Cancer Epidem Biomar Prev
19(2010), pp.1557-1568.
12. Boniol M, Autier P, Boyle P, Gandini S, ‘Cutaneous melanoma attributable to sunbed use: systematic
review and meta-analysis’, BMJ, 345 (2012).
13. McClain SE, ‘Amelanotic melanomas presenting as red skin lesions: a diagnostic challenge with
potentially lethal consequence’, Int J Dermatol,51 (201), pp.420-6.
14. Richard Bränström et al, ‘Melanoma Risk Factors, Perceived threat and Intentional Tanning: An Online
Survey’, Eur J Cancer Prev, 19 (2010) pp.216-226.
15. Heinz, V, ‘Progress in Skin Cancer Research’, Horizons in Cancer Research, (2007), p.43.
16. Grob JJ, Bonerandi JJ., ‘The ‘ugly duckling’ sign: identification of the common characteristics of nevi
in an individual as a basis for melanoma screening’, Arch Dermatol, 134 (1998) pp.103-104.
17. Patrizi A, Neri I, Sabattini E, Rizzoli L, Misciali C., ‘Unusual inflammatory and hyperkeratotic halo
naevus in children’, Br J Dermatol, 152 (2005) pp.357-60.
18. Marsen et al, ‘Revised UK guidelines for the management of cutaneous melanoma’, British Journal
of Dermatology, 2010.
19. Bogle M et al, ‘The role of soft tissue reconstruction after melanoma resection in the head and neck’,
Head & Neck, 23 (2001), pp.8-15.
20. Phan GQ1, Messina JL, Sondak VK, Zager JS, ‘Sentinel lymph node biopsy for melanoma: indications
and rationale’16(2009) pp.234-9.
21. Pieter J Tanis, corresponding author Omgo E Nieweg, Renato A Valdés Olmos, Emiel J Th Rutgers,
and Bin BR Kroon, ‘History of sentinel node and validation of the technique’, Breast Cancer Res, 3
(2001), pp.109-112.
22. ‘Revised U.K. guidelines for the management of cutaneous melanoma’, British Journal of
Dermatology, 163 (2010 ), pp.238-256.
23. Testori A, Rossi CR, Tosti G., ‘Utility of electrochemotherapy in melanoma treatment,’ 2 (2012), pp.15561.
24. Jedd D. Wolchok, Melanoma, (New York; 2015) <http://www.cancerresearch.org/cancerimmunotherapy/impacting-all-cancers/melanoma>
25. Yale J, ‘Biol Med. Focus: Immunology and Immunotherapeutics Ipilimumab and Cancer
Immunotherapy: A New Hope for Advanced Stage Melanoma’, Curr Opin Oncol, 84 (2011), pp.381389.
26. Paolo A Ascierto, John M Kirkwood, Jean-Jacques Grob, et al. ‘The role of BRAF V600 mutation in
melanoma’, J Transl Med, 10 (2012), p.85.
27. Jang S1, Atkins MB, ‘Which drug, and when, for patients with BRAF-mutant melanoma?’, Lancet
Oncol, 14 (2013) pp.1470-2045.
28. C Fellner, ‘Ipilimumab (Yervoy) Prolongs Survival In Advanced Melanoma Serious Side Effects and a
Hefty Price Tag May Limit Its Use’, 37 (2012) pp.503-511.
29. Robert C, Schachter J, Long GV, Arance A, et al, ‘Pembrolizumab versus Ipilimumab in Advanced
Melanoma’, N Engl J Med, 372 (2015) pp.2521-32.
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Aesthetics Journal
Treating the
Brow Area
Case study
Dr Victoria Dobbie presents her
techniques for treating aesthetic
concerns around the eyebrows
Every day I have patients asking me to treat the lines that are
etched across their forehead and/or between their eyebrows. It
is one of the most common requests for aesthetic treatment at my
clinic. In my early days of practice I would have only considered
botulinum toxin type A for the upper third of the face – primarily
because it was the glabella that received the first cosmetic
indication for the use of botulinum toxin type A in 2002.1 The basic
course on the use of toxin was therefore focused on the lines
between the brow, with little consideration to the end position
and shape of the female brow. You may have seen patients with
poor aesthetic results from toxin treatments, where their brows are
too high laterally and too low medially, or too low and flat, giving
the patient a heavy, tired appearance. Either way, they are not
enhancing the patient’s overall appearance – even if the line that
was bothering them was successfully treated. I believe that the
eyebrow is the most dominant feature on the forehead and should
be a key consideration at the diagnosis and planning stage, in
order to improve the aesthetic outcome of forehead and glabella
treatments. Practitioners who consider the brow first get optimal
results that patients love and want to have repeated. Treatment approach
1
Aesthetics
2
3
4
Figure 1: The ideal brow shape
1. Head of brow is in line with the width of the nose.
2. The brow should rise at an angle of 10-20 degrees.
3. Peak of the brow is at the same length as the intercanthal
distance. At its highest it should peak at a PHI ratio of 1:1.618 with
the patient’s hair line.
4. Tail of the brow is at 1:1.618 in relation to the peak and sits above
the head of the brow, along the line that passes through the outer
corner of the eye and tip of the nose.
The ideal brow is based on the principal that PHI or the ratio of
1:1.618 when applied to an individual’s face will make the face more
beautiful. By aiming for the brow to be closer to the ideal position for
the patient, they will have an aesthetically pleasing result.2
When consulting a patient, examine
the brow at rest for any obvious
asymmetry and balance. Even
younger patients can present with
a significant asymmetry, which
will need to be factored into your
treatment and discussed with the
patient before treatment. Watch how
Figure 2: Patient A – frontal
the brow shape alters on movement,
on elevation of the frontalis, and when contracting the corrugators,
procerus and orbicularis oculi. Consider; does the full length of the
brow sit on the orbital rim or is there a natural ptosis? If there is a ptosis
then you need to ask yourself:
1. Is the use of toxin going to exacerbate a ptosis?
2. Can you correct the ptosis by repositioning the brow with
dermal filler?
3. Or, is it more effective to treat the presenting line with dermal filler?
4. If there is excess skin, where is it and how will a toxin treatment
effect the skin laxity? Often in older patients, forehead lines are an
indication of excessive and loose skin.
Patient A (Figure 2) has an obvious asymmetry; with the exception
of the head of the brow, her upper left brow is higher. In addition, the
patient has temporal hollowing, asymmetric forehead hollowing over
her right brow, thin skin, loss of elasticity and poor skin quality.
Examine Patient A in Figure 3 –
does the patient’s forehead have
a 12-15 degree curve? A curve of
this description provides ideal bony
support to the skin of the forehead
and the position of the brow.2 Are
there asymmetries in the bony
support of the forehead?
Figure 3: Patient A – profile
I find this is best analysed by laying
the patient backwards and viewing their forehead from a superior
position. If this is what is causing the lines, then addressing these
asymmetries may give the patient the most effective aesthetic
outcome. Projection of the brow is another consideration as soft
tissue fullness and projection alters as we age. Temporal hollowing
also causes lateral brow laxity, excess muscle contraction and
lateral lines over the brow.3 Patient A (Figure 2) has flattening of the
curve to her forehead and loss of brow projection. Assessment of
skin quality is also fundamental to treatment and product choice:
• What is the skin thickness?
• What is the skin elasticity?
• What is the severity of wrinkle and how many are there?
• How many millimeters of excessive skin do you find?
Treatment plans
I take all of these factors into account when devising an appropriate
treatment plan for my patient. It allows me to explain the limitations
of a single modality and frame their expectations, inform the patient
of any asymmetry before treatment, explain why and how these may
be addressed as they age, and why botulinum toxin alone is unlikely
or no longer able to give them an optimum result. Treatment plans
should give the patient every treatment option with agreed goals,
benefits, risks, financial costs and time involved in appointments. This
is our duty of care as medical professionals.
@aestheticsgroup
Botulinum toxin type A
Botulinum toxin is often the first choice for younger patients with good
bony support, tight skin and good symmetry. In these patients the
result is more predictable and they often see a good result within two
weeks. Consider the position of the brows to enhance the overall
beauty of the patient when planning a toxin treatment.
It’s believed that 80% of middle-aged women have a brow
asymmetry4 and they often have looser skin and show bony ageing.
Dosing of the toxin needs to be adjusted to correct this asymmetry
and a brow lift of 1-3mm can be achieved.5
Dermal fillers
Consider using dermal fillers as they enable you to directly lift and
address any static lines. You can then combine with toxin to treat
dynamic lines with a more predictable outcome. When the brow is
asymmetric, low on the orbital rim or there is significant lateral brow
droop – you need to decide:
• Am I replacing structure to support the position of the brows?
• Or, treating the lines on the forehead directly?
To treat the forehead lines directly, consider the thickness and
elasticity of the skin. Following this, select a product that is soft and
elastic when placed in the superficially layers of the dermis.
To create structure, shape and lift be aware of the danger areas.
These include:
1. Supra trochlear
2. Supra orbital
3. Superficial temporal
The supra orbital and trochlear
run deep from the orbital rim and
move above the muscle to the
dermis at approximately 2cm
above the rim. The safest plane to
inject is deep or very superficial
and not in the dermis where intra
vascular injection is possible.7
Figure 4: Arterial and venous supply forehead6
I use a dermal filler that has
elastic, cohesive properties, in
order to lift the brow without
distorting the skin excessively
whilst allowing it to be moulded.
I place the dermal filler under the
frontalis muscle into the galea
space. This can be achieved
with a sharp needle on to bone.
My preferred method is to use a
micro-cannula – as the muscle
in this area is tight to the bone,
you get a very distinct restriction
on the micro-cannula when
you are in the correct plane. It
is uncomfortable for the patient,
due to the restricted space, but
this technique avoids dermal filler
Figure 5: Soft tissue augmentation
from being placed sub dermally
above the muscle. Dermal filler that is placed sub dermally can shift and
sit above the eyebrow, and so should be avoided. Small deposits of
dermal filler will give a good mechanical lift that raises the brow.
7
Aesthetics Journal
Top tip: For those who employ an aesthetician, booking patients
in to have unruly brows shaped after their two-week review will
enhance the patient’s results and impression of the clinic.
Skin tightening
Ultrasound skin tightening devices can be used to contract the muscle
to lift the brow and promote collagen production to firm and plump
the skin.1 A single treatment can achieve a 2mm brow lift for 89% of
patients.9 The treatment is quick and the discomfort tolerable for most
patients. Treatment can be done to tighten the muscle layer before
placing dermal filler to correct any asymmetry. The upper eyelid can
be treated because the device is ultrasound and not laser. Suh et al9
demonstrated by biopsy two months after ultrasound or radiofrequency
(RF) treatment, that there was significant neocollagenis deeper in the
reticulate dermis and SMAS layer with ultrasound. The neocollagenis
induced by radiofrequency was more superficial in the papillary and
mid to deep dermis. Consequently, I believe that RF cannot achieve
similar results to ultrasound and Bassichis et al 10 demonstrated in
2004 that 24 patients treated with monopolar RF had no decipherable
change in brow elevation. RF has FDA indication to treat lines for
moderate facial wrinkles and rhytides.10 A series of 6-12 RF treatments,
depending on the device, will increase collagenisis leading to skin
plumping; but this does not contract and lift the underlying muscle layer.
Summary
Ageing is multi-factorial and, as our patients age, a single modality
cannot be relied upon to continue to achieve good results. The upper
third of the face is especially challenging due to skin laxity and brow
ptosis. Treatment planning for the upper third of the face requires
combination treatments to regain balance and harmony of the brows,
because they are the strongest feature on the forehead and are more
prominent then any wrinkle.
Dr Victoria Dobbie has 13 years experience in
aesthetics and has carried out more than 20,000
treatments. She is the director of the Face and Body clinic
in Edinburgh, and previously ran her own dental clinic
with the Royal Army Dental Corps.
Dr Victoria Dobbie will discuss off-label uses of botulinum toxin
on the Expert Clinic agenda at the Aesthetics Conference and
Exhibition 2016. Visit www.aestheticsconference.com/programme
to find out more.
REFERENCES
1. Carruthers J, Lowe N, Menter M, et al. A multicenter, double-blind, randomized, placebo-controlled
study of the efficacy and safety of botulinum toxin type A in the treatment of glabellar lines. J Am
Acad Dermatol. 2002;46(6):pp.840–849
2. Swift, Remington Beautiphication a global approach to facial beauty. Clin Plastic Surg 38 (2011)
pp.347-377
3. Vleggaar D, Fitzgerald R Dermatological implications of skeletal aging: a focus on supraperiosteal
volumization for perioral rejuvenation. J Drugs Dermatol. 2008 Mar;7(3):pp.209-20
4. Matarasso A, Endoscopic surgical correction of glabella creases, Dermatol Surgery (1995) 6:p.695
5. Huiligol S Carruthers JA Carruthers JDA, Raising eyebrows with botulinum toxin Dermatol Surg
(1999) 25:pp.373-376.
6. Allergan, inc. (2014). Beneath the Skin of Beauty (Version 3.0) [Mobile application software]. Retrieved
from https://itunes.apple.com/za/app/beneath-the-skin-of-beauty-za/id911962831?mt=8
7. Jean Carruthers, Alistair Carruthers, Jeffrey S. Dover, Murad Alam, Materials, injection site, and
injection techniques, Soft Tissue Augmentation (2013) Saunders; China (3) pp.53-104
8. J.N. Witherspoon, MPH; L. White; D.P. West; S. Ortiz, BA; S. Yoo, MD; J. Havey, BS; R. Agha; N. Martin,
MD; M. Alam, Procedure for evaluating change in eyebrow, Northwestern University, Department
of Dermatology, (2012),<http://www.wrinkless.nl/wp-content/uploads/2012/01/Poster-Proced-for-EvalChange-in-Eyebrow-Position-Induced-.pdf>
9. Suh DH et al, Comparative histometric analysis of the effects of high intensity focused ultrasound
and radiofrequency on skin J Cosmet Laser Ther 2015 Oct 17(5)
10. Bassichis BA1, Dayan S, Thomas JR. Otolaryngol Use of a nonablative radiofrequency device to
rejuvenate the upper one-third of the face, Head Neck Surg. 2004 Apr;130(4):397-406.
11. Sabrina Guillen Fabi, NCBI, Noninvasive skin tightening: focus on new ultrasound techniques (2015)
<http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4327394/>
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EME/030/0714 Date of prep: July 2014
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Aesthetics Journal
Copper in
Skincare
Dr Charlene DeHaven details the uses
and benefits of copper in advanced
skincare
Copper is one of the essential ‘trace metals’ required in small
amounts for proper functioning of the human body and its various
macro and microsystems, including enzyme systems. Other
necessary trace metals include zinc, selenium, magnesium, and
manganese. Minimum dietary requirements must be met for each
trace metal. These requirements are small, but if deficient amounts
are ingested, many systems fail to work properly.12 In addition, copper
is involved with energy creation via its role in cytochrome oxidase,
a superfamily of proteins, which act as the terminal enzymes of
respiratory chains. All living cells in the human body generate energy
in order to function. Copper is required in mitochondria, the tiny
energy factories within each cell that are responsible for metabolism
and energy creation.1 For skin, copper is perhaps best known as a
required cofactor in collagen synthesis. It is also a necessary metal
in a number of other biochemical reactions occurring in the skin, as
listed in Figure 1.3
Copper-Containing Enzyme
Enzymatic Function
Superoxide Dismutase
Antioxidant (superoxide
degradation)
Collagen, elastin synthesis
Collagen synthesis
Energy production
Melanin formation
Lysyl Oxidase
Collagen Proline Dioxygenase
Cytochrome Oxidase
Tyrosinase
Figure 1: These enzymes in the human body require copper for proper
functioning. The copper becomes incorporated into the molecular structure
of each of these enzymes.
Copper may exist in a metallic form or an ionic form. The metallic
form of copper is the type many think of when visualising this metal
– however, copper in metallic form cannot be used by biologic
systems. In order for humans and other organisms to benefit from
copper, it must be present in ionic form. Ionic copper can be joined
to enzyme systems via chemical bonds and is the only form that is
active in the human body.4 Ionic forms of copper look very different
from copper metal; these have no ‘metallic’ appearance because
the copper in them is chemically bound to other substances. Medical
literature details uses of copper ions as antimicrobials with potential to
combat a variety of possible infectious processes including; bacteria,5
herpes viruses,6 leishmaniasis,7 and other conditions where infectious
processes are implicated such Propionibacterium acnes.8
The role of copper within cosmeceuticals
There are numerous potential applications for using copper in
aesthetics; the key factors are outlined below:
Potentiating effects on collagen synthesis
Collagen is the most prevalent protein in the body and most collagen
is found in the skin (Figure 2). Collagen serves as the structural
Aesthetics
framework for numerous tissues including skin, bone, teeth, tendons,
and all other connective tissues.9 Since both vitamin C and copper
are necessary for the formation of healthy collagen, combining
both ingredients in a single formula would be ideal. Studies have
indicated that combining copper and vitamin C together results in a
chemical reaction between the two substances, causing a decrease
in antioxidant activity,10 although, one product claims to have combined
the two successfully.11 Growth factors such as copper tripeptide-1
also increase collagen synthesis.12 This growth factor is a tripeptide
composed of the three amino acids; glycine, histidine, and lysine. This
natural molecule, found in human skin and other tissues, mediates
its effect of encouraging collagen synthesis via decorin,13 a molecule
intimately involved with
the architecturally correct
synthesis of collagen.
Copper tripeptide-1
Figure 2: The triple helix of collagen,
composed of two alpha1 strands and one
also affects matrix
alpha2 strand
metalloproteinase (MMP)
enzymes.14,15 This growth factor belongs to a group of emergency
response molecules that come to the body’s aid in times of stress,
including wound healing,16 tissue remodeling,17 stem cell antisenescence,18 ageing,19,20 post-procedure,21,22 inflammation and
oxidative stress,23 and infection. Copper tripeptide-1 also has antitumorigenic properties, while at the same time encouraging the
growth and normal development of healthy cell lines.24,25
Wound healing
Copper metal ions have been found in higher concentrations
around healing wounds and thus are implicated in wound healing
and inflammatory processes.26 The topical application of copper
ion-containing ointments has been associated with improved wound
healing.27 In addition there is a huge body of scientific evidence
supporting the essential role of copper tripeptide-1 growth factor in
the acceleration of wound healing (Figure 3).10,12,13,17 This compound is
released during tissue injury to signal repair processes to begin.
3 months control
3 months
6 months control
Copper serum
applied twice daily
6 months
Copper serum applied
twice daily for three
months, then once
daily for three months
Figure 3: Two identical full-thickness incisions were made in the thighs of a
54-year-old female, sutures removed at seven days, application of copper serum
began, digital photos taken at three months and six months post treatment.
Antioxidant support system
Copper, in particular copper tripeptide-1 growth factor, has shown
significant impact in optimising antioxidant protection within
formulations (Figure 4).
Equally it has shown to provide a pivotal role in a new wave of
antioxidants. Superoxide dismutase (SOD), which previously
required intravenous administration for delivery, is now available in
topical form. SOD is one of three enzymatic antioxidants made by
the human body. All were designed through evolutionary processes
to neutralise free radical damage.24 This group of antioxidants is
unique in several aspects; they are effective in very tiny amounts
and are not inactivated during the redox process. Furthermore, they
@aestheticsgroup
ORAC TOTAL (umole TE/g)
700
Aesthetics Journal
683.43
Testing independently performed by Brunswick Labs
600
500
Product containing Copper tripeptide-1 growth factor
400
Product containing C, E and Ferulic
300
Product containing CoffeeBerry
200
Cosmeceutical containing 10% vitamin C
206
157
Product containing 1% ldebenone
100
53
14
0
Figure 4: ORAC (Oxygen Radical Absorption Capacity) measures total lipophilic antioxidant capacity. Testing independently
performed by Brunswick Labs. Image provided courtesy of INNOVATIVE SKINCARE.
are not used up while combating free radical processes and persist
in the body for long periods of time, unlike other non-enzymatic
antioxidants, such as vitamin C.28 A study has shown that copper
assists SOD for proper functioning in its antioxidant role.29
firmness and wrinkles.13,15,16 Through the effects of decorin, new
collagen made in injured tissue assumes the correct anatomical
configuration and structure rather than a disorganised scar.31
Role in melanin synthesis
Melanin is designed to give some protection against photodamage.
Copper is necessary for melanin synthesis within melanocytes, which
are found scattered along the Dermal-Epidermal Junction (DEJ) in the
basal layer of epidermis.1 Equally tyrosinase, the enzymatic partner for
copper, is the most crucial enzyme required in melanin synthesis, as its
action is the rate-limiting step in melanin production.30
Although copper is required for human life and for many biologic
processes, too much of a good thing is not positive. Ingesting
large amounts of copper as a supplement can be harmful and
even toxic.32 Both copper and iron have the potential to act as
pro-oxidants and increase free radical damage if found in excess.10
However, providing copper in correct amounts can certainly
assist many aspects of skin functionality, improve skin health, and
maintain youthful vitality of skin appearance.
Conclusion: All good things in moderation
Tissue remodelling
Copper tripeptide-1 and other forms of copper are active for
tissue remodelling, which is the return of injured tissue to normal
architecture and function. It increases keratinocyte proliferation and
normal collagen synthesis, improves skin thickness, skin elasticity,
REFERENCES
1. de Romaña DL, Olivares M, Uauy R, Araya M. J, Risks and benefits of copper in light of new
insights of copper homeostasis, Trace Elem Med Biol. 2011 Jan;25(1):pp3-13
2. Gambling L, Kennedy C, McArdle HJH. Semin, Iron and copper in fetal development. Semin Cell
Dev Biol. 2011 Aug;22(6):pp637-44
3. Stipanuk MH & Caudill MA Biochemical, Physiological, and Molecular Aspects of Human
Nutrition, eds. Zinc, Copper, and Manganese. Grider A. 2013. Elsevier: USA. p830
4. Günter J, Konrad J. A. Kundig Copper: Its Trade, Manufacture, Use, and Environmental Status,
Copper in the Environment, ASM; USA p378
5. Dlewell A, Barnes M, Endres JR, Ahmed M, Ghambeer DK. J, Walkenhorst WF, Sundrud JN,
Laviolette JM. Additivity and synergy between an antimicrobial peptide and inhibitors ions
Biochim Biophys Acta. 2014 Sep. 1839(9):pp2234-42. Epub 2014
6. Drugs Dermatol. Efficacy and tolerability assessment of a topical formulation containing
copper sulfate and hypericum perforatum on patients with herpes skin lesions: a comparative,
randomized controlled trial. 2012 Feb. 11(2):pp209-15
7. Peniche AG, Renslo AR, Melby PC, Travi BL, Antileishmanial activity of disulfiram and thiuram
disulfide analogs in an ex vivo model system is selectively enhanced by the addition of divalent
metal ions. Antimicrob Agents Chemother. 2015 Aug 3. Epub ahead of print
8. Stephens TJ, McCook JP, Herndon JH Jr. J Pilot study of topical copper chlorophyllin complex in
subjects with facial acne and large pores, Drugs Dermatol. 2015 Jun. 14(6):pp589-92.
9. Diegelmann RF, Medscape, Wounds, Collagen Metabolism 2001;13(5) <http://www.medscape.
com/viewarticle/423231>
10. HACIŞEVKĐ, A. An Overview of Ascorbic Acid Biochemistry, Ankara Ecz. Fak. Derg., 38 (3) 233 255, 2009 <http://dergiler.ankara.edu.tr/dergiler/24/1716/18327.pdf>
11. iS Clinical, Super Serum Advance, n.d, <https://www.isclinical.co.uk/super-serum-results>
12. Maquart FX, Pickart L, Laurent M, Gillery P, Monboisse JC, Borel JP, Stimulation of collagen
synthesis in fibroblast cultures by the tripeptide-copper complex glycyl-L-histidyl-L-lysine-Cu2+.
FEBS Lett. 1988 Oct 10. 238(2):pp343-6.
13. Kinsella MG, Bressler SL, Wight TN. The regulated synthesis of versican, decorin, and biglycan:
extracellular matrix proteoglycans that influence cellular phenotype. Crit Rev Eukaryot Gene
Expr. 2004. 14(3):pp203-34.
14. Simeon A, Monier F, Emonard H, Gillery P, Birembaut P, Hornebeck W, Maquart FX, Expression
and activation of matrix metalloproteinases in wounds: modulation by the tripeptide-copper
complex glycyl-L-histidyl-L-lysine-Cu2+. J Invest Dermatol. 1999 Jun. 112(6):pp957-64.
15. Simeon A, Emonard H, Hornebeck W, Maquart FX, The tripeptide-copper complex glycyl-Lhistidyl-L-lysine-Cu2+ stimulates matrix metalloproteinase-2 expression by fiboblast cyultures.
Life Sci. 2000 Sep 22. 67(18):pp2257-65.
16. Pickart L, Published studies on tissue and skin remodeling copper-peptides: copper peptide
studies on skin renewal, wound healing, and hair growth. Skinbiology.com (2014). <http://
skinbiology.com/copperpeptideregeneration.html>
17. Pickart L, The human tri-peptide GHK and tissue remodeling. J BiomaterSciPolym Ed. 2008.
Dr Charlene DeHaven is a board-certified physician in
both Internal Medicine and Emergency Medicine, with an
emphasis on age management and health maintenance.
She currently serves on the lecture faculty for the University
of Washington Department of Family Medicine.
19(8):pp969-88.
18. Choi HR, Kang YA, Ryoo SJ, Shin JW, Na JI, Huh CH, Park KC, Stem cell recovering effect of
copper-free GHK in skin, J Pept Sci. 2012 Nov. 18(11):pp685-90.
19. Leyden J, Stephens T, Finkey MB, Appa Y, Barkovic S, Skin care benefits of copper peptide
containing facial cream. Amer Academy Dermat Meeting. 2002 Feb. Abstract pp68-69.
20. Pickart L. Klatz R, Goldman R (eds.) The human tripeptide GHK (glycyl-L-histidyl-L-lysine),
the copper switch and the treatment of the degenerative conditions of aging. Anti-Aging
Therapeutics Vol XI. American Academy of Medicine:Chicago IL. 2009. pp301-3012.
21. Miller TR, Wagner JD, Baack BR, Eisbach KJ, Effects of topical copper tripeptide complex on
CO2 laser-resurfaced skin. Arch Facial Plast Surg. 2006 Jul-Aug. 8(4):pp252-9.
22. Miller TR, Wagner JD, Baack BR, Eisbach KJ, Effects of topical copper tripeptide complex on
CO2 laser-resurfaced skin. Arch Facial Plast Surg. 2006 Jul-Aug. 8(4):pp252-9.
23. Miller DM, DeSilva D, Pickart L, Aust SD, Effects of glycyl-histidyl-lysyl chelated Cu(II) on ferritin
dependent lipid peroxidation. Adv Exp Med Biol. 1990. 264:pp79-84.
24. Matalka LE, Ford A, Unlap MT, The tripeptide, GHK, induces programmed cell death in SH-SY5Y
neuroblastoma cells. J Biotechnol Biomater. 2012. 2:p144.
25. Hong Y, Downey T, Eu KW, Koh PK, Cheah PY, A ‘metastasis-prone’ signature for early-stage
mismatch-repair proficient sporadic colorectal cancer patients and its implications for possible
therapeutics. Clin Exp Metastasis. 2010 Feb 9.
26. Miratschijski U, Martin A, Jorgensen LN, Sampson B, Agren MS, Zinc, copper, and selenium
tissue levels and their relation to subcutaneous abscess, minor surgery, and wound healing in
humans. Biol Trace Elem Res. 2013 Jun. 153(1-3):pp76-83. Epub 2013 Apr 18.
27. Frangoulis M, Georgiou P, Chrisostomidis C, Perrea D, Dontas I, Kavantzas N, Kostakis A,
Papadopoulos O, Rat epigastric flap survival and VEGF expression after local copper
application. Plast Reconstr Surg. 2007 Mar. 119(3):pp837-43.
28. Fukai, T. Ushino-Fukai, M. Antioxidants & Redox signaling, Superoxide Dismutases: Role in Redox
Signalling, Vascular Function, and Diseases, 2011 Sep 15; 15(6): 1583–1606 <http://www.ncbi.nlm.
nih.gov/pmc/articles/PMC3151424/>
29. Abreu IA, Cabelli DE, Superoxide dismutases – a review of the metal-associated mechanistic
variations. Biochim Biophys Acta. 2010 Feb. 1804(2):pp263-74.
30. Casanola-Martin GM, Le-Thi-Thu H, Marrero-Ponce Y, Castillo-Garit JA, Torrens F, Rescigno A,
Abad C, Khan MT, Tyrosinase enzyme: 1. An overview on a pharmacologic target. Curr Top Med
Chem. 2014. 14(12):pp1494-501.
31. Kinsella MG, Bressler SL, Wight TN. The regulated synthesis of versican, decorin, and biglycan:
extracellular matrix proteoglycans that influence cellular phenotype. Crit Rev Eukaryot Gene
Expr. 2004. 14(3):203-34
32. Araya, M; McGoldrick, MC; Klevay, L M.; Strain, J.J.; Robson, P; Nielsen, Forrest; O, Manuel;
Pizarro, F; Johnson, L; Poirier, K A. (2001). Determination of an Acute No-Observed-AdverseEffect Level (NOAEL) for Copper in Water. Regulatory Toxicology and Pharmacology 34 (2):
137–45. doi:10.1006/rtph.2001.1492. PMID 11603956.
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Sinclair IS Pharma. 1st Floor Whitfield Court, 30-32 Whitfield Street, London W1T 2RQ. United Kingdom. www.sinclairispharma.com
Date of preparation: November 2015 UK/SIPPEL/15/0003
@aestheticsgroup
Aesthetics Journal
Recognising Body
Dysmorphic Disorder
in Aesthetic Practice
Dr Dimitre Dimitrov and Dr Anthony Bewley
advise practitioners on how to best manage
patients with Body Dysmorphic Disorder and
detail appropriate methods of assessment
Body Dysmorphic Disorder (BDD) is a common problem in aesthetic practices, yet the
condition still remains under-recognised and under-diagnosed.1 People suffering from
BDD are concerned with minimal or non-existent defects, develop social avoidance and may
become housebound or even suicidal.2,3,4,5
BDD is primarily a psychiatric health problem and patients usually consult dermatologists,
plastic surgeons, other specialists or general practitioners, but not mental health
specialists,6 as patients firmly believe that their disease is a physical problem. Even when
their problem is recognised as BDD, it is important to be aware that patients may be
resistant to engage with mental health professionals and seek psychiatric help. Instead,
they may simply consult other dermatologists or plastic surgeons in the battle to achieve
the image of ‘perfection’. However, once diagnosed, a holistic psychodermatological
approach, focusing not only on the disease, but also on his/her psychological, emotional,
physical, and social needs has to be taken into account and be treated.
The prevalence of BDD varies in different studies, but all have found that a high percentage
of patients with the disorder presented in aesthetic practices. According to previous studies,
the prevalence of BDD is 1.7-2.4%, but in the setting of general dermatology and aesthetic
procedures, the population can reach 7-20.3%.7,8,9
The patient should be informed
that this is a recognised problem
and there is successful treatment,
however some may not be ready
during the first consultation to
accept that idea
Symptoms of BDD
The fundamental issue with BDD is that the
patient is preoccupied with a real (often
objectively trivial) or an imagined defect in his/
her appearance. The main areas of patient
concern are the face and facial features, skin,
breasts, genitals and buttocks.10 Patients can
present signs of this disorder at any age, but
most patients have noted that symptoms
started to develop in adolescence and
even childhood.10 Most patients with BDD
spend considerable amounts of time in selfreflective, time-consuming and unproductive
rumination. Ritualistic behaviours such
as mirror checking are common, as are
camouflage, covering ‘defects’ and ideas of
reference (some patients believe that others
have noticed their ‘defect’ and are acting on
that knowledge). Affected individuals often
need constant reassurance from others, but
still continue repeatedly to seek dermatologic
or cosmetic referral for correction of the
‘defect’.11 Co-morbidities such as social
avoidance, depression, anxiety and suicidal
ideation are common lifetime prevalences,
with 24-28% for suicide attempts.3,4,5,9 In an
observational study of 200 people with BDD,
followed up for almost five years, the rate of
completed suicide was 22 to 36 times higher
than the general population.9
It is important to recognise patients with BDD
in aesthetic practice for the following reasons:
The prime pathology is psychological
rather than physical.2
• Psychosocial co-morbidities and suicidal
ideation are common.4
• Patients with BDD are rarely satisfied
with the results of their aesthetic
procedures.3,12
• Patients quite often become litigious after
‘failure’ to resolve their ‘defect’.13
• Special attention should be paid to the
problem with informed consent in BDD
patients undergoing plastic surgery/
dermatological procedures. The question
that practitioners should address is: do
the patients with BDD have full capacity
to give a truly informed consent for
cosmetic procedures?14
Violent behaviour toward practitioners can
also become a possibility. For example, 2% of
BDD patients threaten their practitioners and
surgeons physically and at least two cosmetic
surgeons have been murdered by patients with
BDD.15 According to one survey, 12% of plastic
surgeons said that they had been threatened
physically by a dissatisfied BDD patient.15
Once the diagnosis of BDD has been
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Date of preparation: September 2015 UK/SIPSST/15/0003
@aestheticsgroup
Assesment
Recognition of the condition may be achieved with proper screening
with validated questionnaires.16 There are a number of questionnaires
available from various organisations, such as:
• The Cosmetic Procedure Screening Questionnaire (COPS)17
• The Body Dysmorphic Disorder Questionnaire (BDDQ)18
• The Yale Brown Obsessive Compulsive Scale Modified for Body
Dysmorphic Disorder, (BDD-YBOCS)19
• Body Dysmorphic Disorder, NICE Guidance20
• Body Dysmorphic Disorder, Five Questions Psychiatric Evaluation
for Cosmetic Procedure by Veale21
In busy aesthetic practices, the following questions can be a quick
and helpful tool to help you gauge whether a patient may be
suffering from BDD:16
1. Are you worried about how you look? (Yes/No); if you are, do you
think about your appearance problems a lot and wish you could
think about them less? (Yes/No)
2. How much time per day, on average, do you spend thinking about
how you look?
(a) Less than 1 hour a day.
(b) 1-3 hours a day.
(c) More than three hours a day.
3. Is your main concern with how you look that you aren’t thin
enough or that you might become too fat? (Yes/No)
4.How has this problem with how you look affected your life?
(a) Has it often upset you a lot? (Yes/No)
(b) Has it often gotten in the way of doing things
with friends, your family, or dating? (Yes/No)
(c) Has it caused you any problems with school or work?
(Yes/No)
(d) Are there things you avoid because of how you look?
(Yes/No)
As practitioners, you should suspect BDD if the patient answers yes
to Question 1; (b) or (c) to Question 2; yes to Question 3 and yes to
any part of Question 4.16
The following is a more detailed screening questionnaire for BDD
patients with skin concerns.22
1. Do you currently think a lot about your skin?
2. On an average day, how many hours do you spend thinking about
your skin? Please add up all the time that your feature is on your
mind and make your best estimate.
3. Do you feel your skin is ugly or very unattractive?
4.How noticeable do you think your skin is?
5. Does your skin currently cause you a lot of distress?
6.How many times a day do you usually check your skin, either in a
mirror or by feeling it with your fingers?
7. How often do you feel anxious about your skin in social situations?
Does it lead to you avoiding social situations?
8.Has your skin had an effect on dating or on existing relationship?
9.Has your skin interfered with your ability to work or study, or your
role as a homemaker?
Aesthetics Journal
established, sympathetically discussing this with the patient is
crucial, however it is important to still acknowledge that there
is a visible difference in their appearance, (if there really is
one). Dismissing the concern, trying to reassure the patient
that they look fine, or telling them that they should not worry
is usually ineffective. Do not argue about the diagnosis; listen
carefully and with sympathy to the patient’s story, but allow
enough time for discussion. One technique is to ask the
patient to allocate a severity score for their ‘defect’, (this is
usually 10 out of 10 for most patients), and then compare that
with your own assessment of the severity of the ‘defect’ (which
can be considerably less than the patient’s numeric severity
assessment). A discussion about the ‘gap’ between the
patient’s and the practitioner’s assessment can then be a way
to open the discussion about the diagnosis of BDD.
Referral
Referral to a mental healthcare specialist or a psychodermatology clinic may be necessary in the management of
BDD. The role of a dermatologist, surgeon or practitioner is
to prepare the patient for potential psychiatric help. Without
necessary preparation, the patient will usually refuse to seek
psychiatric treatment and may continue their journey with other
doctors. Discussing the distress caused by their concerns may
help patients to understand the need for mental health referral.
The patient should be informed that this is a recognised
problem and there is successful treatment, however some
may not be ready during the first consultation to accept that
idea. Do not force them; just allow them enough time; keep
a good professional relationship and ask if they would like to
come again. Referral to local or regional psycho-dermatology
clinics may be easily accepted by the patient as they may
feel more comfortable to be seen in a dermatology clinic by a
dermatologist and psychiatrist, as many patients may not want
other people to know that they need psychiatric help and may
feel ashamed to be seen going to a psychiatric department.
The recommended treatment for BDD is cognitive behavioural
therapy (CBT) that is specific to this disorder.20 Patients with
moderate or severe BDD may require treatment with a
selective serotonin reuptake inhibitor, often at the maximum
tolerated dose for at least three months.11 Two randomised
controlled clinical trials have proven their efficacy. The first trial
found that fluoxetine hydrochloride, an antidepressant drug, is
more effective than placebo in patients with BDD. The second
trial compared clomipramine, a potent serotonin reuptake
inhibitor, and desipramine, a selective norepinephrine
reuptake inhibitor and results found clomipramine to be more
effective in the treatment of BDD.23,24 Patients with severe
problems should have continuing access to multidisciplinary
teams with specialist expertise in BDD.
Conclusion
Based on our personal experience treating patients with BDD,
the majority may be driven by media pressure in a ‘celebrity’
culture, together with greater availability and popularity of
cosmetic procedures. But early recognition of BDD may help
to prevent progress of the disease, to improve quality of life
of the patient and of their family and may even help to save
the life of the patient and the reputation and wellbeing of the
practitioner.
@aestheticsgroup
Aesthetics Journal
Dr Anthony Bewley is a consultant dermatologist
at Whipps Cross University Hospital and the Royal
London Hospital. He is an honorary senior lecturer
at the Universities of London and Hertfordshire
and has trained in all aspects of adult and child
dermatology, but has a particular interest in psychodermatology
and inflammatory dermatoses.
REFERENCES
1. Dyl J, et al. Body dysmorphic disorder and other clinically significant body image concerns in
adolescent psychiatric inpatients: prevalence and clinical characteristics. (Child Psychiatry & Human
Development, 2006);36, <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1613832/?report=reader>
[Accessed 27th October 2015].
2. Helwick C, ‘Body Dysmorphic Disorder Can Be Lethal’, (Medscape Medical News > Psychiatry, 2011)
<http://www.medscape.com/viewarticle/740015> [Accessed 2nd September 2015].
3. Veale D, Boocock A, Gournay K et al, ‘Body dysmorphic disorder: A survey of fifty cases.’, (Br J
Psychiatry.1996), (168), pp.196-201.
4. Phillips KA, ‘Suicidal Ideation and Suicide Attempts in Body Dysmorphic Disorder’, (Journal of Clinical
Psychiatry, 2005), (66), pp.717-725.
5. Phillips KA, Diaz SF, ‘Gender differences in body dysmorphic disorder’, (Journal of Nervous and
Mental Disease. 1997), (185) (9), pp.570-7.
6. Phillips KA, ‘The Broken Mirror: Understanding and Treating Body Dysmorphic Disorder’, (Oxford
University Press; Oxford, 1996).
7. Haas CF, Champion A, Secor D, ‘Motivating factors for seeking cosmetic surgery: a synthesis of the
literature’, Plastic Surgical Nursing, 2008, Oct-Dec; 28 (4), pp.177-82.
8. Phillips KA, Dufresne RG Jr, Wilkel CS, Vittorio CC, ‘Rate of body dysmorphic disorder. in dermatology
patients’, J Am Acad Dermato,.2000 Mar; 42(3), pp.436-41.
9. Helwick C, ‘Body Dysmorphic Disorder Can Be Lethal’, (Medscape Medical News > Psychiatry, 2011)
<http://www.medscape.com/viewarticle/740015> [Accessed 2nd September 2015].
10. Rhode Island Hospital; Centers & Services, ‘Body Dysmorphic Disorder Program’ <http://www.
rhodeislandhospital.org/psychiatry/body-image-program.html> [Accessed 2nd September 2015].
11. Phillips AK, Pagano ME, Menard W, Stout RL, ‘A 12-Month Follow-Up Study of the Course of Body
Dysmorphic Disorder’, (American Journal of Psychiatry, 2006), 163, (5); pp.907-912.
12. Crerand CE, Franklin ME, Sarwer D, ‘Body dysmorphic disorder and cosmetic surgery’, (Plastic
Reconstruct Surg, 2006) (118), pp. 167-80.
13. Francis TE, ‘Informed Consent in Body Dysmorphic Disorder’, (Medscape Plastic Surgery, 2012).
<http://www.medscape.com/viewarticle/758800_1> [Accessed 2nd September 2015].
Aesthetics
Dr Dimitre Dimitrov is a specialist in dermatology
and venereology. He has worked in the field in his
native Bulgaria, Libya and UAE. In 2011, he received full
registration with the General Medical Council and is
an honorary consultant in Whipps Cross Hospital and
London Royal Hospital.
14. Millard LG, ‘Millard J in Rook’s Textbook of Dermatology’; Eighth edition (eds Burns T et al), (WileyBlackwell, 2010), pp.64.17 – 64.21.
15. Sarwer DB., ‘Awareness and identification of body dysmorphic disorder by aesthetic surgeons: results
of a survey of American society for aesthetic plastic surgery members’, Aesthet Surg J, 2002 (22),
pp.531–535.
16. Ahmed I, ‘Body Dysmorphic Disorder, Medscape’, (Updated 2014), <http://emedicine.medscape.com/
article/291182-overview> [Accessed 2nd September 2015].
17. Veale, D et al, ‘Development of a Cosmetic Procedure Screening Questionnaire (COPS) for
Body Dysmorphic Disorder’ (J Plast Reconstr Aesthet Surg. 2012), <http://www.ncbi.nlm.nih.gov/
pubmed/22000332#> (4) [Accessed 27th October 2015].
18. Body Dysmorphic Disorder Foundation, ‘Questionnaires’, <http://bddfoundation.org/helping-you/
questionnaires/>, [Accessed 27th October 2015].
19. Phillips, KA et al, ‘A severity rating scale for body dysmorphic disorder: development, reliability, and
validity of a modified version of the Yale-Brown Obsessive Compulsive Scale’, (Psychopharmacology
Bulletin, 1997), (1) <http://www.ncbi.nlm.nih.gov/pubmed/9133747#> pp.17-22. [Accessed 27th October
2015].
20. National Institute for Health Clinical Excellence, ‘Core interventions in the treatment of obsessivecompulsive disorder and body dysmorphic disorder’ <https://www.nice.org.uk/guidance/cg031 >,
[Accessed 27th October 2015].
21. David Veale, ‘Body Dysmorphic Disorder, Five Questions Psychiatric Evaluation for Cosmetic
Procedure’, (Cambridge University Press, Advances in Psychiatric Treatment, 2001) (7) pp.125-132.
22. Bewley, A, Veale D et al, ‘Practical Psychodermatology’, (London, J Wiley & Sons, 2014).
23. Phillips KA, Albertini RS, Rasmussen SA, ‘A randomized placebo-controlled trial of fluoxetine in body
dysmorphic disorder’, Arch Gen Psychiatry, 2002 , (59), pp.381-8.
24. Hollander E, Allen A, Kwon J, et al, ‘Clomipramine vs desipramine crossover trial in body dysmorphic
disorder: selective efficacy of a serotonin reuptake inhibitor in imagined ugliness’ (Arch Gen
Psychiatry, 1999), (56), pp.1033-9.
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@aestheticsgroup
Treating
Birthmarks
with Laser
Dr Salinda Johnson details the
different types of birthmark and how
to effectively treat them using laser
As an aesthetic practitioner, I treat adults who bear the constant
reminder of symptoms first seen within one month of them being
born. Today’s younger patients with birthmarks enjoy the benefits of
a science that has nearly come of age; however, many adult patients
still suffer the trauma of looking different from their peers, and are
often reluctant to return to the hospital environment, that sometimes
dismisses their concerns as being only cosmetic. This article therefore
focuses on the treatment of birthmarks in adults. Specifically it will
cover the classification, treatment and expected results of a number of
common types of birthmark.
The progression of treatment options
Vascular laser treatments originated with the treatment of port wine
stain (PWS), using an Argon laser in the mid 1960s.1 It was successful in
reducing the colour of the PWS, but the pulse length (a repeated pulse
of 0.2s) and small spot size (1mm), tended to result in a more general
‘bulk’ heating with resultant burning followed by scarring.2 The use of
laser in medicine changed when a major breakthrough occurred in
1983, following publication of the paper ‘Selective photothermolysis:
precise microsurgery by selective absorption of pulsed radiation’ by
Anderson and Parrish.3 This paper set out the principle that has been
used in the subsequent 30 years of treating of birthmarks – if you can
select a wavelength that is absorbed predominantly by haemoglobin
or melanin, and use that in a pulse that is sufficiently powerful and
timed to match the size of the target, you are able to selectively
damage that target while having little or no negative impact on the
surrounding tissue.3 In practice, lasers target a specific chromophore
– haemoglobin in vascular lesions or melanin in pigmented ones. The
chromophore heats up in the presence of light of certain wavelengths
while the surrounding tissue does not. Heat radiates from the target
into surrounding tissue at a given rate (thermal relaxation time).4,5 But
because different wavelengths are required, and the depth to which
the laser can penetrate the skin depends on the wavelength, multiple
lasers are required. In the 1990s Intense Pulsed Light (IPL), which is
produced by a halogen flash lamp, was introduced.6 Rather than use
one specific wavelength, the
Before
After
raw broadband light of IPL
covers a wavelength of 4001200nm, which non-selectively
targets haemoglobin, melanin
and water. Early lasers and IPL
had standard pulse lengths
Male patient in his 50s before treatment
imposed by the limitations of
and one month after treatment for PWS,
using 3 TX with Ellipse PR 530 applicator the light sources concerned,
(PWS setting)
but advances in electronics
Aesthetics Journal
mean that today’s models are not so restricted. For example, the first
Pulsed Dye Laser (PDL) had a pulse of only 0.45ms – too short for adult
vessels. Now, the ability to create a range of pulse lengths gives the
capability of treating adults. This is important, as the thermal relaxation
time of the target is proportional to its size. For deeper vessels (the
venous component of some lesions) a longer wavelength is required,
and Nd:YAG laser meets these requirements. Many lasers can treat
pigmented lesions, but Q-Switched lasers have been suggested to be
more successful in treating dermal-pigmented lesions,7 as the energy
used is delivered in a pulse measured in nanoseconds, effectively
pulverising rather than heating the pigment. With the exception of
many epidermal naevi, where lack of chromophore restricts treatment,
all of the birthmarks mentioned below (or their residual effects) are
treated using light-based technology.
Vascular Conditions
Diagnosis in adults is a question of looking at the colour and
size of the lesion to determine vessel diameter and depth
– larger vessels that are a dark colour (purple/blue) could
suggest a deeper cause.8 Use a dermascope to gain more
detail where required.
Infantile hemangiomas
These benign vascular neoplasms often involute naturally;
70% of cases do so by the age of seven.9 The drug
propranolol is the current treatment of choice for children,
and given as either systemic medication or topically,10 with the
possible adjunct of PDL or IPL. However, more than 30% of
adult patients who as children had natural involution by age
six, and 80% of patients where this occurred after the age of
six, have residue, scarring or develop telangiectasias.11 I tend
to treat resultant redness with IPL, using a short (5ms) pulse.
Naevus simplex (Stork Bites)
These are present in almost half of newborns as bright patches
of skin.12 Most resolve naturally with no residue within the first
year of life, but 50% of those on the nape of the neck persist
into adulthood.13 Again, the vessels are very small, and a 2 x
2.5ms pulse or single 5ms pulse can reduce the redness.
Naevus flammeus (Port Wine Stains)
This form of birthmark is found in 0.3% of babies.9 They persist
and develop through the life of the patient. Initially bright pink
or red in appearance, as patients age, the vessels dilate and
the lesions darken through purple to a blue colour. In later life
it may become nodular, and bleed spontaneously.14 A longer
pulse (8ms) is more beneficial in adults. Success of treatment
is in part determined by the location of the PWS itself; the
forehead responds well, followed by the remainder of the
face and neck, but results are not quite so good on the trunk
and extremities, due in part to the depth and flow-rate of the
vessels, and in part to the greater likelihood of hypertrophy.15
Pigment Conditions
Epidermal naevi are present in 0.1% of children who are under one
year old.16 There are many subtypes depending on the cell type
contained;16 keratinocytic or nonorganoid epidermal naevi typically
contain only keratinocytes, whereas organoid epidermal naevi may
involve additional types of epidermal cells, such as the cells that
make up the hair follicles or yellow and pebbly sebaceous naevis; the
wart-like verrucous epidermal naevus. While historically these were
removed surgically as some feared the development of basal cell
@aestheticsgroup
Aesthetics Journal
carcinoma,17 most today are removed for aesthetic reasons via
a short surgical procedure performed under local anaesthetic.
Café au lait macules (CALM)
14% of adults have one or more café au lait macules, which can
occur anywhere on the body.18 While IPL can work in some
cases, Q-Switched Nd:YAG is treatment of choice, as the much
faster pulse can shatter the pigment, rather than heating it.
Dermal melanocytoses
These are a group of deeper dermal pigmented lesions
including Mongolian spot (affecting the lumbrosacral area and
often not persisting into adult life), Nevus of Ota (affecting the
face) and Nevus of Ito (back and shoulders). All tend to present
as a blue-brown lesion requiring Q-Switched Nd:YAG.
Conclusion
Before treating the patient, it is vital to ensure that they have
a realistic expectation of the treatment result and are aware
that treating an adult for a birthmark is likely to involve several
sessions and result in skin that looks better, but is not totally
perfect. A patch test to determine the suitability of the patient
for treatment is essential, as is a full medical history. The
rewards of such treatments are not just skin-deep; it is possible
not only to change the appearance of the patient, but also to
change their entire outlook on life, and the way in which they
are viewed by society.
Aesthetics
Dr Salinda Johnson is an aesthetic practitioner and has
lectured and trained in the specialty for many years. Dr Johnson completed a specialist fellowship programme in
cosmetic dermatology in 2000 and has continued to hone her
techniques and expertise in the field ever since, incorporating
up-to-date procedures and best practice as they develop.
REFERENCES
1. Solomon H, Goldman L, Henderson B et al. Histopathology of the kaser treatment of port-wine lesions: biopsy
studies of treated areas observed up to three years after laser impacts. J Invest Dermatol 1968; 50: 141-146
2. Dixon JA, Huether SE, Rotering SH. Hypertrophic scarring in argon of port-wine stains, Plast Reconstr Surg
1984;73:771–779
3. Anderson RR, Parrish JA. Selective photothermolysis: precise microsurgery by selective absorption of pulsed
radiation, Science 1983;220:524–527
4. Altshuler GB, Anderson RR, Manstein D, Zenzie HH, Smirnov MZ. Extended theory of selective photothermolysis,
Lasers Surg Med. 2001;29(5):416-32
5. Ross EV. Extended theory of selective photothermolysis: a new recipe for hair cooking? Lasers Surg Med.
2001;29(5):413-5
6. Goldman MP, Eckhouse S, Photothermal sclerosis of leg veins, Dermatol Surg. 1996 Apr;22(4):323-30
7. Chan HH, Kono T, The use of lasers and intense pulsed light sources for the treatment of pigmentary lesions Skin
Therapy, Lett. 2004 Oct; 9(8): 5-7
8. Cleveland Clinic, Vascular Disease, (2015) <https://my.clevelandclinic.org/services/heart/disorders/vascular-disease>
9. Pratt, A G Birthmarks in Infants, Arch Dermatol 1953: 67:302
10. Beth A, Drolet P, Frommelt P et al. Initiation and Use of Propanolol for Infantile Haemangioma, Report of a
Consensus Conference, Paediatrics: 2013: 131, 128
11. Finn MC, Glowacki J, Mulliken JB, Congenital vascular lesions: clinical application of a new classification, J Pediatr
Surg. 1983 Dec. 18(6):894-9
12. Alexander K. C. Leung, MD Port-Wine Stain Versus Salmon Patch: How to Tell the Difference (2011) <http://www.
pediatricsconsultant360.com/content/port-wine-stain-versus-salmon-patch-how-tell-difference>
13. Juern AM, Glick ZR, Drolet BA, et al. Nevus simplex: a reconsideration of nomenclature, sites of involvement, and
disease associations, J Am Acad Dermatol 2010;63:805–14
14. Nie JM et al, Port Wine Stains and the response to argon laser therapy; successful treatment and the predictive
role of color age and biopsy Plast Reconstr Surg; 1980: 65,130
15. CR Srinivas, M Kumaresan, IJDVL, Lasers for vascular lesions: Standard guidelines of care, Volume 77 Issue 3, (2011)
<http://www.ijdvl.com/article.asp?issn=0378-6323;year=2011;volume=77;issue=3;spage=349;epage=368;aula>
16. Justin J Vujevich, MD, Anthony J Mancini, MD. The epidermal nevus syndromes: Multisystem disorders, JAAD:
Volume 50, Issue 6, June 2004, pp. 957-961
17. Nevus Outreach, Nevus Removal, (2015) <http://www.nevus.org/nevus-removal_id599.html>
18. Kopf AW, Levine LJ, Rigel DS, Friedman RJ et al, Prevalence of congenital-nevus-like nevi, nevi spili, and café au
lait spots, Arch Dermatol. 1985 Jun; 121(6):766-9
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Aesthetic Journal November 2014 Issue
@aestheticsgroup
Aesthetics Journal
Assessing the Lips
for Successful
Rejuvenation
Dr Souphiyeh Samizadeh provides an
overview of lip-treatment trends and shares
advice on clinical evaluation techniques
Lip aesthetics
Throughout human history, we have
ornamented our lips in many ways for
various reasons, including cultural beliefs,
beauty and aesthetics, courtship and
social status (Figure 1).1 As well as being
one of the key aesthetic units of the face,
lips play a significant role in phonation
and swallowing, so for practitioners aiming
to augment or enhance lips, successful
treatment is essential.2
Studies examining the profiles of
Caucasian female models in the late
20th century found that fuller and more
anteriorly positioned lips were more
fashionable.3,4 For 65 years from 1930,
Nguyen and Turley studied male model
profile changes from photographs
collected from leading fashion magazines
in order to analyse the way that the male
profile had changed through time. They
reported significant changes in the ideal
lip aesthetics, which included:5
• Increasing lip protrusion
• Increasing lip curl
• Increasing vermilion display
As a result, and with the evolution of
treatments available, lip augmentation
has become progressively popular
in recent years, reflecting the cultural
trends in youth and beauty. It has been
reported that lip augmentation is one of
the most popular and requested aesthetic
procedure since the introduction of
modern dermal fillers.1, 6
What makes an ‘ideal’ lip?
Beauty ideals and aesthetic standards vary
across eras and cultures. In Western culture,
plump and well-defined lips tend to be
preferred.1, 7 In the early years of medical
aesthetics, despite cultural preferences for
plump lips and admiration of models with
voluptuous lips, no actual guidelines existed
Figure 1: Examples of various ideal lip aesthetics in different cultures and time periods
for assessment and enhancement of the
lips.8 Following research, however, studies
suggest that the ‘ideal lip’ should have the
following characteristics:
• Fullness and volume1
• Correct balance between the upper and
lower lips1
• Well-defined vermilion border1,8
In my opinion, lips should also be
harmonious with other facial features
of the individual. Enlarged, full lips in a
very petite face will not be aesthetically
pleasing as this would be out of proportion
with the rest of face. Sexual dimorphism
should also be kept in mind when treating
lips, as men have a larger mouth width,
philtrum width, total lip height, and lip
volume compared to women.9,10 Techniques
for augmentation and enhancement of
the lips have evolved with advances in
biotechnology and the various temporary,
semi-permanent and permanent fillers and
implants available on the market. In order to
be able to use these different products and
techniques successfully, an understanding
of lip anatomy, terminology (Figure 2),
assessment and aesthetics is essential.
2
9
3
1
4
8
5
7
6
Figure 2: Lip anatomy and terminology
1.
2.
3.
4.
5.
6.
7.
8.
9.
Philtrum
Philtrum columns
White roll
Cupid’s bow
Vermillion border
Oral commissures
Upper incisor teeth
Upper lip tubercle
Cutaneous upper lip
Assessing lips
I advocate examining your patients in their
natural sitting position as this is a standardised
and reproducible position for upright
examination.2,11 It is also important to examine
lips while relaxed and during animation in
order to assess the natural position of lips
and symmetry of muscle movement to detect
any asymmetry, and to assess action and
hyperactivity of muscle groups.2,12 The position
of the lips is closely related to the teeth and
@aestheticsgroup
Aesthetics Journal
Aesthetics
In my opinion, lips should also be
harmonious with other facial features
of the individual. Enlarged, full
lips in a very petite face will not be
aesthetically pleasing as this would be
out of proportion with the rest of face
alveolar processes,13 yet it is paramount to
keep in mind that the lips are only one factor of
an attractive smile. Other factors that contribute
to the lower face and smile aesthetic, and
those that should be assessed (ideally by a
dental professional), include:14
The dentitions, gingivae and alveolar bone:
• Crown length
• Crown width
• Incisor crown angulation
• Midline
• Open gingival embrasure
• Gingival margin
• Incisal plane
• Gingiva-to-lip distance
Skeletal components:
• The relative position of the mandible to
maxilla
Soft tissue factors:
• Lip and soft tissue morphology
• Prominence of chin and nose
Clinical evaluation
Systematic clinical evaluation of the lips with
assessment of a number of parameters
results in a better understanding of the
aesthetics of the lips and a more successful
treatment planning. The following systematic
evaluation can be followed as suggested by
Dr Farhad Naini:2
Lip height:
• Upper and lower lips
• Lower lip/chin height
• Ratio of upper lip to lower lip/chin height
• Interlabial gap (gaps between the lips at
rest)
• Upper and lower lip vermilion height
Lip thickness: Lip thickness is an important
parameter during analysis as it is directly
correlated with lip prominence and can be
influenced by ethnic background. Unlike
thick lips, thinner lips usually more readily
follow the teeth and jaw movements.2 As
such, aesthetic effects of loss or movement
of teeth in individuals with thinner lips
would be more noticeable.
Lip contour: This can be evaluated in frontal
and profile views to evaluate lip curvature, lip
curl and inclination. Excessive or reduced lip
curl could be due to the position and strength
of dentoskeletal support for the lips. For
example, maxillary dentoalveolar retrusion
could result in a flat upper lip.2
Lip inclination: The support of lips is provided
by the dentoalveolar. The inclination of the
lips provides an indication of prominence of
the underlying dentoalveolar. Protrusion or
retrusion of the upper and lower incisors will
result in protrusion or retrusion of the lips.
When upper incisor teeth impinge in the lower
teeth, it can result in eversion of the lower lip.2
Lip posture: Assess lip posture and lip seal
in natural head position in repose. The two
should be assessed when relaxed with
normal muscle tone (without excessive
muscular contraction). Each person has a
unique characteristic orolabial soft tissue
posture (lip posture) and if the lip seal does
not occur in the rest position, adaptive
postures are used. This means the patient
will have a continuous contraction of
circumoral musculature.
Lip prominence: In profile, the prominence
of the lips can be assessed relative to the
prominence of the nose and chin. The
prominence of the lip can vary due to
soft tissue factors such as lip thickness,
dentoalveolar factors such as position of the
incisor teeth, or skeletal factors.2
Lip activity and function: Practitioners
should assess the patient for hypertonic
(hyperactivity or overactivity) or hypotonic
(low muscle tone or underactivity) lips. A
hypertonic lower lip, also known as a ‘straplike’ lower lip may retrocline the lower incisor
teeth.2 A hypertonic upper lip levator muscle
can result in a gummy smile. Hypotonic upper
or lower lips appear flaccid and may result in
overstretching of the lips to achieve lip seal.
This is common in individuals with increased
lower-face height.2
Conclusion
While this article has hopefully provided
readers with a detailed overview of
considerations to take into account when
treating lips, it is also imperative that
practitioners understand how lips age
and the anatomy of the perioral region.
Knowing how, where and when to treat the
lips should lead to successful rejuvenation
and satisfied patients.
Dr Souphiyeh Samizadeh is
a dental surgeon with a special
interest in medical aesthetics.
She is an honorary clinical
teacher at King’s College London
and the clinical director of the Revivify
London clinic. She has presented at both
national and international conferences,
and is actively involved with research into
aesthetic medicine.
REFERENCES
1. Niamtu J, ‘New lip and wrinkle fillers’, Oral and maxillofacial
surgery clinics of North America, 17 (2005), pp.17-28.
2. Naini FB, ‘Facial Aesthetics: Concepts and Clinical Diagnosis’,
Wiley-Blackwell (2011).
3. Auger T, Turley P, ‘Aesthetic soft-tissue profile changes during
the 1990s’, Journal of Dental Research, (1994) pp.368-368.
4. Auger TA, Turley PK, ‘The female soft tissue profile as
presented in fashion magazines during the 1900s: a
photographic analysis’, Int J Adult Orthodon Orthognath
Surg, 14 (1999) pp.7-18.
5. Nguyen DD, Turley PK, ‘Changes in the Caucasian male facial
profile as depicted in fashion magazines during the twentieth
century’, Am J Orthod Dentofacial Orthop, 114 (1998), pp.
208-217.
6. Morris CL, Stinnett SS, Woodward JA, ‘Patient-preferred
sites of restylane injection in periocular and facial soft-tissue
augmentation’, Ophthalmic Plastic & Reconstructive Surgery,
24 (2008) p.117-121.
7. Bisson M, Grobbelaar A, ‘The esthetic properties of lips:
a comparison of models and nonmodels’, The Angle
orthodontist, 74 (2004) pp.162-166.
8. Klein AW, ‘In Search of the Perfect Lip: 2005’, Dermatologic
Surgery, 31 (2005) pp.1599-1603.
9. Sforza C, Grandi G, Binelli M, et al., ‘Age- and sex-related
changes in three-dimensional lip morphology’, Forensic Sci
Int, 182 (2010), p181-187.
10. Gibelli D, Codari M, Rosati R, et al., ‘A Quantitative Analysis
of Lip Aesthetics: The Influence of Gender and Aging’, Aesth
Plast Surg, 39 (2015) pp.771-776.
11. Bansal N, Singla J, Gera G, et al., ‘Reliability of natural head
position in orthodontic diagnosis: A cephalometric study’,
Contemporary Clinical Dentistry, 3 (2012) pp.180-183.
12. Mani V, ‘Surgical Correction of Facial Deformities’, JP
Medical, (2010) p.290.
13. Turley PK, ‘Evolution of esthetic considerations in
orthodontics’, Am J Orthod Dentofacial Orthop, 148 (2015)
pp.374-379.
14. Burrow SJ, ‘The impact of extractions on facial and smile
aesthetics’, Seminars in Orthodontics: Elsevier, (2012)
pp.202-209.
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Refs: 1. Fabbrocini G et al, Eur J Acne, 2012. 2. Truchuelo M et al, Actas Dermosifiliogr, 2014 3. Manfredini M et al, hi. tech dermo, 2103 4. Capitanio B et al, JEADV, 2014.
@aestheticsgroup
Aesthetics Journal
Managing
Acne
Dr Terry Loong shares her holistic
approach to treating acne and advises
practitioners on the best guidance
to give to patients suffering from the
condition
Acne is an aesthetic concern that is very personal to me. Both
my late mother and I suffered from the condition as adults
and, sadly, my mother’s acne-scarred skin hugely affected her
confidence. Unfortunately the technology and knowledge we
have available today was not present when she was alive, so it
inspired me to change the way I utilise skincare and how I treat my
acneic patients.
In this article, my aim is to share with you some of the most
common advice I give my patients suffering with acne and
alternative approaches to acne, aside from skincare, to ensure
faster clearance and longer maintenance of good skin.
How widespread is the problem?
According to Yale University School of Medicine,1 acne is the most
common skin disorder in the world. Globally, acne has a lifetime
prevalence of more than 90% in people of all ages. Around 80% of
adult acne cases occur in women and 50% of those women suffer
with acne right through to their 40s and older.
Acne is an inflammatory skin disease ranging from mild comedonal
forms (blackheads and whiteheads) to severe inflammatory cystic
acne of the face.1 According to the Acne Academy,2 facial scarring
from the condition affects up to 20% of people and 92% of acne
sufferers have felt depressed, with 14% having had suicidal thoughts.
Most sufferers will develop acne during their teenage years
(73%) but according to the Journal of the American Academy of
Dermatology,3 54% of women over the age of 25 have some facial
Aesthetics
acne. Interestingly, the journal notes that, according to various
studies, the average age of having the problem is 31.3 Most adult
acne occurs on the cheeks (81%), chin (67%) and jawline (58.3%).
The majority of sufferers have inflammatory papules – red, raised
bumpy spots (55%), while fewer have a comedonal problem, which
present as black or whiteheads (6%). Research has shown that
adult acne is more treatment resistant and prone to relapse, even
after the use of antibiotics and isotretinoin (Roaccutane) therapy.
Likewise, adults often have sensitised skin, or a combination of
skin conditions in addition to their acne, which makes treatment
more challenging than teenagers with acne, who generally have
more resilient, uniform, oily skin.3 The skincare industry has
seen the global acne market aiming to rise to the challenge with
new skin products, new prescriptions, new treatments and new
technology being introduced to tackle the problem.4 In 2009,
$2.9 billion was spent on this growing market and it is estimated
that the global acne market will reach revenues of $3.02 billion
by 2016.2 In my practice, I mainly see women with adult acne
between their late 20s to mid-40s. My patients typically come to
me after having spent a lot of time seeing different doctors who
have only recommended skincare or skin treatments, which has
not completely resolved the problem. As such, patients tend to be
ready to look at alternative options or a more holistic solution to
their skin concerns. I also have patients who come to me wanting
to avoid going down the Roaccutane, antibiotic or birth-control pill
route – again hoping I can offer them a more holistic approach to
their treatment.
Advice I give to my patients with acne
Before they attend their first consultation, patients will complete a
15-page questionnaire that looks not just at their general medical
history, but also takes a deeper look at their gut health, hormonal
balance, nutritional status, supplement history, skincare products
in current use and their skincare routines. This allows a thorough
exploration of all possible aspects of a patient’s life including their
nutrition, supplements, sleep patterns, exercise and stress levels,
which may contribute to the condition of their skin. We don’t
often have the luxury of time in the clinic so by having the patient
complete the questionnaire beforehand, we get to know the
patient much better before we have even met them.
I find that when patients complete the questionnaire beforehand, it
starts the rapport building process right from the very start, which I
believe is vital for patients to trust you as a practitioner.
During the first consultation, and after we have discussed their
answers to the questionnaire, I typically like to give a mini crash
course on the following:
What causes acne?5
I draw the patient a diagram explaining how acne is formed,
involving the sebaceous follicles, excessive oil production,
sluggish skin cell turnover, clogging of the pores, inflammation,
Propionibacterium acnes, hormonal fluctuations, some
pharmaceutical agents, stress and inappropriate use of products
on the skin, heat, friction and humidity.
What are hormones and how do they affect acne?5
This is where my main interest lies as I see a lot of hormonal
imbalances in patients due to their modern day lives. I explain
the various types of common hormones, e.g. cortisol, insulin,
oestrogen, progesterone and testosterone and how they fluctuate
@aestheticsgroup
through the ages, through stress and with the use of prescriptive
medication. Imbalanced hormones can cause excess oil gland
production, skin inflammation, and an increased number of the
acne-causing bacterium.
The gut-skin connection and how to improve it6
The gut contributes to about 70% of our immune system and is
involved largely in activities of digestion, metabolism, assimilation,
nutrient absorption and detoxification. If all this is not functioning
optimally, then this could lead to poor skin healing, skin sensitivity
and even breakouts.
Appropriate skincare and routine for oily mature skin types that
tend to be more ‘combination’ and can have dry patches prone
to wrinkles7 – I like to keep the patient’s skincare routine simple,
as, in my opinion, simplicity is the most likely way of achieving
compliance and consistency. I try my best to recommend just three
Aesthetics Journal
products at the first session, as typically patients who come to
see me have tried many products and have often lost confidence
in them. I like to choose products depending on the patient’s
personality type. For instance I assess if they like to try products
often but never give it enough time for it to be effective as the
products are too slow to act. Or maybe they’re minimalist and
don’t normally use products so I recommend the basic essentials
to help them build their confidence with skincare and skin routine.
Some patients’ skin is sensitive and they may not be as willing or
prepared to go through the dry phases of some acne products.
Some don’t mind; so it really depends on their personality type. If
patients can see an improvement in the first three weeks with just
three products, their confidence in you as a practitioner will grow.
The typical products I recommend are: a good gentle exfoliator,
an acne serum containing at least salicylic acid, glycolic acid and
retinol, and a day or night oil-control lotion.1 I also examine patients’
skin and recommend a session with my clinical therapist for a
Alternative solutions for acne
While I do believe medication has a role to play, especially in severe cases of acne, due to the possible side effects medicine can have,
such as causing damage to the gut, my approach has always been to look at what we can do to facilitate the skin’s repair first, before
reaching out for the prescription pad. The most important thing is to educate your patients and create a partnership working with them
and their acne. It’s a journey that will leave you with very loyal patients in many years to come.8 15 In my book, The Hormonal Acne
Solution,9 I summarised my hormonal adult acne system, where I combined internal solutions (Phase 1) with external options (Phase 2) to
control the occurrence or re-occurrence of acne. Depending on what the patient’s budget, goals and commitments are, I encourage them
to work on both phases simultaneously.
Here is a summary of the different steps:
Phase 1: Take control of acne internally
Phase 2: Take control of acne externally
• Step 1: Reduce inflammation to lessen eruptions: This step is used largely
to manage patients’ stress and cortisol levels. Lifestyle changes can help to
manage stress and create more balance in one’s life, so I recommend that
patients exercise more often, spend time in nature, switch off digital devices
after 8pm and have a good night’s sleep. I also encourage patients to take
part in an elimination diet to remove common food triggers, e.g. dairy, gluten,
caffeine, alcohol, peanuts and sugar. If they are able, they can also opt for a
food sensitivity blood spot test, which can accurately check for up to 95 food
sensitivities.16 My patients often markedly reduce their skin eruptions within
three weeks of the elimination diet.
10
• Step 2: Digestion optimisation and sugar balancing:11 This step restores gut
health and flow, maximising the gut’s ability to eliminate ‘used’ hormones and
absorb nutrients that affect genes in a positive way. This step also supports
the body’s detoxification process and optimises the skin’s repair mechanism
through proper nutrition. Sugars can be balanced by eating cleanly and
appropriately. I often recommend my patients do a stool test to check for
inflammation, microbes or viruses, which, if present, will need addressing
through supplementation or medical repair foods.
• Step 3: Hormonal harmonisation:12 Once inflammation is managed and the
gut health is optimised, we can then look at balancing the patient’s hormones. I
believe hormones naturally balance themselves out with a little help. As such, I
like to wait until we complete steps 1 and 2, before recommending anything to
address the hormonal imbalance. By this point, hormones should be very much
aligned and skin should have improved. Depending on what I find and how the
patient’s symptoms have improved, I might recommend specific nutrients and
precursors, herbs/supplements or bio-identical hormones that we can introduce
to balance and optimise hormonal equilibrium. One in particular is Agnus
Castus, a herb that can potentially naturally regulate hormones. 17
• Step 1: Skin Awareness:13 This is one of
my favourite steps as patients really get
to know their skin and how it works. I aim
to educate my patients about how skin
changes throughout their monthly cycle
and with each special milestone in their
life. By knowing and working with their
skin, they will begin to understand what
products will be most suitable for home
use, and which treatment to use during the
different stages of their cycle.
• Step 2: Skincare: Often patients come in to
the clinic confused about which products to
use – this is a great opportunity for you to
educate them on effective ingredients and
skin routines that they can do at home.
• Step 3: Skin Treatments: My philosophy
on treatments is if you can prevent and
treat acne at home, in-clinic treatments
are only the ‘icing on the cake’. While
patients can of course have medical
facials in the clinic to enhance their home
routine, as well as treatments to help
clear their acne scars and pigmentation,
providing advice on how they improve
their overall health and wellbeing in the
long term is more important than offering
a one-off skin treatment.
103758 Dermalux Half_P_Ad Accred:Layout 1 10/11/2015 16:45 Page 1
medical facial with full extractions of comedones (papules) to
clear any congestion of the skin and remove superficial sources
of inflammation. I explain that, in my opinion, it’s best to properly
cleanse the skin in the clinic first, as this should then make it
easier to maintain good skin health with home products.
Summary
As practitioners working in skincare and aesthetics, we are
in a privileged position to be able to gain the trust of our
patients and help them manage their acne; not only to treat
and hopefully reduce it, but the ability to clear the aftermath in
the form of scars and pigmentation. By incorporating holistic
solutions into your practice, you will not only help your patients
achieve better skin, but also help them feel better in themselves
in terms of their energy levels, concentration, confidence and
overall wellness – which, in my opinion, is priceless.
The basis for
skin beauty
and health
Dr Terry Loong graduated from Guy’s and St. Thomas’
Hospital and completed her postgraduate qualifications
with the Royal College of Surgeons. Dr Loong’s earlier
training was in general and plastic surgery before she
began specialising as an anti-ageing doctor.
Disclosure: Dr Terry Loong is the author of The Hormonal
Acne Solution and is currently exploring the idea of creating a
CPD-accredited training course based on the book. She is actively
seeking interest from practitioners looking to learn more.
REFERENCES
1. Cordain L, Lindeberg S, Hurtado M, Hill K, Eaton SB, Brand-Miller, ‘Acne Vulgaris: a disease of
Western civilization’, J. Arch Dermatol, 138(2002), pp.1584-90.
2. Acne Treatment, Acne: The Facts and Stats. (AcneTreatment.org, 2012) <http://www.
acnetreatment.org.uk/acne-facts-and-stats/>
3. Collier CN, Harper JC, Cantrell WC, Wang W, Foster KW, Elewski BE, ‘The prevalence of acne
in adults 20 years and older,’ J Am Acad Dermatol, 58 (2008) pp.56-9.
4. Howard D, ‘Why is adult acne on the rise?’, Dermal Institute <http://tiny.cc/5ebz4x>
5. Gary W. Cole, What causes acne (emedicinehealth.net, 2014) <http://www.emedicinehealth.
com/acne/page2_em.htm#acne_causes>
6. Whitney Bowe and Alan C Logan, ‘Acne vulgaris, probiotics and the gut-brain-skin axis - back
to the future?’Gut Pathog. 3:1 (2011) <10.1186/1757-4749-3-1>
7. Mayo clinic, Choosing an effective acne product (2015) <http://www.mayoclinic.org/diseasesconditions/acne/in-depth/acne-products/art-20045814?pg=2>
8. Dr Mercola, Accutane Acne Drug Widely Overused says UK Dermatologist (mercola.com,
2012) <http://articles.mercola.com/sites/articles/archive/2012/12/12/acne-drug-accutane.aspx>
9. Dr Terry Loong, ‘Chapter 3: The Perfect Dance in The Hormonal Acne Solution’, 1st edition.
Create Space, Amazon, 2014
10. Bowe WP, Joshi SS, Shalita AR, ‘Diet and acne’, J Am Acad Dermatol. 63 (2010) pp.124-41
11. Rachel Reily, Long term links to dairy and high sugar foods to acne (SkinInc.com, 2013) <http://
www.skininc.com/skinscience/physiology/Long-term-Research-Links-Dairy-and-High-SugarFoods-to-Acne-200252611.html>
12. Seirafi H, et al, ‘Assessment of androgens in women with adult-onset acne’, International
Journal of Dermatology, 46 (2007) pp.1188-91
13. Raghunath RS1, Venables ZC, Millington GW, ‘The menstrual cycle and the skin’, Clin Exp
Dermatol, 40 (2015) pp.111-5
14. Bowe WP, et al. Effective over-the-counter acne treatments, Seminars in Cutaneous Medicine
and Surgery. 2008; 27:170
15. Ruth Williams Downside to Antibiotics, The Scientist, <http://www.the-scientist.com/?articles.
view/articleNo/36329/title/The-Downside-of-Antibiotics-/>
16. Invivo clinical, IgG4 95 Food Antibodies, <http://www.invivoclinical.co.uk/catalogue_item.
php?catID=3010&prodID=83327#.VjTskYSTDFI>
17. Tracy Raftl “Q+A for Vitex Agnus Castus for Female Hormonal Acne” The Love Vitamin,
<http://thelovevitamin.com/9662/q-about-vitex-agnus-castus-for-acne/>
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@aestheticsgroup
Aesthetics Journal
Aesthetics
Spotlight On: Radara
Aesthetics explores the efficacy of the new microchannelling skincare system aimed at restoring skin
quality and reducing the signs of ageing
Introduction
While ‘Adara’ is the Greek word for ‘beautiful’,
Innoture Medical Technology explains that
the name ‘Radara’ intends to represent skin
radiance and beauty; supporting patients on
their journey to improved skin health.
The manufacturer believes that its microchannelling patches and hyaluronic acid (HA)
serum offer a unique treatment that targets
the signs of ageing, while improving elasticity,
hydration and skin support.1
Studies into the efficacy of the product have
supported these claims, suggesting that,
depending on the starting skin condition,
fine lines and wrinkles were reduced by
an average of 35% in four weeks, with
noticeable improvements in just two weeks.2
But, how does Radara work? And how should
it be administered in practice?
Using Radara
Transdermal delivery is a commonly used
technique for administering a number of
therapeutic substances3 – however the key
challenge is achieving effective ingredient
delivery past the stratum corneum. Innoture
claims that Radara patches have been
specifically designed to greatly enhance the
delivery of the high-purity Radara HA serum,
allowing for effective penetration, which
should provide maximum skin benefits. The
patches are developed using a patented
printing technology, which aims to deliver
a flexible, ultra-thin design tailored to fit the
lateral canthal areas. The patches are coated
with microscopic plastic structures, similar to
needles, less than half a millimetre in length
which when applied to skin, can painlessly
create hundreds of tiny micro-channels in the
epidermis. These ‘micro-channels’ allow for
the Radara HA serum to flow through the skin
barrier, directly targeting the deeper layers of
the skin.
Study design
During February and March 2014, a
32-person, split-face study was conducted
to examine the effectiveness of Radara.2
The study was independently verified
by an accredited facility in Germany and
results were based on both qualitative
and quantitative data submitted by a
dermatologist and the study participants.
According to Innoture, the aim of the study
was to examine the product for tolerance
as well as improvement in wrinkle depth
over an eight-week period. Results were
measured with the PRIMOS (Phaseshift Rapid
In-vivo Measurement of Skin) optical threedimensional measuring device.
Before beginning the trial, the 32 female
participants, aged between 35-55 years old,
underwent a dermatological examination
to assess their suitability. Participants were
required to have healthy skin in the test
area – ‘crow’s feet’ or the lateral canthal lines
– and to not use other skincare products
during the study. Women with severe or
chronic skin inflammation were excluded, as
were those that had used skincare products
with active ingredients seven to ten days
before the study began. All 32 participants
were photographed and evaluated before
beginning the trial and at one-week, twoweek and four-week intervals. Then 16
participants were selected for analysis at the
end of the rest-period, to provide an eightweek data set. Overall, the study comprised
a four-week application period followed by a
four-week rest period.
Participants were instructed to apply the
Radara micro-channelling patches in
combination with the HA serum once daily
to the test area on one side of their face.
The patch was initially applied with light
pressure to the test area, before being
removed to allow serum application and
then re-applied for a further five minutes.
On the other side of their face, participants
only applied the HA serum.
Assessment of the study
All 32 study participants dermatologically
tolerated the micro-channelling patch and
HA serum during the course of the four-week
application period, with the independent
dermatologist stating Radara was tolerated
“very well”. No undesired or pathological
skin reactions in the test area were reported
during the study, nor were there any
medical interventions or interruptions to the
application in any of the participants.
Skin roughness was measured on the 16
participants who were analysed up to week
eight, and showed an improvement in fine
lines and wrinkles of up to 35% (with the
standard error margin between 20 and
46%) on combined usage of the patch and
HA serum at the four-week interval. This
measured a 46% greater effectiveness versus
application of the serum alone. At week eight,
Radara patches and the serum were shown
to offer continued results, even after the fourweek rest period, with overall improvement
of skin roughness at 19% compared to
measurements taken before treatment
began. Innoture explains that it must be noted
that all the patients’ skin is different and may
have had different starting points in terms of
skin quality and level of wrinkling.
Skin improvement was also graded by
dermatologists and participants at one,
two and four-week intervals by means of a
questionnaire, tolerability analysis, subject
wrinkle assessment using the Facial Wrinkle
Scale (FWS), dermatologist-assessed
wrinkle assessment and the 3D objective
wrinkle assessment using the PRIMOS
imaging system. These methods measured
the reduction of fine lines and wrinkles,
smoothness and firmness. After two weeks,
75% of participants recorded a positive
change in skin firmness, rising to 88% at
week four. Skin smoothness achieved an
81% positive change over the two and fourweek intervals, whilst 72% of participants
saw a positive reduction in fine lines and
wrinkles after only two weeks. On the
Garnier scale, a two-grade improvement was
seen over four weeks. Aesthetic practitioner
Dr Benji Dhillon, who peer-reviewed Radara,
noted the smaller differences between
scores at the four-week period, but believes
this is due to the fact it is an early time-point
to measure neo-collagenesis. He highlights
that the stronger data is actually at the
eight-week point, stating that, “Despite the
study limitations, such as a lack of statistical
powering, the exclusion of males, and lack
of Fitzpatrick data, the results from this study
are compelling in supporting the efficacy
of Radara in combination with HA serum to
help improve the appearance of wrinkles
within the area.”
REFERENCES
1. Innoture Aesthetics, ‘In vitro penetration studies and
biocompatibility of microneedle array-based delivery
systems’, Project Report, Queens University, Belfast, Data
on File.
2. Innoture Aesthetics, ‘Specialist dermatological report on
the optical 3D-Measurement of the surface of the skin
Quantitative evaluation of the roughness of the surface of
the skin with the calculation of standardized skin roughness
parameters according to DIN 4768ff’, Dermatest GmbH I
Engelstrasse 37 I 48143, Münster, Data on File.
3. Innoture Medical Technology, Microneedles (UK, Innoture
Medical Technology, 2015) <http://www.innoture.co/
microneedles.htm>
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Aesthetics Journal
Aesthetics
A summary of the latest
clinical studies
Title: Histopathological analysis of 226 Patients with Rosacea
according to subtype and severity
Authors: Lee WJ, Jung JM, Lee YJ, Won CH, Chang SE, Choi JH,
Moon KC, Lee MW
Published: The American Journal of Dermatopathology,
October 2015
Keywords: Rosacea, histopathological, perifollicular,
inflammation
Abstract: The aim was to evaluate the histopathological
features of rosacea according to clinical characteristics
such as subtype and severity. We retrospectively analysed
histopathological findings in 226 patients with rosacea, which
included 52 patients with the erythematotelangiectatic rosacea
(ETR) and 174 patients with the papulopustular rosacea (PPR)
subtype. The frequency of each histopathological finding was
compared between subtypes. Histopathological features were also
compared according to the severity, through subgroup analysis
within each subtype group. Perivascular and perifollicular
lymphohistiocytic infiltration were common dermal findings in
both subtype groups, but the intensity of dermal inflammatory
infiltration was higher in PPR than in ETR. Follicular spongiosis
and exocytosis of inflammatory cells into hair follicles were noted
in both subtypes; but these findings were significantly more
common in the PPR subtype. The intensity of inflammatory
reactions, especially perifollicular infiltration, was higher in PPR
patients than in ETR patients.
Title: Development and characterisation of a rapid polymerising
collagen for soft tissue augmentation
Authors: DeVore D, Zhu J, Brooks R, Rone-McCrate R,
Grant DA, Grant SA
Published: Journal of Biomedical Materials Research,
October 2015
Keywords: Collagen, polymerisation, soft tissue, augmentation
Abstract: A liquid collagen has been developed that fibrilises
upon injection. Rapid polymerizing collagen (RPC) is a type I
porcine collagen that undergoes fibrillisation upon interaction
with ionic solutions, such as physiological solutions. The ability
to inject liquid collagen would be beneficial for many soft tissue
augmentation applications. In this study, RPC was synthesized
and characterised as a possible dermal filler. Transmission
electron microscopy, ion induced RPC fibrillogenesis tests,
collagenase resistance assay, and injection force studies were
performed to assess RPC’s physicochemical properties. An
in vivo study was performed which consisted of a one, three,
and six month study where RPC was injected into the ears of
miniature swine. The results demonstrated that the liquid RPC
requires low injection force (<7N); fibrillogenesis and banding
of collagen occurs when RPC is injected into ionic solutions,
and RPC has enhanced resistance to collagenase breakdown.
The in vivo study demonstrated long-term biocompatibility
with low irritation scores. In conclusion, RPC possesses
many of the desirable properties of a soft tissue augmentation
material.
Title: Nasolabial symmetry and esthetics in cleft lip and palate:
analysis of 3D facial images
Authors: Desmedt DJ, Maal TJ, Kuijpers MA, Bronkhorst EM,
Kuijpers-Jagtman AM, Fudalej PS
Published: Clinical Oral Investigations, November 2015
Keywords: Cleft lip, cleft palate, imaging, morphology
Abstract: 84 subjects (mean age 10 years, standard deviation
1.5) with various types of nonsyndromic clefts were included:
11 had unilateral cleft lip (UCL); 30 had unilateral cleft lip and
alveolus (UCLA); and 43 had unilateral cleft lip, alveolus, and
palate (UCLAP). A 3D stereophotogrammetric image of the
face was taken for each subject. Symmetry and esthetics were
evaluated on cropped 3D facial images. The degree of asymmetry
of the nasolabial area was calculated based on all 3D data points
using a surface registration algorithm. Esthetic ratings of various
elements of nasal morphology were performed by eight lay raters
on a 100 mm visual analog scale. Statistical analysis included
ANOVA tests and regression models. Nasolabial asymmetry
increased with growing severity of the cleft (p = 0.029). Overall,
nasolabial appearance was affected by nasolabial asymmetry;
subjects with more nasolabial asymmetry were judged as having
a less esthetically pleasing nasolabial area (p < 0.001). However,
the relationship between nasolabial symmetry and esthetics was
relatively weak in subjects with UCLAP, in whom only vermilion
border esthetics was associated with asymmetry.
Title: Classification by causes of dark circles and appropriate
evaluation method of dark circles
Authors: Park SR, Kim HJ, Park HK, Kim JY, Kim NS, Byun KS,
Moon TK, Byun JW, Moon JH, Choi GS
Published: Skin Research and Technology, September 2015
Keywords: Causes, classification, dark circles, evaluation
Abstract: It is not easy to classify dark circles because they
have various causes. To select suitable instruments and detailed
evaluation items, the dark circles were classified according to the
causes through visual assessment, Wood’s lamp test, and medical
history survey for 100 subjects with dark circles. We performed
a randomised clinical trial for dark circles, a placebo-controlled
double-blind study, using effective parameters of the instruments
selected from the preliminary test. Dark circles of vascular type
(35%) and mixed type (54%), a combination of pigmented and
vascular types, were the most common. 24 subjects with the
mixed type dark circles applied the test product (vitamin C 3%,
vitamin A 0.1%, vitamin E 0.5%) and placebo on randomised
split-face for eight weeks. The effective parameters (L*, a, M.I.,
E.I., quasi L*, quasi a* and dermal thickness) were measured
during the study period. Result showed that the L* value of
Chromameter, Melanin index (M.I.) of Mexameter and quasi
L* value obtained by image analysis improved with statistical
significance after applying the test product compared with the
placebo product. We classified the dark circles according to
the causes of the dark circles and verified the reliability of the
parameter obtained by the instrument conformity assessment
used in this study through the efficacy evaluation.
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Aesthetics Journal
patient base. Once your patients arrive for their treatments, you
will then need to have highly-skilled clinical staff who can perform
procedures at a consistently high level, remaining focussed and
attentive to patients at all times.
When recruiting new staff members, don’t just look at their skills and
experience, think about personality, too. Look for the passion and
enthusiasm that will translate into the motivation to do a great job.
After hiring a team of exceptional staff, you then need to keep them
motivated in order to reach your business goals.
Team
Motivation
Victoria Vilas explains how staff
incentives can motivate your team
and boost trade
A modern and stylish clinic based at a prestigious address,
innovative technology and high-end products are not the only
elements necessary for a prosperous aesthetics business. Without
a dynamic and productive workforce, your clinic is unlikely to reach its
full potential to become an acclaimed name in the industry. As such, a
team of dedicated, enthusiastic and skilled staff members are needed
to deliver an exceptional service.
Managing competition
The treatment menu that you provide may match other clinic
offerings in your region, so in order to stand out from the
competition, you must deliver those treatments at the highest
possible standard. It is important that you also focus on the
customer journey that begins the moment a potential patient first
gets in contact, whether by phone or in person. For this reason,
it is essential that you pay the same attention to non-clinical staff
members as you do to practitioners. Your receptionist or patient
coordinator is likely to be the first point of contact for patients, and
the quality of that experience could attract or discourage a new
Look for the passion
and enthusiasm that will
translate into the motivation
to do a great job
Attainable targets and tangible benefits
Practitioners and clinic staff are likely to be on a basic salary
with the chance to increase their earnings through commission
or bonuses gained from selling additional treatments or retail
products to patients. When setting out the terms of individual
commission rates or team bonuses, it is a good idea to think
about realistic targets that are achievable. If targets are set so
high that your staff members fail to reach them on a regular basis,
your team will become disheartened and you will probably find it
becomes harder to maintain their enthusiasm for the work in hand.
This doesn’t mean you have to set targets so low that you end up
paying out more than the business can afford in bonuses. Take
time setting out your commission or bonus structure, taking into
account both your business profits and the value you should place
on high-performing staff.
However, the benefits you provide for your staff don’t have to just
be financial. Offering a package that can make staff members feel
valued and supported, and a working week that takes into account
a healthy work/life balance, will also help to keep your team happy
and productive. Don’t overwork your staff with schedules that leave
them very little free time, and be fair with their holiday allowance
and the flexibility they have to book time off. Pension contributions
will soon be a necessity for businesses,1 but you could also
consider benefits such as private health insurance and childcare
vouchers, or even negotiate discounted rates for the local gym.
After all, benefits that help to keep your staff fit and healthy can
only benefit the performance of your clinic.
A pleasant working environment
The environment your staff work in, and the other team members they
share their day with, will have a big impact on their happiness, and
in turn, their productivity. While it may be a rather simple element to
consider, try and make sure that all staff members have a comfortable
space to work in. You should provide a space for your staff to relax
during their breaks as it isn’t always convenient for them to go out
of the clinic for their lunch, depending on location and bad weather.
A comfortable, quiet space will allow your staff to recharge during
their break times, which will help them to be consistently productive
throughout the working day. Also remember to make sure that your
staff members do take their breaks, even if you run a very busy clinic.
It can become quite common for staff to work through their breaks if
they have a heavy workload, however, remember, staff members who
become tired and irritable are unlikely to stay motivated and provide
the level of service you require of them.
In regards to putting your team together, unfortunately, there is no
magic formula for putting a group of people in one place who all get
on fantastically well. This doesn’t mean you have to single people
out and think about letting them go; instead, try and think of ways to
encourage inclusion in your team. Try holding group meetings where
every staff member can actively share their opinions, and think about
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Aesthetics Journal
organising group activities or social events you can all enjoy together.
If staff members get to know each other away from the stresses of the
working day with some fun activities, you’ll probably find that they get
on better at work, too.
Effective management and clear communication
The most crucial element to building and maintaining a motivated
workforce is how you manage your team. An effective manager will
be able to lead and inspire, even if there are no financial incentives or
exciting benefits to offer staff. An excellent, communicating manager
should stay in touch with their team, holding regular one-to-ones to
check on staff performance and ensuring that the team are happy
with the workload. Managers don’t have to be best friends with their
team, but good communication will ensure that small issues can be
identified and dealt with before they become big problems. When
staff members understand the importance of a task and exactly how
it needs to be carried out, they are likely to be more receptive to your
requests. A good manager will explain tasks carefully – if they are
simply giving orders to their team, a lack of understanding could make
staff members feel unsure of what they are supposed to be doing, and
this may not just make them worry, it could also lead to mistakes being
made. Make sure your staff members are fully trained in every aspect
of their role, and understand your clinic’s protocols and procedures.
Empower your staff with the knowledge they need to do their job
well, and they will feel far more confident and enthusiastic to carry out
set tasks. Good communication isn’t just about informing your staff
of the clinic’s performance, it’s also important to make sure you listen
to what they have to say. Medical staff and front-of-house teams will
have the most contact with your patients, therefore they are likely to
have valuable insights into your patient’s likes and dislikes. Your staff
can help develop your business and keep it up-to-date with the latest
trends. You don’t have to agree with everything they say, but you may
find that you can learn as much from your team as they do from you.
Remember to recognise employees when they have done a good job.
Don’t just assume that staff members know when you are happy with
their performance – put it into words. You may offer financial incentives
for good work, but offering praise will also give your staff a confidence
boost, and will make them feel like a valued member of the clinic
team. Praise shouldn’t only be given to those who have made big
achievements, as team members who may not be the top performers
probably need a morale boost more than the high achievers. Think of
ways you can encourage all team members equally. You will also have
to offer some constructive criticism to your team at certain points, so
this praise will help to balance that out, and keep morale up.
Continuing development and staff promotion opportunities
If you want to make sure that your team remains motivated, and that
they stay loyal to your clinic as long-term staff members, you must
consider their individual career progression, not just the future of
your business. Think about where you can offer training that helps
your staff members develop their skills, and what opportunities you
could offer for promotion. Young, ambitious practitioners and sales
staff will not want to stay at the same level forever – they will want to
progress to a more senior position and a higher salary. If your clinic
has a structure that makes progression impossible, you are likely to
have a high turnover of staff, as your team will more than likely look
for opportunities elsewhere. This could harm your business, as a
constantly changing workforce doesn’t suggest that your business
offers any stability or long-term prospects to new team members, and
the cycle could continue.
Aesthetics
If you want to make sure
that your team remains
motivated, and that they
stay loyal to your clinic as
long-term staff members,
you must consider
their individual career
progression, not just the
future of your business
Retaining your best staff members is crucial to your clinic’s success.
Would you rather give an employee a small salary increase, or lose
them and their regular patients to a competitor? Think carefully
about what you can offer your employees before it becomes too
late. While some staff members will be looking for financial rewards,
others will be looking to progress to a more senior level, perhaps
taking on management responsibilities. Even if you have a clinic
manager in place, this does not prevent you from giving others more
responsibility. For example, if you have a high-performing aesthetic
nurse who appears to have the professionalism to manage others,
think about making that person a senior practitioner in title, and giving
them the task to train and supervise their juniors. The more staff you
have in your clinic, the bigger the workload for your clinic manager, so
promoting others to junior management positions could also help your
clinic to run more smoothly.
Conclusion
Whether you are running a startup or a well-renowned clinic,
remember that keeping up the level of staff happiness and motivation
is an ongoing task that you must consider on a regular basis. The
most successful clinics are those that are run by business owners
and managers who keep in touch with their staff, so it is imperative
to give praise where praise is due, and reward your team for a job
well done. With effective and intuitive management, a happy working
environment, and a business structure that allows good employees to
stay in their positions long-term, you are more likely to have the loyal,
professional and enthusiastic team you desire.
Victoria Vilas is the operations and marketing
manager at ARC Aesthetic Professionals, a recruitment
consultancy specialising in the medical aesthetics and
cosmetic surgery sector. Since 2008, the team have
aimed to help numerous organisations within the
industry grow their businesses by hiring the most talented aesthetic
professionals in the UK.
REFERENCES
1. Government Digital Service, Workplace pensions – employers’ obligations (London: GOV.UK, 2015)
<https://www.gov.uk/workplace-pensions-employers>
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Aesthetics Journal
Finding the
Funding Key to
Business Growth
Peter Nolan offers advice on finance
options for your clinic
According to this year’s Key Note Market Update report,1 the UK
cosmetic surgery industry is expected to grow in the coming years
to a total value of £913 million, up from £725 million in 2014.
Non-surgical procedures are also becoming increasingly popular. Less
invasive practices, such as microdermabrasion and laser treatment,
now account for 85% of the market,1 meaning medical aesthetic
practitioners can look to the future with a sense of justified optimism
about business success. A significant problem, however, still remains
with regards to weak bank lending. Difficulty in obtaining funding from
the banks has shown to be a challenging hurdle for businesses to
overcome, potentially putting the brakes on growth and expansion.
This can prove detrimental. Rapid technological advancement in the
cosmetic industry has meant that continual investment in expensive
equipment could be necessary in order to stay ahead of competitors
and become more business efficient. The good news is that if it’s not
possible to obtain funding from the more traditional routes, there are
alternative options available.
Option 1: Lease don’t buy
Equipment such as laser and IPL devices can cost a clinic well into the
tens of thousands and can easily put a strain on company cash flow.
Buying equipment upfront affects the company balance sheet as it
means money having to leave the cash flow straight away. Leasing,
on the other hand, allows owners to spread the cost over a three to
five-year period through regular payments, freeing up money to be
invested elsewhere across the business and helping to build a strong
credit history. Today’s customers are becoming ever more discerning
and there is an increasing appetite for advanced cosmetic procedures,
which can cost upward of £100. Microdermabrasion treatments using
low-cost consumables, for example, can not only deliver fantastic
results for image conscious consumers but can also deliver strong
profit margins. Just a couple of treatments a month over a three-year
period can be enough to cover the equipment finance costs.
How leasing agreements work
Leasing is effectively a fixed or minimum term rental, where the leasing
company (lessor) buys the asset on behalf of the customer and agrees
to lease it back to them for a specified period of time. At the end of
the minimum term, the customer can return the equipment or continue
to use it, but this gives them the opportunity to frequently upgrade
equipment in a rapidly developing market like medical aesthetics.
You don’t ‘own’ any of the asset during the term, but there is usually
an opportunity to effectively take ownership at the end of your
agreement if you wish to do so. Most customers upgrade their
equipment, meaning that they can have brand new kit for the same
regular instalment as their old kit. This helps them to stay one step
ahead of their competitors and offer services that keep clients
Aesthetics
returning to their clinic. Interest rates are entirely dependent on
the financial performance of the proposed lessee; new start clients
inevitably pay a higher interest charge than that paid by businesses
with a strong track record and good credit history, as the lessor
is taking a significantly greater risk. With some flexible leasing
arrangements, you can also include equipment servicing in the lease
cost or choose to vary your monthly payments.
Benefits of leasing
Leasing partners with experience in the sector and good contacts
with medical aesthetic equipment suppliers are more likely to look
favourably on offering asset finance for equipment they are familiar
with. They can recognise the potential returns-on-investment a piece
of equipment can generate and are more likely to provide approval
on the back of it. They will also know which suppliers provide the most
reliable and robust technology. Paying a fixed monthly amount over an
agreed term can also make it easier to control finances and plan ahead
and can help create a strong credit history for your business. There are
also tax benefits to be enjoyed. Capital allowances on the equipment
you lease can be claimed and interest on the finance payments is
tax deductible. If equipment is hired under an operating lease, you
can also write off the total amount of your leasing agreement against
corporation tax by using Operational Expenditure (OPEX).
Option 2: Borrow against hard assets
Did you know your existing equipment can be used to release
working capital? If your cash flow has been left at breaking point due
to money being used up elsewhere, a reputable finance specialist
might offer to lend money against your hard assets, for instance IPL
systems, which have a clear monetary value. The lender will base the
loan terms and conditions on a fair evaluation of the equipment while
considering other outstanding debts the company may already have,
to check that business revenues can cover the new cost comfortably.
As long as the specialist believes the business plan demonstrates
a considered strategy, further securities may not be needed. For
medical aesthetic practitioners, this might mean proof of realistic sales
forecasts, based on past performance, or for new operations, detailed
competitor research with audience segmentation and affordability
studies, to check demand in the area for aesthetic services. An
individual’s financial stability will also be taken into consideration, as a
strong fallback position will give the lender greater confidence in your
ability to pay back financed capital. If assets are already subject to
existing lease finance terms, payments can sometimes be spread over
a longer term, helping to reduce monthly outgoings and providing
more financial flexibility.
Conclusion
Ultimately, a well-structured finance package should minimise your
risks while maximising your return. And with a heady mix of drive,
determination and financial support in place, the road to business
success should prove that little less rocky – and all the more rewarding.
Peter Nolan is the chief underwriter at Academy
Leasing and has several years’ experience working within
the finance and leasing industry. His work involves
offering advice on responsible lending decisions, as well
as analysing clients’ business plans and predicting the
potential risk and return on investment on leased equipment.
REFERENCES
1. Lauren Davidson, Have we reached peak plastic surgery? (London: The Telegraph, 2015)
< http://www.telegraph.co.uk/finance/newsbysector/retailandconsumer/11569454/Have-wereached-peak-plastic-surgery.html> [accessed 7 October 2015]
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Aesthetics Journal
Aesthetics
Introducing Laser
and IPL Hair
Removal to Clinics
Christine Clarke details the benefits of
introducing hair removal to your clinic
portfolio and advises on how to do it
successfully
Introduction: history, demand and the opportunity to upsell
The aesthetic industry today offers more exciting business opportunities than
ever before in regards to expansion, innovation and setting trends. Ensuring
that ‘permanent hair reduction’ is an easily accessible clinic treatment could
pay dividends to the clinic as a solid investment in your services and treatment
offerings. The desire for smooth, hair-free skin can be traced as far back as
ancient Egyptian times with evidence of hair removal methods such as sugaring,
the use of clam tweezers and flint razors been found dating back to 1900BC.1,2
In today’s society, tweezing, threading, depilatory creams, buffing, waxing,
shaving, sugaring, electrical epilation (electrolysis), laser and intense pulsed
light (IPL) treatments ensure that the demand for hair removal is ever present.
According to Statista, in 2014 a reported 1.12 million women in the UK admitted to
using hair removal products once a day or more.3
Providing the best possible service at your clinic is crucial to success, as is
maintaining a solid business core that can bring a consistent financial return. In
this article, I shall explain how a ‘bespoke’ permanent hair reduction service can
be a valuable asset to an aesthetic clinic.
Patient demand
I personally work with a multi-platform device offering both IPL and 1064LP
Nd:YAG which in my experience has proven to offer permanent hair reduction
opportunities for all Fitzpatrick Skin Types (FST) I to VI (Figure 1),2 alongside a
variety of equipment offering electrical epilation.
The device offers hair removal on the face, areola, underarm and bikini line
throughout the year, and from my personal experience, turnover varies between
25% during the summer months and 45% in the winter months. The quieter
summer months can be put down to the fact that when skin has colour in the
form of an active tan, it cannot be treated using existing laser/IPL equipment, as
use of both modalities is restricted by the amount of melanin present in the skin.
If implemented, there is a potential risk of skin scorching/burning, which can
result in possible blistering, scarring and hyperpigmentation.4
The societal change in attitude toward unwanted forms of hair growth such
In 2014 a reported 1.12 million
women in the UK admitted to
using hair removal products
once a day or more
as hypertrichosis,5 means an increasing number of
consumers openly seek solutions. You need only to look
at the advertising and treatment menus in the high street
windows of beauty salons, medi-spas, aesthetic clinics
and the plethora of hair removal products available on the
shelves to see this change in society. Although, statistically,
the average turnover from hair removal as a stand-alone
procedure appears to be undocumented here in the UK,
making it harder to gauge.
Unless one has fair hair or has no wish to embark on
the route of permanent reduction, in my opinion, these
treatments seem to be on most people’s to-do lists, both
male and female, resulting in open discussion among
friends socially – which can be considered as the best
form of marketing.
Fitzpatrick Scale
I.
White, always burns, never tans
II. White, usually burns, difficulty in tanning, may
freckle
III. White, sometimes burns, average tan
IV. Moderate brown, rarely burns, tans easily
V. Dark brown, rarely burns, tans easily
VI. Black, tans/darkens easily
Figure 1: Fitzpatrick Scale
Choosing the right device(s)
The consumer can be easily confused by the choice of
treatment modalities on the market, as can sometimes
the professional. A sound understanding of not only the
treatments you wish to introduce into your practice, but
also what options are available, will guide you in selecting
the right machine. Practitioners can do this by attending
major aesthetic exhibitions and taking time to collect the
various literature available and speak in depth with the staff
at the stands; there will often be a trainer present who can
answer any queries you may have and advise you of the
most appropriate devices and equipment for your clinic.
I recommend that practitioners go armed with a list of ‘prior
to purchase’ questions, as well as an idea of both budget
and method of payment. These could include:
• Costings of the annual financial outlay for maintaining
the equipment after the warranty period is over,
including consumables such as flash lamps in the IPLs.
• Whether the company offers a monthly payment
scheme to help manage cash flow for on-going service
maintenance contracts and consumables.
• Investment in attending online and classroom-based
courses, which are designed to provide practitioners
with the basics of using lasers and IPL systems, prior
to purchasing, as this should give you a valuable
step forward into starting to understand laser and IPL
equipment.
@aestheticsgroup
Aesthetics Journal
Enhancing your clinic profile and increasing footfall
There are some essential considerations to make for your clinic, which
will hopefully enhance the clinic profile and increase footfall. One
consideration is the staff – employ practically skilled practitioners,
who are also empathetic and people-friendly. In addition, qualityassured equipment is vital in order to achieve the safest results
possible. Make sure you have an excellent support service contract
with the equipment supplier, which can include policies such as 24hour emergency phone line incase of equipment failure, quarterly
maintenance visits and regular customer updates. A demographic
profile can be of assistance in the choice of equipment; for example,
if your clinic is located in a predominantly FST IV patient area, then
you might consider investing in a laser specific to the needs of those
patients or a combination of more than one modality.
Other pre-purchase considerations include:
• Members of staff obtaining substantial knowledge.
• A member of staff to acquire a Level 4 NVQ in the provision of
laser and light treatments.
• Consumables required, such as disposable gloves, postprocedure cooling product, tissues and cotton wool.
• Location of the equipment, the space available and ventilation
needed.
• Layout of treatment room; can this room be multifunctional? If so,
the machine in situ could be a marketing tool in itself.
• Acquisition of referrals and developing a clientele; for example,
working with or employing an electrologist who should be the
ideal candidate to further train in the use of IPL or lasers.
Clinical and financial success lies in the skill of bringing them all
together. The patient who comes to your clinic for hair removal is a
loyal, trusting staple of any aesthetic business, as they both need
and rely on the service offered. However, one of the mistakes made
by many clinics is the lack of continuity in the provision of the same
practitioner performing the treatment on the same patient; building
a valuable relationship between the practitioner and patient can
increase trust and encourage the patient to return to your clinic for
future treatments. This is where the smaller, more bespoke clinic can
benefit when considering competition with the larger aesthetic clinics.
Pricing of treatment
Competitive pricing is crucial. Undercutting your competitors’ prices
may initially increase your footfall, but in the long-term can negatively
impact on your profit margin, cash flow and, inevitably, the reputation
of the clinic. As with all procedures a clinic may offer, it is essential
to conduct market research on your local competitors to carry out
a price comparison, alongside the cost of the initial investment to
determine the financial return. For example, if the clinic is located
where the demographic is predominantly FST IV-VI and investment
has been made in the latest combined laser of Alexandrite and
long-pulsed Nd:YAG, then the pricing and advertising should reflect
the uniqueness of both the equipment and the forward thinking of
the clinic’s investment. On the other hand, to over price oneself in a
market where there is a lot of choice available is not a constructive
approach to business.
Consultation
Including a test patch in the consultation is a vital part of any
procedure and this is where you could gain or lose a potential
Aesthetics
patient. It is the first point of contact and must be charged for; I
charge £50 and will provide up to an hour of my time to educate,
reassure and perform the treatment to a small area of the body
requiring the procedure. In my experience, this practice often
ensures a returning patient who is then booked in at reception prior
to leaving for their first full treatment. The unsure patient must always
be given time to consider their decision; persuasion should never be
part of the package.
For the aesthetic clinic the ‘test patch consultation’ will always be the
area of least financial return, but this time is your investment in the
patient returning for consecutive treatments often paid for upfront as
a course.
Courses of treatment
Courses of treatment are an excellent way of ensuring treatment
continuity, but it is important to remember that not every patient is a
suitable candidate for the procedure.
‘Payable in advance’ is always a good source of income for any
aesthetic clinic with typical packages such as:
• Eight treatments for the price of six
• Six treatments for the price of five
The above are constructive packages; in my experience, however,
body hair usually requires eight treatments for both IPL and lasers,
with back areas on average requiring twelve sessions or more.
Treating facial hair growth requires truly bespoke treatment planning.
The cause is a variable as is the problem area specific to each
patient. A comprehensive consultation exploring the advantages,
expectations and realistic outcomes will facilitate a mutually
agreeable and affordable hair reduction management plan.
Conclusion
As with all laser and IPL applications, the equation is simple; the
equipment is the physics, the presenting condition to be treated is the
physiology and the practitioner is the active element between the two.
Ideally, the correct application of the appropriate light therapy, plus
ideal target chromophore/presenting condition will equal successful
outcomes, which will in turn increase customer satisfaction. In return,
you will recoup word-of-mouth, advertising and testimonials alongside
a ready-made patient base for other procedures and products your
clinic may offer. Ideally, one multi-functional hair removal machine, with
perhaps two part-time practitioners who both offer electrical epilation
alongside the laser/IPL would provide your clinic with a solid core of
hair removal options.
Christine Clarke is the owner and lead aesthetic
practitioner of the Christine Clarke Clinic. She delivers
NVQ Level 4 in the application of laser and light therapies
at her premises in Sheffield, along with bespoke basic and
advanced skin analysis and treatment.
REFERENCES
1. Tannir, D. and Leshin, B, Sugaring: An Ancient Method of Hair Removal. (American Society for
Dermatologic Surgery, 2001), (27), < http://www.ncbi.nlm.nih.gov/pubmed/11277903> [Accessed 16th
September 2015] pp.309-311
2. Fernandez, A. A., França, K., Chacon, A. H. and Nouri, K, ‘From flint razors to lasers: a timeline of
hair removal methods’. (Journal of Cosmetic Dermatology, 2013) (12) < http://www.ncbi.nlm.nih.gov/
pubmed/23725310> [Accessed 16th September 2015] pp.153-162
3. Statistica, ‘Number of women using hair removers, shavers and razors in the United Kingdom (UK) in
2014, by frequency of use (in 1,000)’ (2015) <http://www.statista.com/statistics/302795/women-s-hairremoval-product-usage-frequency-in-the-uk/>
4. S Vano-Galvan, ‘Laser Hair Removal: A Review’, (College of Family Physicians of Canada, 2009),
<http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2628842/> [Accessed 28th October 2015] pp. 50-52
5. The Trichological Society, ‘Hair and its Growth Cycle’ (2015) < http://www.hairscientists.org/humanhair/growth-cycle> [Accessed 27th October 2015]
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undergraduate, it is not surprising at all.
However, the necessity of doing so is important and becomes
clearer when patients start defaulting on their payments. From
cheques bouncing to credit cards failing and counterfeit notes being
used – if you have been in business for long enough you will have
experienced all of these issues. If you haven’t experienced such
problems, the system you operate clearly works so don’t change it!
Patient
Cancellations
Professor Bob Khanna shares advice
on managing late or cancelled clinic
appointments
Deposit systems
When I set up my first clinic in Ascot in 1997, I remember having a
conversation with my receptionist about a ‘great’ idea that I had – to
take a deposit from each new patient to secure a booking. Jackie
thought I was joking when I said this and, when she realised I
wasn’t, told me that it would never work as, “no one else does this!”
I replied, “In that case, there is even more reason to do it!” To this
day I have maintained this policy and my Failure To Show (FTA) rates
are extremely low.
My belief has always been that we must get commitment from the
patient and a simple deposit system can be a very powerful tool to
help us do so. Patients are very unlikely to miss an appointment if
they are aware that they may be charged and that they have left a
deposit with the clinic. The ideal amount for securing a new patient
booking should be high enough for them to want to turn up, but
not too high that it becomes a deterrent for booking. Ironically, I
set the consultation price at £45 in 1997 and this has remained the
same ever since. I only see this price as a holding fee and an FTA
deterrent, so it is not something the clinic is aiming to profit from. Let
us not forget that it is of course in everyone’s interest for the patient
to actually attend rather than miss an appointment.
Following a new patient consultation, a patient will need to be
booked in for a subsequent appointment for the appropriate length
of time, depending on the procedure. I think it is wise to take at
least 25-50% (or more) of the full fee of the treatment to secure
such bookings. Again, this will commit the patient to treatment and
facilitate cash flow for the clinic in order to purchase the appropriate
materials required for the case. One should not be hesitant with
taking deposits or money upfront as this concept is endemic in
today’s society. From ordering a Big Mac at McDonalds to booking
a flight, we would be required to pay upfront. Why then, are
practitioners so reluctant to operate a deposit system? I suspect it
has something to do with an inbuilt duty of care we all have. Being
too business-like can make many practitioners feel uneasy. In view of
the fact that we receive absolutely no training in business skills as an
Cancellations
There is nothing like a last-minute cancellation to sour your mood as
a practitioner, especially if it is for an appointment of more than one
hour. However, one has to also realise that certain life circumstances
are unavoidable and practitioners must, therefore, be flexible too.
The problem occurs when you encounter the ‘serial offender’. This
is the patient that is frequently late or, more often, cancels at the last
minute, usually on the day, citing, “I’ve been called into work”, “I feel
ill”, or that classic… “My car didn’t start up!” So, how do we prevent
patients taking us for a ride?
Firstly one must have a clear written practice policy that states
the cancellation ‘rules’ that each patient has to sign on registering
with the practice. Ideally, this should be updated every year to
allow clarification of any changes for your patients. As a deterrent,
staff should make it very clear that cancellations inside of 48
hours may incur a late cancellation fee. This fee can either be the
full treatment fee or a pay-per-minute fee, for example, £2 per
appointment minute missed.
Since it is more beneficial to retain a patient, from a long-term
perspective, one must exercise a degree of discretion. Hence, a firsttime offender may be granted a pass, so long as they are informed
that, on this occasion, they narrowly missed being charged the
cancellation fee. The reception team should document this fee and
the reasons for cancellation so you can check how many times it has
happened. A fee ought to be taken from the deposit if the patient
repeats this activity again. If you are too lenient, the patient may
become complacent and keep re-offending.
It works both ways
All of the above is designed to make the patient respect our clinical
time. As I have mentioned previously, rather than for profit, any such
fees should act as a deterrent and send a clear message that FTAs
and late cancellations are not acceptable.
However, practitioners and clinic staff must therefore appreciate that
for this to be fully respected, then it has to be a two-way process.
For example, if one is running substantially late (more than 30
minutes) or if a clinic day has to be cancelled at short notice then I
think it is only fair that the patient is compensated. Rather than offer
a monetary fee, a gift voucher towards treatment at the clinic could
be a better idea so you retain their custom. The mere gesture of this
will alleviate most of the patient’s anxiety and annoyance, serving as
a reminder of how valued they are at the clinic. Retaining patients is
a key aspect to a successful business; achieving patient loyalty and
respect is a testament to how well they are treated by the whole
team, in all aspects of their care, and must not be taken for granted.
Professor Bob Khanna is a cosmetic and reconstructive
dental surgeon and runs clinics in Ascot and Reading,
carrying out a full spectrum of treatments from aesthetic
dentistry, surgical implantology and bone regeneration
procedures. He has also trained thousands of aesthetic
practitioners, dentists and plastic surgeons in non-surgical facial
rejuvenation procedures.
@aestheticsgroup
Aesthetics Journal
How do you target men?
Whilst marketing to female patients is
commonplace, successfully reaching men to
promote treatments can prove to be more
difficult. We also have the added job of
needing to widen men’s knowledge of what
treatments they can have outside of botulinum
toxin and fillers.
Marketing
to Men
Charlotte Moreso shares advice on how
to entice male patients into your clinic
According to the British Association of Aesthetic Plastic Surgeons, surgical procedures
for men dropped by 15% in 2014.1 Practitioners interviewed for this article, however,
suggest there has been a rise in popularity of non-surgical treatments such as fillers,
botulinum toxin and body treatments. Some proof of this lies in the results of a nationwide
survey commissioned by Syneron Candela that indicated a third of men would now
consider laser hair removal in a clinic.2
So where is the business coming from if it’s no longer just women funding this segment of
the market? Various factors could have an influence, including:
• Workplace: Marc Moreso, CEO of Leisurejobs.com says, “Men are increasingly under
pressure to look younger for longer in the boardroom due to competition from younger
recruits in the work environment. Youthful looks equal energy, ideas and a go-getting
attitude in the minds of employers.”
• Rules of Attraction: Men now know that there are ways, other than a new haircut, in
which they can make themselves look more attractive to a potential partner. These can
include both surgical and non-surgical treatments.
• “If it’s good enough for her...” In the same way as men started using, or rather
‘borrowing’ their partner’s skincare at home before realising they can buy their own,
men have witnessed women having non-surgical treatments for so long that it has
paved the way for men wanting and having them too.
• Media: According to Ben Isaacs of ShortList magazine, “Advertising and men’s
grooming pages within mainstream press has increased dramatically within the last five
to 10 years, meaning men are more likely to find it acceptable to look after their looks in
the same way women do.”
• Celebrity and the ‘David Beckham Effect’: This ‘real’ sportsman and his groomingbased advertising, alongside his overall appearance, has made being a beautiful male
acceptably manly. More recently, celebrities such as Simon Cowell and Gordon Ramsay
have admitted to having botulinum toxin treatments.4
It has been reported in the US that the most popular non-surgical treatment for men is
botulinum toxin.3 Harley Street-based dermatologist Dr Ariel Haus comments, “I have seen
a real increase in the number of men coming for treatments over the last three years.
More and more men are increasingly interested in botulinum toxin to give them a ‘fresh’ or
‘less tired’ look. Men now realise that it does not have to result in a frozen look, and that
appeals to them.”
The male market is a huge opportunity to
expand your patient base, but we know we
cannot market to men the same way you
would to women. Males and females are, of
course, very different socially, biologically and
psychologically. However, both genders tend
to want to gain attention and look attractive –
we just need to talk to them in different ways
and through different mechanics.
From my experience, I believe there are four
main ways to reach male patients:
1. Partners: Reach men through the wives
and girlfriends with in-clinic materials and
newsletters. Most women will confess to
having been the prime purchaser of their
partner’s toiletries in the past, especially
during the weekly shop, and women are
key influencers with their partners. So let
the ladies do the talking. Even if you don’t
have a large male patient base, you can still
create a male menu for women to read and
take home.
2. Online: Ensure you have a mix of search
engine optimisation (SEO) and pay-perclick (PPC) tactics to market your clinic and
treatments for men within the search results.
SEO provides search engines with relevant
information and keywords to rank your site
higher organically in search results. PPC
utilises search engines’ paid advertising
platforms (such as Google Adwords) to list a
website in search results.5
According to Paul Handley of SEO Copywriter
UK, “If you are looking to run PPC advertising,
males will click on brand search terms over
generic keywords. However, although PPC
can be a good ‘quick fix’ for page one results,
organic SEO will yield far more traffic to your
site.” He explains, “In recent studies, it has
been suggested that natural rankings in search
results leads to 94% of clicks (the remaining 6%
allocated to PPC).6 Organic search positions
(as opposed to PPC listings) also receive
far more clicks from males than females. To
demonstrate the importance of natural SEO
further, the top three organic search positions
in Google account for 79% of all clicks, leaving
just 21% for all other listings.”6
Also be sure to use your social media accounts
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to deliver male-targeted messaging and treatment options. Even
consider placing digital adverts and banners on local sites they may
use, for example local sports clubs. Contact the sites directly through
the contact tab on their websites to enquire about prices directly, and
ensure you negotiate as there is often room for movement in price.
Double chin: Entice men to reclaim the face of their youth with underchin treatments using radiofrequency or similar technology.
3. Promotions: Create ‘his and her’ treatments around Valentine’s
Day. Develop a couple’s promotion to entice patients to come and
experience treatments together. Why not focus on treatments like
body shaping for the abdomen or ‘love’ handles, or develop a
‘dinner date facial’. It’s important to note, however, that botulinum
toxin cannot be promoted or discounted in any deal as it is a drug.
Once you have the male half of the partnership in your clinic, it’s the
perfect opportunity to let him know about the range of treatments
available.
4. Local Businesses: Look in your local area surrounding the clinic.
There are likely to be some small and larger businesses such as
wine bars and social clubs that you could target with treatment
materials. Offer free consultations to men looking to enhance their
appearance. Create a flyer with a menu of treatment options. Don’t
blind them with too much information though, just include enough
to peak their interest.
• Lunchtime Light Treatments: Blue and red light treatments that fit
into the lunch-break.
• The 30-minute Man-Peel: A range of peels to rejuvenate in just
half an hour.
• Workaholics Reviver Treatment: Combination treatments to
refresh the skin and restore youthful looks. Typically, a course of
three to six treatments would ensure they return to the clinic for
optimal results.
Creating the ‘Man Menu’
It’s often the case that men won’t realise the variety of aesthetic
options open to them, so ensure you create a very specific menu of
treatments for men. Divide them clearly into face and body treatments
for clarification.
I have successfully run male-specific marketing campaigns for a large
aesthetic company in recent years using imagery of toned men and
catchy strap lines such as ‘Fit & Firm’ and language that they can
relate to such as ‘turbo charge your torso’ and ‘high-tech solution’. This
successfully captured their attention and encouraged them to try the
latest body treatment to rid them of concerns such as love handles
and abdominal ‘over-load’. Ideas include:
Body
Men’s body treatments could include those targeting:
• Love handles: Ultrasound, radiofrequency, fat freezing.
• Laser hair removal: Back, abdomen, chest and buttocks.
• Gynaecomastia: Radiofrequency, ultrasound and fat freezing
treatments are all options for this area of concern.
Dr Anita Sturnham, founder of the NURISS clinics, says, “With the
increasing popularity of advertising campaigns that employ perfectly
honed male celebrities such as David Beckham, it is no wonder
that many men feel under pressure to improve their appearance. I
am sure that the media drives both men and women’s insecurities
with their perfected appearance. I am personally noticing more and
more male patients coming to see me at my clinic with concerns
about their stomach region. It is typically a difficult area to lose
weight from, even with a strict diet and exercise regime, so stomach
toning treatments and non-surgical body contouring treatments are
becoming popular.”
Face
Line erasers: Filler, botulinum toxin, laser and radiofrequency all work
well to decrease facial lines and wrinkles.
Eradicate redness: Older men can suffer from broken capillaries, so
promote your skincare and treatment options for this.
Men tend to like things to be quick, clear and direct, but also
appealing. Here are a few ideas to implement that might work:
Also look into male specific treatments you may not offer already.
This is something that Dr Sherif Wakil, founder of SW Clinics, has
had great success with. Dr Wakil says, “I have introduced the P-Shot
(male sexual rejuvenation with PRP) to Europe and the UK last year
and since then I have seen quite an increase in the number of my
male patients interested in the treatment, not only from the UK but
also from Europe and the Middle East.”
He continued, “Looking back, there was definitely an increase in
male patients coming to my clinic over the past few years, especially
after the recession period. I believe this could be explained by the
fact that a lot of middle-aged men have been made redundant and
were forced to apply for jobs along with other candidates in their
twenties, obviously they had to take care of their looks to give a
good impression on an interview. I believe, since then, they have
seen what positive effect procedures could have on their lives.”
Summary
Devise your man menu and create a clinic flyer for distribution
at local businesses, always being mindful of using ‘man-friendly’
language and imagery they can relate to. Lastly, note that it is always
worthwhile writing a press release detailing all the treatment options
for men and sending this to your local newspapers and magazines,
with an invitation for them to try a treatment in their lunch-break in
return for editorial coverage.
Charlotte Moreso is managing director of True Grace PR.
Charlotte has worked as a PR and marketing consultant
in the health and beauty industry for more than 20
years, running highly successful campaigns for global
commercial brands, smaller UK beauty brands and in more
recent years, creating news for the UK’s leading aesthetic treatments,
doctors and clinics. Her work has won several industry awards.
REFERENCES
1. British Association of Aesthetic Plastic Surgeons, ‘New statistics show extreme surgery’s gone bust –
surgeons welcome more educated public’ (2015), <http://baaps.org.uk/about-us/press-releases/2039auto-generate-from-title> [Accessed 28th October 2015]
2. Censuswide Survey of 1,000 UK consumers March 2013 for Syneron-Candela Gentle Lasers. Data on
file via Syneron Candela.
3. American Society for Aesthetic Plastic Surgery, ‘The American Society for Aesthetic Plastic Surgery
Reports Americans Spent More Than 12 Billion in 2014; Procedures for Men Up 43% Over Five Year
Period’ (2015), http://www.surgery.org/media/news-releases/the-american-society-for-aesthetic-plasticsurgery-reports-americans-spent-more-than-12-billion-in-2014--pro [Accessed 30th October 2015]
4. Vicki-Marie Cossar, ‘The rise of Brotox: plumbers and businessmen copy Simon Cowell’s Botox
look’ (London: Metro.co.uk, 2013) < http://metro.co.uk/2013/02/25/the-rise-of-brotox-plumbers-andbusinessmen-copy-simon-cowells-botox-look-3510335/> [Accessed 28th October 2015]
5. Silverwood-Cope, S, ‘Natural Search accounts for 94% of Search Engine clicks, PPC 6%’ (Intelligent
Positioning, 2012), <http://www.intelligentpositioning.com/blog/2012/08/natural-search-accounts-for94-of-search-engine-clicks-ppc-6/>, [Accessed 30th October 2015]
6. David Towers, ‘PPC accounts for just 6% of total search clicks’, (Econsultancy, 2012), < https://
econsultancy.com/blog/10586-ppc-accounts-for-just-6-of-total-search-clicks-infographic/>, [Accessed
30th October 2015]
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Aesthetic Journal 0ctober 2015 issue
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Aesthetics Journal
Aesthetics
“You don’t just say goodbye to patients who
have a problem, you help them and hold
their hand the whole way through”
Mr Nigel Mercer details his experiences of the plastic surgery
and aesthetic industries and the valuable skills he has learnt
along the way
As the president of the British Association of Plastic
Reconstructive and Aesthetic Surgeons (BAPRAS), Mr Nigel
Mercer’s devotion to plastic surgery and aesthetic medicine is
clear. He explains that he has aspired to work in medicine ever since
he was a child, “I wanted to be a doctor since I was four, as I was
fascinated by biology and how the organs of the body worked – I
was very focused from an early age.” But it wasn’t until he saw one
of the first colour supplements in a newspaper that he developed a
curiosity for plastic surgery. “When I was 11, I picked up a supplement
from a Sunday newspaper and it had some images of children
from France who’d had a bony disfigurement of the skull and face
treated; I remember seeing one child who went from looking very
strange to completely normal after surgery, and I thought ‘wow, that’s
fantastic’ and then the rest of my life was really programmed to go
into medicine.”
Mr Mercer gained his medical degree from the University of Bristol in
1980 and, from then on, was determined to work in plastic surgery;
however, he found it a tough industry to break in to. “Plastic surgery
was just as popular as a profession then as it is now, so you had to
go off and do something else for about 18 months while you waited
for an opening. You’d do your training, get your surgical qualification,
then the people in charge would say ‘great, lovely to have you… but
come back in two years time’.”
Subsequently, Mr Mercer spent around 18 months working in
orthopaedics; treating backs, hips and carrying out arthroscopic
surgery. “I remember sitting there thinking ‘how is this making me
a better surgeon?’ But in fact, it got me used to looking after sick
patients, improving my manual dexterity and stitching, so it actually
did make me a better surgeon and I appreciate that.”
Over the years, Mr Mercer spent time perfecting his surgery skills
in centres of excellence in London, Glasgow, Bristol and Canada.
Today, he divides his time between his private practice Bristol
Plastic Surgery, and his NHS practice in Bristol, where he is the
senior consultant.
Although a specialist in surgery, Mr Mercer also acknowledges
how non-invasive medicine complements his practice. “The world
of aesthetic medicine has moved forward dramatically, and it’s not
just ‘a bit of botulinum toxin and a bit of filler’; its complete facial skin
rejuvenation. I can do a great facelift but if the skin looks as though
it’s 200 years old, then it doesn’t look right. So we’ve incorporated
aesthetic treatments into our practice.”
Appointed president of BAPRAS this year, Mr Mercer is also a
member of several associations, which are very important to him.
“Next year, I’ve taken almost all my annual leave for the BAPRAS
meetings!” he comments. “I was at a conference in Lisbon recently
and when I got back to the airport to travel home, the passport
officer said ‘Did you like Lisbon?’ and I had to unfortunately reply,
‘I haven’t even seen it!’ But these meetings are so important. It’s
fantastic to have the opportunity to work with practitioners from
around the world. You get to meet some really interesting people; it’s
an enormous privilege.”
For Mr Mercer, treating patients isn’t just a one-off procedure;
it’s a process, and to him, every conversation with a patient is
a psychological intervention. He feels its important to correct
surgery if patients aren’t happy and make sure they know he’ll
be there to help them whenever they need it. “You can do a
facelift and have a fantastic result, but if the patient is a smoker
or sun-worshipper, then it’s likely that in a year’s time, the skin’s
dropped; and that’s disappointing. But, metaphorically, you hold
their hand and say, ‘I don’t like this either, lets do something about
it.’ If revision surgery is needed, you do that. You don’t just say
goodbye to patients who have a problem, you help them and hold
their hand the whole way through.”
What treatment do you enjoy giving the most?
I love treating noses and faces. There’s a degree of natural
variation in noses and you never quite know what you’re
going to find when treating one. I have a mental image of what
I think is normal for that patient and then try and create it –
that’s the challenge!
What’s the best piece of career advice you’ve ever
been given?
Mr Douglas Harrison, who was one of my main trainers, said
to me, ‘The one thing you need to make sure of is that you
sleep well in your bed at night – so don’t take risks.’ If I have a
complication, I feel terrible about it and can lose sleep over it.
So minimising complications and risk is terribly important for me.
Do you have an industry pet hate?
I really don’t like the profit motive involved with aesthetics –
some people come into it just because they think they can
make a lot of money. When I teach students I say, ‘You’re
never going to be rich! You’ll be comfortable, but you’re never
going to be rich.’ And that’s true.
What aspects do you enjoy most about the industry?
I love the people! The industry is full of such nice people and
a lot of us have ‘grown up’ together in the specialty. I’m lucky
to have developed lifelong friendships. The patients can be
exacting but it’s great to get to know and help them.
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The Last Word
Dr Asim Shahmalak argues why it’s time
to end the hard sell in aesthetic practice
Patients quite rightly expect us to put their interests first, regardless
of whether it benefits our practice or not. In my work as a hair
transplant surgeon I have treated some big names in show business,
but for every celebrity that has had a hair transplant, there is another
that I have had to turn away. While my practice may have benefited
enormously by the global publicity, I had to say ‘no’ as, if I treated them,
I would not be acting in the patient’s best interests and, thus, I would
have been failing in my duties as a medical professional.
Unfortunately, not every clinic has the same ethics. In my opinion, it
has become apparent that hard-sales tactics are being used to the
detriment of the patient. Patients will be told, ‘If you book today, you
can have 25% off’ – pressuring them into making a decision quickly.
Other clinics will offer price matches on foreign clinics, in the same
way you see supermarkets matching its competitor’s prices on
branded goods. I’ve also seen botulinum toxin offered as part of a
‘3 for 2’ deal, like tubes of toothpaste at the chemist.
I have spent more than 30 years building my reputation as a
successful practitioner and establishing my hair transplantation
clinic, which, to my knowledge, is one of only four such clinics in
UK that is doctor-owned and run. While many other clinics have
Patients seeking repairs
have come to me blaming
foreign hard sells; they are
lured by the cheaper prices
abroad but bitterly regret
cutting corners on cost
Aesthetics
excellent doctors working in them, it is not always the medical
professionals who are in charge of running the business.
To my knowledge, a sales team or ‘consultants’ (as they are often
described to perspective patients) are running some clinics.
Their primary interest is not always that of the patient – and can
be, instead, focused on making a sale and generating profits for
the business. This can mean patients are being treated too early or
when there is little chance of a successful treatment because they
are not suitable.
I often see the results of this recklessness as around 10% of my
workload is what we could call ‘repair work’ – fixing the poor
surgery provided by other clinics. Most of my repair jobs arise from
patients who have gone abroad for treatment. The most popular
locations tend to be Greece, Turkey and Spain, and increasingly
India and Pakistan, too. In each case, the regulation in these
countries is not as strict as it is here; patients can have
a hair transplant without ever seeing a fully qualified surgeon –
a technician rather than a doctor will do the grafts. Patients seeking
repairs have come to me blaming foreign hard sells; they are lured
by the cheaper prices abroad but bitterly regret cutting corners on
cost. If you buy cheap, you buy twice.
Clinics pushing patients into undergoing a treatment too quickly
is not just an issue in hair transplantation surgery – the issue is
prevalent right across the aesthetics industry. From breast implants
to filler injections, there are rogue procedures taking place that are
damaging the reputations of us all, and making some patients wary
of seeking treatment that has the potential to transform their lives.
Moving forward
It pains me to see the hard-sell tactics being used so blatantly. There
have been significant developments in the aesthetics industry within
the last 10 years, and while technologies have advanced right across
the board, offering patients highly sophisticated treatments which
produce far better results than ever before, the principles and values
underpinning some of the clinics in our field leave a lot to be desired.
I think the way forward is to put more power into the hands of
doctors and clinicians who are experts in their field and to rely less
on sales people and consultants, who may put profit ahead
of their patients’ best interests. I believe the best way to do this is
to bring in tighter regulation in the UK. The British Association of
Hair Restoration Surgery (BAHRS) is keen to liaise more closely with
the General Medical Council and the health sector to bring in even
tougher laws, as are other bodies such as the British Association of
Aesthetic Plastic Surgeons (BAAPS).
In the hair transplantation sector, we are now moving towards
a system where you would not be able to operate unless you were a
member of the BAHRS, which insists on the highest ethical standards.
The most important thing we are all working for in aesthetics is our
reputation as medical professionals. As such, it is vital that we do not
feel pressurised into focusing on sales and profit instead of the care
of our patients. People pay for quality so, remember, your reputation
doesn’t need to be built on how many sales you make, more so, it
should reflect the high level of care and successful treatments you
offer your patients. It’s time to end the hard sell.
Dr Asim Shahmalak is a hair transplant surgeon
and gained his medical degree from the University of
Karachi, Pakistan in 1988. He founded the Crown Clinic
in Manchester eight years ago and also has consulting
rooms in Harley Street. He is a hair loss expert on
Channel 4 show Embarrassing Bodies.
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Tel: 01400 281902
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AestheticSource
Contact: Sharon Morris
+44 01234 313 130
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Services: NeoStrata and Exuviance
Bausch + Lomb UK Ltd
0845 600 5212
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+44 01923 208950
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Hamilton Fraser
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0800 63 43 881
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Healthxchange Pharmacy
Contact: Steve Joyce
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John Bannon Pharma and
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info@johnbannon.ie
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MACOM
Contact: James Haldane
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james@macom-medical.com
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HA-Derma
IBSA Italia’s aesthetic
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0208 455 48 96
info@ha-derma.co.uk
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Harley Academy
0203 28 27 568
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enquiries@harleyacademy.com
ClinicMate
Aesthetic Search Engine
01844 355653
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Silhouette Soft
Tel. 020 7467 6920
Contact: Emma Rothery
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silhouettetraining@sinclairpharma.com
Med-fx
Contact: Dyan Williams
+44 01376 532800
sales@medfx.co.uk
www.medfx.co.uk
Medical Aesthetic Group
Contact: David Gower
+44 02380 676733
info@magroup.co.uk
www.magroup.co.uk
Sinclair Pharmaceuticals
info@sinclairpharma.com
0207 467 6920
www.sinclairispharma.com
Medico Beauty
Contact Name: Andy Millward
+44 (0) 844 855 2499
training@medicobeauty.com
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MedivaPharma
01908 617328
info@medivapharma.co.uk
www.medivapharma.co.uk
Service: Facial Aesthetic Supplies
Candela UK Ltd
Contact: Head Office 0845 5210698
info@syneron-candela.co.uk
www.syneron-candela.co.uk
Services: Syneron Candela are
Global brand leaders in the
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Contact: Isobelle Panton
isobelle@thermavein.com
07879 262622
www.thermavein.com
Merz Aesthetics
+44 0333 200 4140
info@merzaesthetics.co.uk
Laser Physics
+44 01829773155
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Lynton
+44 01477 536975
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www.lynton.co.uk
Polaris
Lasers
Medical
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From
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MATTIOLI ENGINEERING
+44 01234841536
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Carleton Medical Ltd
Contact: Nick Fitrzyk
+44 01633 838 081
nf@carletonmedical.co.uk
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Services: Asclepion Lasers
Eden Aesthetics
Contact: Tania Smith
+44 01245 227 752
info@edenaesthetics.com
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Lumenis UK Ltd
Contact: Nigel Matthews
+44 020 8736 4110
UKAesthetics@lumenis.com
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Contact: Sarah Jayne Senior
www.cosmeticinsure.com
0845 6008288
sales@cosmeticinsure.com
DermaLUX
Contact: Louise Taylor
+44 0845 689 1789
louise@dermaluxled.com
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Service: Manufacturer of LED
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Neocosmedix Europe
Contact: Vernon Otto
+44 07940 374001
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vernon@neocosmedixeurope.co.uk
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Fusion GT
0207 481 1656
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Soft luminous powder blends effortlessly
Youthful sun kissed glow
Works for all skintones
4T Medical
01223 440285
info@4tmedical.com
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Allergan
+44 0808 2381500
www.juvedermultra.co.uk
BTL Aesthetics
Lex Myatt
01782 579 060
info@btlnet.com
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01400
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thecosmeticnurse@mail.com
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Training Accredited by Leading Aesthetic Insurance Companies
CPD Points
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blowmedia
Creative and Digital Design agency
Contact name: Tracey Prior
tracey@blowmedia.co.uk
0845 2600 207
www.blowmedia.co.uk
Lifestyle Aesthetics
Contact: Sue Wales
+44 0845 0701 782
info@lifestyleaestheics.com
www.lifestyleaesthetics.com
Flawless Aesthetics and Beauty
5 Squirrels
Own Brand Skincare
www.5squirrels.com
info@5squirrels.com
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Lawrence Grant
Contact: Alan Rajah
+44 0208 861 7575
lgmail@lawrencegrant.co.uk
www.lawrencegrant.co.uk/
specialist-services/doctors.htm
z
WELLNESS TRADING LTD –
Mesoestetic UK
Contact: Adam Birtwistle
+44 01625 529 540
contact@mesoestetic.co.uk
www.mesoestetic.co.uk
Services: Cosmeceutical Skincare
Treatment Solutions, Cosmelan,
Antiagaing, Depigmentation,
Anti Acne, Dermamelan
Aesthetics | December 2015
Zanco Models
Contact: Ricky Zanco
+44 08453076191
info@zancomodels.co.uk
www.zancomodels.co.uk
Dr. Catalin Calinoiu
Contact: +40.724645555
zfill@zfill.forsale
www.zfill.forsale
The VYCROSS™ Collection is the latest generation of CE-marked Juvéderm ® HA dermal fillers, building on the strong heritage
and benefits of the Juvéderm ® Ultra range, helping to create natural-looking results and high patient satisfaction.1-5
The VYCROSS™ Collection includes:
JUVÉDERM® VOLBELLA® with Lidocaine
JUVÉDERM® VOLUMA® with Lidocaine
JUVÉDERM® VOLIFT® with Lidocaine
JUVÉDERM® VOLIFT® Retouch® with Lidocaine
1. Raspaldo H. J Cosmet Laser Ther. 2008;10:134-42. 2. Eccleston D, Murphy DK. Clin Cosmet Investig Dermatol. 2012;5:167–172. 3. Callan P et al. A 24 hour study:
Clin, Cosme and Investig Derm, 2013. 4. Muhn C et al. Clin Cosmet Investig Dermatol. 2012;5:147-58. 5. Jones D et al. Dermatol Surg. 2013;1–11.
UK/0721/2015
Date of Preparation: October 2015

Results Without Compromise

Transcription

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