The external skin barrier – CPD

VOLUME 1/ISSUE 4 - MARCH 2014
Just for you
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to the practice of facial and body aesthetics
Register free for ACE 2014, London 8th & 9th March
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The external skin
barrier – CPD
Dr Mervyn Patterson on the key role of
the epidermis. CPD accredited article
Focus on
Injectables
Rejuvenation using
needles: new
approaches, new
products, new science
Platelet Rich
Plasma
Dr Sarah Tonks
investigates PRP
methods for your
practice
Nose reshaping
Dr Sotirios
Foutsizoglou shares
his techniques for
non-surgical nose
augmentation
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Contents • March 2014
INSIDER
06The Word
Mr Paul Harris on the government response to the Keogh Report
06News
The latest product and industry news
11 On the Scene
Out and about in the industry this month
14News Special: IMCAS
We report on the International Master Course on Aging Skin in Paris
CLINICAL PRACTICE
The skin barrier Page 24
CLINICAL PRACTICE
19 Special Focus: PRP
Dr Sarah Tonks explores the uses of platelet rich plasma in aesthetics
24CPD Clinical Article
Dr Mervyn Patterson discusses the importance of the external skin barrier
28Techniques
Miss Jonquille Chantrey explains the 8-point lift technique for facial rejuvenation
32Clinical Focus
Dr Beatriz Molina on treating lips using Emervel
34Techniques
Dr Askari Townshend on delivering Sculptra using needles
37 Spotlight On
We discuss SkinCeuticals’ new Advanced Pigment Corrector
38Clinical Study
An investigation into the use of the 1440nm Wavelength with Sidelaze800 delivery
42Spotlight On
Dr Iryna Stewart explains the mechanisms of the Hyalual Daily DeLux spray
44Treatment Focus
Dr Sotirios Foutsizoglou discusses non-surgical nose reshaping
50Abstracts
The latest clinical studies
IN PRACTICE
HR Considerations Page 54
Clinical contributors
Dr Sarah Tonks is an aesthetic doctor and previous
maxillofacial surgery trainee with dual qualifications
in both medicine and dentistry. She practises cosmetic injectables and hormonal based therapies.
Dr Mervyn Patterson is a co-owner of Woodford
Medical and has worked in aesthetic medicine
over the past fifteen years. He specialises in the
latest injectable anti-ageing treatments.
Miss Jonquille Chantrey is a surgeon specialising in
aesthetic medical procedures, with a practice in Cheshire. She has been published in peer-reviewed journals
and presents at plastic surgery conferences worldwide.
Dr Beatriz Molina practised general medicine for
12 years, before opening her first practice. She now
practises as a cosmetic doctor, alongside teaching
techniques in botulinum toxin and dermal fillers.
Dr Askari Townshend is an international
Sculptra trainer as well as lead UK Sculptra trainer
and medical consultant for Sinclair Pharma. His
interests include injectables, lasers and peels.
Dr Iryna Stewart is managing director of Rederm
and founder of IS clinics. After 15 years in the NHS,
she has dedicated the last five to aesthetic medicine,
specialising in skin rejuvenation and restoration.
52Aesthetics Conference and Exhibition Special Focus
The latest news from ACE 2014
Dr Sotirios Foutsizoglou is founder and medical
director of SFMedica. He has written for numerous
UK publications and presented at national and
international conferences and expert meetings.
IN PRACTICE
54Managing staff absence
Lawyer Vanessa Di Cuffa on setting rules for employee holiday and sick leave
56Boosting online presence
John Castro outlines simple digital strategies to improve sales
58Cash Flow
Business consultant Kurt Won explains how to maximise your cash flow
60Call Handling
Gilly Dickons discusses the importance of making a good first impression
62In Profile
We speak to Dr Terry Loong, Best New Clinic winner at the Aesthetics Awards 2013
64The Last Word
Aesthetics’ Editorial Advisory Board’s views on the Government response to the Keogh Report
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Editor’s letter
Just before we went to press, the government
finally published its response to the Keogh report.
The industry response was mixed, ranging from
outrage to cautious optimism. We were disappointed,
although far from surprised, to see Keogh’s key
Leah Hardy
recommendation of a compulsory register for
Editor
aesthetic practitioners being rejected outright and
lasers and lights seemingly slipping off the UK regulatory agenda. But
what should happen next regarding injectables, which are the focus
of this issue of Aesthetics journal? The government response was
frustratingly vague about plans to change the law. As Keogh himself
has pointed out, it was impossible to classify fillers as prescription-only
medicines due to EU legislation. However, we believe the government
should be introducing legislation to make fillers prescription-only
devices. Unfortunately, even this would not regulate every type of filler
until 2018. The EU Medical Devices Directive will reclassify all fillers as
medical devices, but manufacturers will then have a three-year grace
period to apply for CE marking. Controlling who administers fillers is
also complicated; the MHRA states that all medicines may potentially
be administered by non-medics under the direction of a prescriber.
However, the prescription model makes the prescriber responsible
for the patient, which is where prescribers and regulatory bodies have
the opportunity to self-regulate. The major filler companies voluntarily
CE mark their products as medical devices, do not sell direct to non-
medics, and indicate on their pack inserts who should administer
their products. They regard injectables as medical treatments, are
dismayed to see their products in the hands of unqualified injectors
and support stronger legislation. If the GMC, GDC and NMC issue
strict guidance about selling on, about who is an appropriate person
to use prescribed toxins, and about the importance of practitioners
only working within their competencies, with firm sanctions against
those who breach the rules, then the industry could improve ethics
and standards. The Committee of Advertising Practice with the
Advertising Standards Authority has independently created codes to
meet Keogh’s recommendations and is moving to deal with websites
and advertising campaigns that breach them, even unwittingly.
Health Education England is also working on training and standards.
We at Aesthetics strongly support moves within the industry to
improve training and education, hence our introduction of CPD
accredited content and the strong educational focus of the Aesthetics
Conference and Exhibition 2014. While we still need legislation in the
industry, for which continued lobbying is vital, regulatory bodies can
devise their own codes of conduct supported by the industry itself. We
have seen unprecedented cooperation between ethical aesthetics
practitioners for European standards and UK training standards. This
must continue and develop if we are to create a safer industry for
patients. To see more about the government response to Keogh,
visit our website www.aestheticsjournal.com.
Editorial advisory board
We are honoured that a number of leading figures from the medical aesthetic community have joined Aesthetics
journal’s advisory board to help steer the direction of educational, clinical and business content
Dr Mike Comins is president and Fellow of the British College
of Aesthetic Medicine. He is part of the cosmetic interventions
working group, and is on the faculty for the European College of
Aesthetic Medicine. Dr Comins is also an accredited trainer for
advanced Vaser liposuction, having performed over 3000 Vaser
liposuction treatments.
Amanda Cameron is a sales and marketing professional,
and was one of the first nurse injector trainers in the UK for
dermal fillers. With over 20 years experience in the industry
in both the UK and Europe, Amanda has extensive knowledge
of medical aesthetics and business development.
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 an aesthetic doctor and previous
Sharon Bennett is currently vice chair of the British
Dr Nick Lowe is president of the BCDG and a consultant
Association of Cosmetic Nurses (BACN) and also the UK lead on
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).
dermatologist with over 30 years of experience who practises
in London and California. Dr Lowe is Clinical Professor of
Dermatology at the UCLA School of Medicine in Los Angeles,
as well as director of a clinical research company specialising
in skin ageing.
maxillofacial surgery trainee with dual qualifications in both
medicine and dentistry, who fell in love with the results
possible through minimally invasive methods. Now based
at Beyond Medispa in Harvey Nichols, she practises cosmetic
injectables and hormonal based therapies.
PUBLISHED BY
EDITORIAL
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suzy@aestheticsjournal.com
Leah Hardy • Editor
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leah@aestheticsjournal.com
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The Word
Legal
This month the Government’s response to the Keogh
review has left many stakeholders shocked by the lack of
implementation of the majority of its recommendations.
Without decisive action from our regulatory authorities, it
is more important than ever that surgeons and clinicians
share knowledge and expertise in order to benefit
patients, and that we work together to eradicate the
‘cowboy’ practitioners, who prey on vulnerable people.
A key component of Keogh’s recommendations was the
call to publish outcome data across all providers. The
Government appears to have ignored this proposal,
missing a vital opportunity to establish greater clarity in
the cosmetic sector and, as a consequence, increasing
the risks to patients. It is now crucial that we collectively
address the data vacuum to ensure that treatments on
offer are evidence-based, and that all centres produce
freely-available safety results.
We know of the risks, as well as the benefits, of aesthetic
treatment and as professionals we invariably agree that
these treatments are not appropriate for every would-be
patient. However, in a culture where ‘enhanced’ beauty
is increasingly popular (the BAAPS 2013 annual audit
showed record numbers of patients going under the
knife), our shared goal must be to educate the public
about the dangers of an unregulated sector, where
cheap, unproven and often unsafe aesthetic treatment is
sold ‘off the shelf,’ like toothpaste or nail varnish. BAAPS
has long been calling for an injection of common sense to
remodel the sector, and our collective efforts must ensure
that patient care always comes before profit.
Mr Paul Harris
Consultant plastic surgeon and council member of
the British Association of Aesthetic Plastic Surgeons
RCN indemnity scheme no
longer covers aesthetic practice
Changes to the Royal College of Nursing
(RCN) indemnity scheme means that
aesthetic nurses will no longer be
covered. At present the RCN indemnity
scheme is a contractual arrangement
providing members with cover for clinical
negligence claims.
Commencing July 1, 2014, all employed
RCN members will be excluded from
the scheme’s coverage in a bid to stop
employers moving the burden of risk onto
the RCN.
Most self-employed members will still be covered by the scheme, apart
from those working in the field of aesthetic medicine. Christopher Cox,
director of legal service at the RCN, claimed that the RCN has spent in
excess of £1,500,000 on aesthetic claims since 2004. “In the light of the
claims history involving aesthetic practitioners, the RCN will in future no
longer be able to provide indemnity cover for our members practising in
this area,” he said. “This will affect both self-employed members and those
working under a contract of employment. Members practising in aesthetics
remain protected by the full range of other legal advice and support
services available to RCN members, including workplace difficulties, NMC
referrals, personal injury accidents and so on. “
The BACN responded, stating, “Those 78% of members (BACN) who are
also RCN members will have been shocked to hear the news that the
RCN, from July, will exclude aesthetic nursing from their insurance cover.
Whilst we have no expectation that the RCN will change its stance, we
will be asking for further information on why and how they reached this
momentous decision, which we feel sends out a very negative message
without the necessary detail to qualify it.”
Training
Talk Aesthetics
#Keogh
Tchauhanconsultancy / @tchauhan01
@aestheticsgroup this is a wasted opportunity
patient safety clearly not important for gov
#advertising
ReVamp / @ReVampClinics
@aestheticsgroup great piece on POM and
advertising... first rule of Botox club...you can’t
say Botox #Simple
#ACE
Dr Johanna Ward / @DrJohannaWard
I am presenting a masterclass at @
aestheticsgroup conference on 8 March for
anyone interested in the science & art of @
CoolSculptingUK #ACE
If you would like to be featured in
next month’s letter section, email us at
editorial@aestheticsjornal.com, or follow
us at Twitter @aestheticsgroup and include
#talkaesthetics in your comments.
6
Mesotherapy society
launches in UK
The Society of Mesotherapy of the United Kingdom (SOMUK) has been
launched to promote the use of Mesotherapy in the UK. The society
provides access to the latest Mesotherapy tools and information for all
disciplines including: Facial rejuvenation, Lipolysis, Fat Reduction, Cellulite,
MesoSculpting, Mesolift, Mesobotox, Alopecia and Pain Management.
Mesotherapy remains relatively unknown to many aesthetic practitioners in
the UK, though a popular aesthetic treatment in France, South America, and
Europe. The SOMUK is the exclusive member of the International Society of
Mesotherapy (SIM) and works closely with the French Society of Mesotherapy.
SOMUK courses are CPD accredited within the UK.
President Dr Philippe Hamida-Pisal said, “The SOMUK teaches the art,
science, techniques and procedures of Mesotherapy to licensed practitioners,
regardless of their specialty. We provide education and hands-on training
within the UK and across the globe.” New member Dr Mohamed Bocus said,
“I am a GP in the UK and traditionally we are sceptics about the benefits of
alternative medicine. However, with growing interests from patients we need
to learn more about what is available.”
Aesthetics | March 2014
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News in Brief
Technology
Dutch company launch new
cloud-based patient app
Clinicminds has launched a cloudbased app for patient relationship
management. The Dutch
software development company
has launched the Clinicminds
application, which has so far
been taken up by two UK clinics,
to addresses the full clinical
workflow: from appointments to
invoicing and client analytics.
The cloud-based nature of the
app means that all patient data is
stored in a secure and accessible
point. Data can be accessed by
the practitioner from any location,
and from any device with internet
access. The app was created by a
team of software developers and
medical aesthetic physician Toby
Makmel. A clinic owner himself,
Makmel was inspired to create
the the CRM application because
of his desire for a simple and
all-encompassing tool for patient
management.
“At the time, we were looking for an
application covering the full clinical
workflow, that was user friendly
and also affordable for smaller
clinics,” said Makmel.
Tested over the course of a year
by medical aesthetics practitioners,
the cloud-based app has so far
received favourable reviews. Since
the software stores patient details,
including personal information as
well as treatment information, it
is also possible to use the app in
order to compile patient analytics.
This function allows practitioners
to gather data useful for marketing
campaigns that target specific
kinds of patients, in specific
postcodes.
One Dutch client said, “The
Clinicminds app allowed us to
organize our day-to-day work much
more efficiently allowing us more
quality time with our patients.”
Accreditation
PaPPS Accreditation
launched to improve psychoemotional support
The Wright Initiative is launching a new Pre and
post Procedure Support Accreditation body. The
Wright initiative, which works with practitioners to
ensure patients are prepared, mentally and physically,
for their treatments, has established the PaPPS
Accreditation due to the rise in demand for psychoemotional support in conjunction with surgical and
non-surgical treatments. The PaPPS Accreditation
follows the PaPPS Initiative, which was shortlisted for Industry Body of the
Year at the Aesthetics Awards in December.
The requirements to become PaPPS accredited include holding one or
more of the following registrations: NMC, GMC/Specialist register, BACN,
BAAPS or BAPRAS. Founder Mr Norman Wright said,”The benefits of
being PaPPS Accredited for clinicians involves dedicated PaPPS training
and access to the PaPPS support line six days a week.”
The PaPPS Accreditation will go live on Tuesday 2 April 2014.
Medical Aesthetic Group appoints new
members
Medical Aesthetic Group (MAG) has appointed
Simon Bell as special product consultant for
hyaluronic acid dermal filler Stylage. His role will
include consolidating and increasing sales in the
UK, and supporting doctors and clinics that offer the
treatment. “HA fillers are perfect tools for the job, but
Stylage has the added benefit of shortened recovery
time and increased duration of results, which makes
it a unique and attractive proposition for doctors,”
Bell said. Laurinder Young has been appointed as
sales coordinator across all MAG brands, and Pauline
Hume will be running training and sales support for
topical products including Inno Aesthetics, Mene and
Moy and Simildiet.
Venus Concept launch Venus Viva
Venus Concept have launched new facial treatment
scanner VenusViva, which uses nano fractional
smart scan technology to even skin texture, tighten
skin, smooth deep lines and wrinkles and reduce
appearance of scars. It includes two hand pieces, the
Firm FX fractional radio frequency handpiece, and the
Firm (MP)2 magnetic pulse hand piece. It has a short
downtime of only three to four days, and does not
require topical anaesthesia.
Dr Harold Lancer publishes rejuvenation book
Renowned Beverly Hills dermatologist Dr Harold
Lancer has written a book detailing his 3-step method
on rejuvenating skin at home to maintain youthful
skin and reverse the ageing process. Younger: The
Breakthrough Anti-Aging Method for Radiant Skin
details Dr Lancer’s regimen, which involves skin care
products and lifestyle choices such as diet, exercise,
and stress management, to stimulate the skin’s own
healing power. His book is due to be released on
March 27.
Chromogenex launches
i-Lipo Touch
Chromogenex has
launched new low level
laser diode device i-Lipo
Touch for non-invasive fat
reduction. The system uses
photobiomodulation to stimulate
the body’s natural response to
fat-burning, targeting areas of
excess fat. The lasers trigger a chemical signal in
the fat cells, which breaks down stored triglycerides
into free fatty acids and glycerol to then be released
through channels in the cell membranes. It can be
performed on all skin types and body areas with
unwanted fat, and the manufacturers claim it can
remove four to five inches off the waistline after a
course of treatments.
Aesthetics | March 2014
7
Insider
News
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Laser
New Duetto MT hair removal device uses Mixed
Technology to treat dark skin and fine hair
A new innovation in laser
technology addresses the
issue of Fitzpatrick skin type
IV with thin hairs, such as
those on the face. Long pulsed
Nd:YAG (1064 nm) laser and
Alexandrite (755 nm) laser is
a versatile combination used
for gold standard hair removal
results. These wavelengths
are optimal for hair removal in
low and high Fitzpatrick skin
types respectively. However,
the 755nm wavelength may
be too aggressive for some of
these skins and the 1064nm just
too gentle for the low melanin
content in the hairs.
MT or Mixed Technology,
found within the Duetto MT
from Lynton Lasers, allows a
practitioner to simultaneously
deliver a mixture of both Alex
(755 nm) and Nd:YAG (1064 nm)
in varying proportions. Dr Sam
Hills, the Clinical and Training
Manager at Lynton says, “Mixing
the efficacy of the Alex with the
safety of the YAG in this format
means these hairs can now
be successfully treated. Mixed
Technology also has other
Industry
benefits such as increased
safety when treating tanned
skin and reduced discomfort v’s
Nd:YAG alone. The high power
and the large spot sizes allow
fast treatment at deep skin
layers, at fluences sufficient to
completely damage the hair
follicles in all body areas. The
Duetto MT is the only laser in
the world with this technological
innovation, offering increased
clinical efficacy. The Duetto
can also emit the two
wavelengths independently,
simultaneously or sequentially.
This characteristic is particularly
important when treating
previously sun-exposed skin
or skin types higher than
Fitzpatrick Skin Type 4. In these
cases, the suggested protocol
combines a small amount of
Alexandrite energy (always less
than 12 J/cm2) with a low dose
of Nd:YAG laser energy (always
less than 25 J/cm2). Using this
mixed modality results in more
effective, safer and less painful
treatments when compared to
treatments performed with the
Nd:YAG 1064 nm laser alone.”
Appointment
Cosmeceuticals and
SkinBrands announce
business merge
Dr Red Alinsod joins
ThermiAesthetics
advisory board
and along with new training
programmes for businesses.
David Beesley, managing
director at SkinBrands, said,
“With the merger, we now have
Companies Cosmeceuticals
over a dozen brands to create
Ltd. and SkinBrands have
the benefits of a one-stop shop
announced they will be
service. Practitioners will be
merging to provide the
able to cherry-pick the best
professional market with a
range of skincare brands and products to meet the needs
treatments. The new company, of their patients, and it will
provide a more harmonious
which will be known as
and easily workable business
SkinBrands @ Cosmeceuticals
will have eight full-time business relationship between us and
our customers.”
development managers
ThermiAesthetics, creator of the ThermiRF temperature
controlled radiofrequency system, has announced the
appointment of Dr. Red Alinsod, MD, FACOG, FACS as
Chairman of its Women’s Health Advisory Clinical Board.
He will help develop strategies and devices to treat specific
gynecological conditions.
“We are privileged to have a world renowned urogynecologist,
with an outstanding clinical experience in treating women
for vaginal laxity, as chairman of our Women’s Healthcare
Advisory Board,” said Paul Herchman, Chief Executive Officer of
ThermiAesthetics. “
Dr. Alinsod founded “CAVS” (Congress for Aesthetic
Vulvovaginal Surgery) in 2005 and is considered one of the
pioneers of this evolving field.
Practitioners & their patients feel the difference...
“The favourable safety profile has lead to high patient satisfaction and
subsequent recommendations from one patient to another,
increasing our practice1”
n
Not palpable2
®
No Tyndall Effect1
®
Comfortable on injection2
®
BEL065/0813/LD
Date of Preparation:
December 2013
1. Kuhne, U et al. Five-year retrospective review of safety, injected volumes, and longevity of the hyaluronic acid Belotero Basic for facial treatments in 317 patients. J Drugs
Dermatol. 2012 Sep; 11(9):1032-5 2. Data on File: BEL-DOF2_001 Belotero Juvederm Study MRZ 90028_4007
Injectable Product
of the Year 2013
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Email: customerservices@merz.com
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Vital Statistics
Topical
Study shows Galderma’s
Mirvaso gel safe and effective
Galderma Laboratories, LP, has announced the publication of the
long-term efficacy and safety results of a one-year, open-label, noncomparative study of Mirvaso (brimonidine) Topical Gel, 0.33% in patients
with moderate to severe facial erythema (redness) of rosacea.
Mirvaso was approved by the U.S. Food and Drug Administration in
August 2013 as the first and only topical treatment indicated for the
persistent facial erythema of rosacea in adults 18 years of age or older.
The results of this study, in which 276 subjects applied Mirvaso for at
least one year, demonstrate that Mirvaso is safe and effective when used
once daily for up to 12 months. The study results were published in the
January issue of Journal of Drugs in Dermatology.
“The positive results of this long-term study provide additional evidence
of the efficacy and safety of Mirvaso for patients with the persistent facial
redness of rosacea,” said Humberto Antunes, president and CEO at
Galderma Laboratories. “Since we launched Mirvaso commercially in the
United States in September 2013, we have seen widespread adoption by
dermatologists, underscoring the important need for an effective topical
prescription treatment for this most common symptom of rosacea.”
Mirvaso is a topical gel which works by constricting the dilated facial
blood vessels to reduce the redness of rosacea. Mirvaso should be
applied in a pea-sized amount, once daily to each of the five regions of
the face: the forehead, chin, nose and each cheek. The study indicates
Mirvaso works quickly to reduce the redness of rosacea from day one of
treatment and lasts up to 12 hours before the redness returns.
Consistent results were observed throughout the 12 month study. In
addition, no evidence of tachyphylaxis (a sudden decrease in response
after drug administration compared to prior usage) was reported. With
regard to safety, no new major safety findings were observed in this
study as compared to the vehicle-controlled pivotal studies. The most
common adverse events (≥4% of subjects) were flushing (10%), erythema
(8%), worsening of rosacea (5%), nasopharyngitis (5%), skin burning
sensation (4%), increased intraocular pressure (4%) and headache (4%).
Subjects were allowed to use other rosacea therapies (oral and topical)
in addition to Mirvaso. Mirvaso is due to launch in the UK in April. It will
be a prescription-only medicine.
From the age of
1%
20
we lose
of collagen
every year
Murad UK
Last year saw a
41%
rise in liposuction
procedures
British Association of Aesthetic Plastic Surgeons
This year
4,500 IMCAS
conference
in Paris
travelling from
participants
attended the
80
International Master Course on Aging Skin
The average person loses
50 to 100 hairs per day
American Academy of Dermatology
of South Korean women
have undergone
plastic surgery
to alter their faces
An estimated
20%
International Society of Aesthetic Plastic Surgeons
reduction in hair growth can be expected with
each treatment of laser hair removal
ACE
1532 aesthetic practitioners
have registered for ACE 2014
At time of printing, 1532 aesthetic
practitioners have registered for the
Aesthetics Conference and Exhibition
2014, more than twice as many
attending CN EXPO last year. 18% of
registrants are clinic managers and
directors, 17% are dentists, 15% are
aesthetic nurses and 15% are cosmetic
doctors. Also registered are GPs, surgeons, dermatologists, aestheticians,
laser therapists and other aesthetic professionals. Join practitioners from
across the country at ACE 2014 on Saturday 8 and Sunday 9 March at the
Business Design Centre in London. www.ace2014.co.uk
Aesthetics | March 2014
American Academy of Dermatology
19%
would use
their partner’s
of men
Fa c e
C rea m
Smart Beauty Guide
y Contour
Bod
in g proceduces
for gynaec
o mastia rose
24%
in
2013
British Association of Aesthetic Plastic Surgeons
9
Insider
News
aestheticsjournal.com
Events diary
Research
EternoGen unveils the
potential of advanced collagen
replenishment portfolio
8th - 9th March 2014
Aesthetics Conference and Exhibition ACE 2014, London
www.ace2014.co.uk
3rd - 5th April 2014
Anti-Ageing Medicine World Congress AMWC 2014, Monaco
www.euromedicom.com/amwc-2014
20th September 2014
British College of Aesthetic Medicine
BCAM Conference 2014, RIBA,
66 Portland Place, London
www.bcam.ac.uk
25th - 26th September 2014
The British Association of Aesthetic Plastic
Surgeons - BAAPS Meeting 2014, London
www.baaps.meetings.org.uk
3rd October 2014
British Association of Cosmetic Nurses BACN Meeting 2014, London
www.cosmeticnurses.org
At the IMCAS conference in Paris, EternoGen LLC presented its latest
research on its Advanced Collagen Replenishment therapy portfolio for
cosmetic use in regenerative dermatology. EternoGen has developed a new
type of collagen dermal filler which it claims has overcome issues with previous
collagen formulations, such as allergic reactions and short duration of effect.
The innovative EternoGen portfolio comprises Rapid Polymerizing Collagen
(RPC) and Gold Nanoparticle Collagen (CG Nanomatrix).
The products have been formulated with integral shielding protection from
collagenase degradation. Additionally, they are designed to provide high
biocompatibility facilitating natural integration with the skin at a cellular level.
EternoGen says the research presented at IMCAS, “Demonstrates the ability
of EternoGen advanced collagen replenishment to overcome the limitations of
earlier generations of collagen.”
EternoGen plans to launch its Rapid Polymerizing Collagen (RPC) portfolio
in late 2014. Christopher Inglefield, leading UK plastic surgeon, said, “The
absence of collagen from the physician’s armamentarium has been felt
keenly in recent years. RPC is particularly suited for delicate and challenging
treatments in the peri-orbital and peri-oral areas where the risk for lumps and
product migration needs to be minimized. A clinical study in the naso-labial
folds using RPC is underway and the experience to date is very encouraging.”
Surgical
Training
BAAPS reveal increase in
operations on men
ACE 2014 additions
With ACE fast approaching we are delighted to welcome
the following exhibitors: Medira, Silhouette Soft, 3D Medic,
Statistics from the British Association of Aesthetic Plastic Surgeons (BAAPS) Sedation Solutions, ThermaVein, 5 Squirrels, BioCorrex,
Pay4Later, Society of Mesotherapy UK, Hydropeptide and
have revealed that the number of cosmetic operations in 2013 increased
Lamprobe. Also, joining Dr Tapan Patel and Dr Raj Acquilla at our
by 17% since 2012. Figures show that men account for one in 10 aesthetic
Free Exhibition Clinical Programme will be Dr Maria Gonzalez,
plastic surgery procedures. Body contouring procedures showed the
Dr Sach Mohan, Dr Leah Totton, Dr Sarah Tonks, Dr Sotirios
biggest increase amongst men, with an increase of 28% for liposuction,
and gynaecomastia surgery up by 24%. Former BAAPS president Mr Fazel Foutsizoglou, Mr Adrian Richards, Dr John Ashworth, Mr Simon
Fatah said, “Men are becoming more body-image conscious due to men’s Ravichandran, Dr Martyn King, Dr Gabriela Mercik, Dr Britta
Knoll, Dr Johanna Ward and Lorna Bowes. For details of our full
magazines and the media. Gynaecomastia can occur for no pathological
reason, and is a feature in a young person that can affect their confidence.” programme and to book your visit go to www.ace2014.co.uk.
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Other Areas of the Face. Dermatol Surg 2007; 33 (Supp 2): s112-s127. 2. DoF-1-001_01
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Insider
On the scene
aestheticsjournal.com
Venus Freeze Business Development seminar, London
The Venus Freeze Business
Development seminar took
place on February 10 at the
Millennium Hotel Knightsbridge, with the aim of helping
attendees promote their
businesses and increase sales
utilising the Venus Freeze.
Clinical and practice
enhancement manager Tracey
Mancuso led the seminar
alongside guest speaker and
international clinical specialist,
Anna Olsen. The seminar was
attended by clinic, salon and
spa owners.
The seminar included short
demonstrations using the
Venus Concept machines, as
well as Mancuso and Olsen
talking on ensuring financial
success. Venus Freeze delivers
treatments for the face and
body using magnetic pulses
and radio frequency, including
cellulite improvement, body
contouring, skin tightening and
wrinkle reduction, as well as
the patented ‘Venus Freeze
Facial’.
Michael Dodd, managing
director of Venus Concept UK,
said, “I was extremely pleased
with the turn out for the Venus
Business seminar. Tracey
Mancuso provided excellent
resources, and up-to-date
examples to reinforce tips
and concepts on the Venus
Freeze. The seminar definitely
met my expectations and from
the general feedback from
our clients it was extremely
practical and insightful, with
clinical key points.
“I was especially delighted
with the comments on the new
Venus Viva and Venus Legacy
from those who attended. My
team and I look forward to
hosting the next Venus event,”
he said.
3d-lipolite launch, London
The launch of the 3d-lipolite program took place on Jan 27 at the
Royal Society of Medicine. The programme – a combination of diet,
exercise, motivation and support along with non-surgical treatment
– was discussed in length by a panel consisting of Roydon Cowley,
Josh Yardley and Dr Martyn King and Sharon King. Dr Martyn King
and Sharon King were responsible for developing the weight
loss and body-contouring programme. “We have developed
this programme exactly how we would want it in our clinic,”
said Dr Martyn King. “With this approach, patients get the same
service wherever they go, with the same level of professionalism.
Everyone is individual, but as long as this is the core principal
then all patients will have a successful programme.” The stages
of the programme include a detox phase, which lasts for two
weeks, and an active phase, which lasts as long as is required for
the patient. The final stage is a maintenance phase, in which the
patient remains on a controlled diet. The programme administers
sessions of cryolipolysis and fat cavitation, as well as sessions of
radiofrequency and vacuum rolling where required.
Dr Johanna Ward, one of the doctors who attended the launch in
order to find out more about the programme, said “I like the idea
of combining clinician-led guidance with technology. I think it’s
exciting that this can be rolled out at a national level with exacting
results. We’re thinking of taking it on at our clinic.”
Regency Aesthetics
Launch, London
The launch of new nonsurgical cosmetic clinic
Regency Aesthetics took
place on January 23 on Upper
Wimpole Street. The event saw
50 clinicians, industry leaders
and celebrities attend, and
included a champagne and
canapés reception, tour of the
clinic, and free skin consultation
and analysis. The new clinic,
run by medical director and
facial aesthetics practitioner
Dr Rikin Parekh, contains two
large treatment rooms and a
smaller consultation room, and
offers treatments including
anti-wrinkle injectables, dermal
fillers, and skin rejuvenation
treatments such as skin peels,
micro-needling, PRP Therapy,
mesotherapy hydration
Aesthetics | March 2014
treatments and medical
skincare. It also offers machine
treatments, including Ultrapulse
CO2 laser skin resurfacing, M22
IPL and Nd:YAG laser platforms
for treating acne, pigmentation,
rosacea, vascular lesions and
veins, and the Fractora platform
for skin resurfacing, tightening
and non-surgical fat reduction.
Additionally, their treatment
package includes their own
bespoke No-Knife Facelift,
and the TiteFX fat reduction
treatment for the body.
Alongside Dr Parekh, the team
contains four specialist medical
professionals. Treatment
protocol includes consultation,
specialist photography and
computerised skin analysis for
every patient.
11
Insider
On the scene
aestheticsjournal.com
I-Lipo Ultra launch, Inverness
The launch of laser lipolysis system I-Lipo Ultra from
Chromogenex at the SHRINKme clinic marked the
first I-Lipo system available to patients in Scotland.
The event took place at the Thistle Hotel in Inverness
on January 16, where UK and European Chromogenex
product specialist Jo Briggs demonstrated how the
treatment works. Clinic owner Iona Urquhart said, “We
have been seeing consistently good results, with many
of my clients losing in excess of 10 inches before the
eight sessions are finished.” I-Lipo can treat calves,
knees, thighs, buttocks, stomach, arms and chin, and
targets excess fat without damaging fat cells using
low-level laser. “I-Lipo Ultra is supported at the clinic
by gentle lymphatic stimulation using the Reviber
plate, which accelerates fat out of the body,” Urquhart
said. “Using this programme, the client can complete
the whole treatment in the clinic, without the need to
go home and exercise.” The I-Lipo course includes
eight 30-45 minute treatments, taken twice a week at
regular intervals. “Watching people shrink substantially
in a few short weeks and seeing their self-esteem and
confidence grow is hugely rewarding,” Urquhart said.
Inaugural Meeting of the Allergan Medical
Institute, Amsterdam Advanced Technical
Training: Excellence in Aesthetic Care By Dr Mervyn Patterson
On January 24-26, Allergan invited leading aesthetic doctors from
all over Europe to share and discuss advanced aesthetic injection
techniques. The meeting is part of a major new initiative by Allergan
to help improve the delivery of injectables to patients by providing
advanced technical training and encouraging a consensus in best
practice techniques. The meeting was lead by an international faculty
of experts who shared their extensive experience using botulinum
toxin and hyaluronic acid fillers. Multiple small group sessions with high
quality video technology allowed for a clear, precise demonstration
of injection techniques, and the informal atmosphere facilitated a
high level of discussion. “There is a clear need for improvement in
the delivery of injectable treatments and Allergan are really raising
standards by getting together all the leading doctors to improve quality
of training,” said Dr David Eccleston, a cosmetic physician from the UK.
“This training, by way of detailed cadaveric dissection, reinforces the
importance of understanding anatomy to ensure safe treatments.”
Midface augmentation techniques were demonstrated to show an
indirect improvement in the infraorbital area, a good choice for less
experienced clinicians looking to improve this popular area. Chin
augmentation was an additional focus, with treatments designed to
project the chin forward and improve the jaw line. Delegates also
received advice on how to use fillers in the chin and mental crease
area to support the lower lip. Dr Gregor Wahl, a dermatologist
from Germany was tasked with leading the presentation on the
management of the infraorbital area. “Treating the tear trough with
hyaluronic acid fillers can be at times challenging,” he said. “The
meeting allowed a discussion of the possibilities and limitations.”
Dr Raina Zarb Adami, a plastic surgeon specialising in non-surgical
treatments from London, commented on a demonstration by Dr Boris
Sommer, a consultant dermatologist from Germany. “I was impressed
with the technique demonstrated by Dr Sommer for volumisation of
the lip. This is a different approach with small boluses of filler being
placed in the body of the lip to give volume and support, something
I will definitely be introducing into my daily practice.” Revitalisation
techniques for the hand were discussed in a separate session
led by Dr Hervé Raspaldo, an aesthetic surgeon from France. He
demonstrated the use of a cannula for delivery of a very even layer of
filler just under the skin to significantly improve the look of the ageing
12
hand. Dr Raspaldo, and indeed all of the faculty members, reinforced
the need for strict adherence to a sterile technique whilst injecting.
The use of hyaluronic acid fillers in the forehead and temple region
is currently of considerable interest and much discussion was given
in the meeting to the placement of filler under the eyebrow to give
support and lift. Dr Mauricio de Maio, a plastic surgeon from Brazil,
skillfully managed the treatment of complex and difficult cases. With
clear treatment goals set out, his staged treatments displayed the
lifting potential of correctly placed facial filler. Importantly, he gave
expert advice on how to prioritise treatment steps to gain maximal
improvement within the patient’s budget.The new training format
of the Allergan Medical Institute proved to be a success amongst
delegates. Dr Tapan Patel, a specialist in facial aesthetics based in
the UK, said, “Yet again Allergan raises the standard of training above
and beyond what we have had before.” Mr Kambiz Golchin, a plastic
surgeon from Ireland, added, “I have great respect for the emphasis
placed by Allergan on training and increasing the safety profile of
procedures.” Dr John Quinn, a specialist in aesthetic medicine from the
UK said, “The conference really reinforced the concept of overall facial
volumisation for rejuvenation, and thus treating the patient holistically.”
A spokesperson for Allergan explained that one of the company’s
main objectives is to improve patient outcomes by teaching others
to be better injectors. He said, “The Allergan Medical Institute was
developed to promote excellence in practice and this conference is
just one of the steps on the road to achieving our objective.”
Dr Mervyn Patterson has no financial disclosures in the area of
dermal fillers.
Aesthetics | March 2014
The Award Winning Laser
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ACE
Special Focus
aestheticsjournal.com
The Aesthetics Conference
and Exhibition 2014
1532 registrants
100 exhibitors
57 speakers
59 CPD points
to choose from
40 lectures and
masterclasses
26 clinical
demonstrations
13 business
workshops
2 days
1 event
Book Now
Over 1532 have already registered
for their place at ACE 2014.
To book your FREE place today call
01268 754 897 or visit
www.ace2014.co.uk
After months of preparation, the
Aesthetics Conference and Exhibition
2014 is set to be the largest medical
aesthetics event in the UK this year.
Comprising a huge programme of exhibitors, workshops, masterclasses and
lectures, ACE provides visitors with the unique opportunity to get up-to-date
on the latest product, service and technique innovations and hear from worldrenowned experts on the topics most relevant to the medical aesthetic industry
today.
Dr Mike Comins, head of the ACE steering committee, said, “I look forward to
the wide selection of CPD accredited education available at the conference.
The masterclasses, lectures, live
demonstrations and workshops are
vital learning tools for practitioners,
which will allow them to progress in
their careers and expand their skills
and knowledge base.”
ACE programme coordinator
Amanda Cameron said, “We have
tried to put together an educational
and interesting programme so
that the audience will not only be
entertained but they will leave
equipped with new skills to enhance their businesses. The mix of clinical,
business and practical sessions is unique and this will create an event that is not
to miss.”
“ACE is a huge compendium of learning and development,” said BACN vicechair Sharon Bennett. “I’m really looking forward to the expert clinics with
demonstrations and intelligent, innovative presentations from an impressive line
up of experts.
“ACE has understood and captured
the essence of a rapidly evolving
specialty and set a new level for
aesthetic excellence and learning,”
she said.
Cosmetic dermatologist Dr Raj
Acquilla, who is demonstrating at
the conference, said, “This will be
my third year presenting at ACE,
which is a great opportunity for
aesthetic practitioners of all levels to come together to learn and share the latest
knowledge and techniques in our exciting and rapidly advancing specialty. This
year I will be sharing injection strategies from my teaching experience around
the world.”
Aesthetics | March 2014
53
The
Award
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Laser
The
TheAward
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WinningLaser
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Clinical study data available on request
Clinical Practice
Special Focus
aestheticsjournal.com
Dr Sarah Tonks discusses what you need to know when selecting
a PRP method for your practice
Investigating Platelet Rich Plasma
The use of Platelet Rich Plasma (PRP) in aesthetics
is relatively recent but has gained considerable
publicity due to its adoption by celebrities such as
Kim Kardashian and Bar Refaeli, who were both
depicted with their faces smeared with whole
blood rather than PRP, resulting in a dramatic effect.
However, PRP has been used clinically in humans
since the 1970s in opthalmic surgery, orthopaedics
and sports medicine.
Much of the interest around PRP has come from
the idea that this is an autologous substance and
therefore considered to be ‘safer’ than traditional
dermal fillers and botulinum toxins. WhatClinic.
com reported an increase in enquiries regarding
the procedure of 807% over the previous year in
2013. Although PRP is now offered by many clinics
and there are numerous systems on the market,
some uncertainty remains over its efficacy and
proposed mode of action. Some have expressed
doubts as to whether this truly represents evidencebased medicine due to the lack of robust clinical
trials and outcomes. Indeed a recent Cochrane
review in 2012 stated that at the moment there was
insufficient evidence to support the use of PRP.1
However, at a microscopic level in a study of PRP
treated fibroblasts, the PRP treated groups showed
more proliferation and differentiation of fibroblasts
into myofibroblasts which are essential for wound
healing and increased contraction of the wound
during healing time.2 PRP stimulates endothelial
cells near their application site and favours the
proliferation and formation of new capilliaries.3
Doctors report a high satisfaction and return rate
from patients.
What is PRP?
Generation of PRP involves centrifugation of
autologous blood to separate the plasma and buffy
coat portion of the blood, which contains high levels
of platelets. Most people have a baseline blood
platelet count of 200,000 (+/- 75,000) and although
Before
After
the ideal concentration of PRP is at the moment unclear, most PRP systems
produce a substance containing concentrations of growth factors that are threefive times that in normal plasma. A count of 1,000,000/μL or 338% more than the
normal total blood platelet count has been proposed as being the ideal4. Studies
have shown that PRP with a low platelet concentration does not work and too
high concentrations have an inhibitory effect on cell growth. The concentration of
PRP for bone regeneration was found to be best around 1,000,000/ μL.5
A separate study found that higher leukocyte content increases inflammation and
reduces tissue regeneration so it is important to exclude as many of these cells
as possible from the PRP.6 Platelet Poor Plasma (PPP) is blood plasma with a very
low number of platelets, usually <10,000. This can be found in the top fraction of
the centrifuged blood. PPP is still a useful fraction of blood: it has been shown
that both PRP and PPP, when activated with calcium and thrombin, can induce
proliferation of dermal fibroblasts.7
The Growth Factors
PRP contains high concentrations of growth factors and more than 800 different
proteins and it appears that the growth factors work together synergistically.8
Growth factor secretion begins 10 minutes after clotting with more than 95%
of pre-synthesised growth factors secreted within an hour, however platelets
continue to synthesise growth factors for at least seven days.9 Ideally the PRP
must be used on the application site 10 minutes after activation to harness the
growth factors. After the death of the platelet, the macrophage takes over wound
healing by secreting some of the same growth factors.4
PRGF and TGF- ß1
IMPORTANT COMPONENTS OF PRP
• Three isomers of platelet derived growth factors PDGF PDGF-α α, PDGF- α β and PDGF- β β
• Vascular endothelial growth factor VEGF
• Two of the transforming growth factors TGF- β1, TGF- β2
• Epithelial growth factor EGF
The major effects of PRP are derived from PRGF and TGF- β1, which are
concentrated in the alpha granule of the platelet and released during platelet
activation. Both PRGF and TGF- β1 stimulate cell proliferation and differentiation
resulting in tissue formation.10
Could it be dangerous?
Although no undesirable effects have been reported, hypotheses exist as to
the over expression of growth factors and their receptors related to tumour
formation and dysplastic tissue. However it is thought that the circumstances
leading to neoplasm growth require more continuous doses of growth factors
over time than those in PRP, which degrade in seven-ten days.11 Nonetheless, the
use of PRP should be avoided in patients with pre-cancerous lesions, in areas of
epithelial dysplasia and those with a history of exposure to carcinogens.12
Types of kits
Several commercially available methods to obtain PRP are currently used in
the clinical setting and there are many kits, centrifuges and vials available. The
centrifugation process should be sterile and suited to platelet separation without
© Regen Lab
Aesthetics | March 2014
19
Clinical Practice
Special Focus
aestheticsjournal.com
lysing or damaging the platelets. Not all systems have been created to produce
sufficiently viable platelet and this has led to criticism regarding the efficacy of
PRP. When anti-coagulated blood is centrifuged, three layers form due to the
differing densities of the blood components; the bottom layer consists of red
blood cells, the middle of platelets and white blood cells, and the top plasma
layer.3 It is important to reduce platelet fragmentation during centrifugation.
Integrity of the membrane can be preserved by the use of acid citrate dextrose
type A anticoagulant and low gravity forces during centrifugation.4 Dr Daniel
Sister, anti-ageing and hormone specialist at BeautyWorksWest and pioneer
of Dracula therapy, speaks on considerations when applying PRP. “The type
of harvesting kit, centrifugation methods and time play a crucial role,” he says.
“Plasma is autologous, so most new systems now come without the gel-like
separation, because plasma is not totally hermetical and filaments of the gel get
mixed with the plasma. All systems must be closed.” “There is also the cost per
ml of active plasma to consider,” he says. “The new systems harvest 20cc in one
kit and are more efficient, have better ration of growth factors and are cheaper
than previous systems.” In the UK the most widely available kits available include
Angel, Regen, Tropocells, BTI Technologies, Dracula and Selphyl.
The Angel system is unique amongst the described systems in that the
outcome is customisable. The haematocrit level can be adjusted to the desired
percentage (usually 2-7% in aesthetics), which will determine the amount of white
blood cells in the PRP. In order to activate the platelets the most commercially
used method is to add thrombin or calcium to the PRP, although it can be used
without activation as in vitro the platelets are activated by contact with collagen.
Addition of calcium replenishes that which was bound by the acid citrate
dextrose type A anticoagulant. Previously, bovine thrombin was used as an
activator which was associated with the risk of life threatening coagulopathies via
immunologic problems and factor V deficiencies; however the adverse reactions
Amount of
blood taken Method of
taking blood
Sterile blood
tubes?
Size of tubes
Amount of PRP
obtained
Concentration of
PRP: normal blood
Centrifuge time
Centrifuge speed
Spinning angle
of centrifuge
After
© Angel system
reported were related to the source and quantity of
the thrombin used.13 The addition of calcium is now
considered to be a safer option.2
How is it used?
The indications for PRP are numerous. There
is evidence for its use to diminish dark circles
around the eyes, hair growth and cutaneous
regeneration.14,15 PRP is most often performed as a
superficial treatment. It can be used intradermally
with a 30g needle, in a linear thread, cross-hatching
or using the fan technique. It can be used like
mesotherapy, in a micro injection or micro papular
technique with a 32g needle. Additionally, it is being
used supraperiosteally to assist with slowing of
bone remodelling and ageing, although at present
there is no strong evidence base for this.16
PRP is being used in combination with fat to improve
the survival of grafted fat with good results.17
ANGEL
REGEN
SELPHYL
TROPOCELLS
BTI
DRACULA SKIN
REJUVENATION
50ml
8ml
18-36ml
10ml or 30 ml
54ml
20ml
Butterfly needle
and vacutainer
Closed system
Butterfly set for 10ml blood
draw. Needle and syringe
could be used for 30ml
blood draw
Butterfly cannula with
vacutainer vials Needle and
syringe
Yes
Yes
Yes
Yes, endotoxin free
Yes
8ml
10ml
15ml or 50ml
9ml
20ml
4-5ml
9-18 ml
10ml blood draw = 6-2ml
depending on platelet conc
needed. 30ml blood draw =
18-6ml conc platelets
4-8 x baseline platelet
concentration when
diluted with PPP
1.8-2.5-fold
+2.2 (yield 74.1%)
17mins
5mins
6mins
First cycle: 3700rpm
Second cycle: 2700rpm
3200 rpm
First cycle: 3800
rpm Second cycle
(optional): 1800 rpm
Needle and syringe.
Has a specific kit with
ACDA anticoagulant
No tubes. Uses dedicated
sterile hospital quality set
N/A
6-10mls
N/A
45°
Activation
substance
None - self activating
when injected with
small lumen needle
Number of
treatments
3 treatments, 4-6
weeks apart and then
every 6-18 months
3 treatments every 4
weeks apart and then
every 6 months
Method of
separating PRP
LED cellular
photospectometry
and fractionation
Thixotropic gel
20
Before
Calcium gluconate
(optional)
24ml dependent on
heamocrit
Minimum 6ml
3-5 x above baseline
1-2x volume blood
(depends on fraction
being used)
3.44 x initial
concentration
10mins
8mins
8mins
580g
1800
1500 RCF (or g)
Only one cycle
90⁰
90° preferred or 45°
n/a under patent 30°
Calcium Chloride
None, activation in situ
Calcium chloride Calcium
gluconate
optional
3 treatments
every 6 weeks
3 treatments every 4-6
weeks and then every
6–18 months
3 treatments at 3-4 weeks
apart for 3 months, top up
every 6-12 months Twice a year
Cycloaliphatic polymer
inert gel, 100%
biocompatible
Manually using a plasma
transfer device Mechanical with
sodium citrate
Aesthetics | March 2014
Mechanical filter
duction
Fat Re
lipomed
ing
Skin Tighten
A Powerful Three Dimensional Alternative to Liposuction
Cellulite
No other system offers this advanced combination of
technologies designed to target fat removal, cellulite
and skin tightening without the need to exercise
This NEW advanced device is dedicated
exclusively to the clinical market
COME AND SEE
US AT STAND 79
Why choose 3D-lipomed?
• A complete approach to the problem
• Prescriptive
• Multi-functional
• Inch loss
• Cellulite
• Face and Body skin tightening
• Highly profitable
• No exercise required
• National PR support campaign
• Clinician use only
Cavitation
Complete start up and support
package available from under
£400 per month
advantages of this technology are high treatment efficacy, no pain
Cavitation is a natural phenomenon based on low frequency
ultrasound. The Ultrasound produces a strong wave of pressure
to fat cell membranes. A fat cell membrane cannot withstand this
pressure and therefore disintegrates into a liquid state. The result is
natural, permanent fat loss.
Duo Cryolipolysis (New)
Using the unique combination of electro and cryo therapy 20-40% of
the fat cells in the treated area die in a natural way and dissolve over
the course of several months.
Two areas can now be treated simultaneously.
Radio Frequency Skin Tightening
Focus Fractional RF is the 3rd generation of RF technology. It utilises
three or more pole/electrodes to deliver the RF energy under the
skin. This energy is controlled and limited to the treatment area. Key
as less energy is required, shorter treatment services and variable
depths of penetration.
3D Dermology RF (New)
The new 3D-lipomed incorporates 3D Dermology
RF with the stand alone benefits of automated
vacuum skin rolling and radio frequency.
Before
After
“I am so pleased to be given the opportunity to have the first medical version of the
award winning 3D Lipo machine in my new clinic. This multi-platform technology offers a
powerful non-surgical alternative to lipo suction with the addition of skin tightening and
cellulite reduction modalities. I’m so proud to be able to offer my clients the very latest
result driven technology.”
Dr Leah Totton - Winner of The Apprentice 2013
For further information or a demonstration
call: 01788 550 440
www.3d-lipo.com
www.3d-skintech.com
Clinical Practice
Special Focus
aestheticsjournal.com
Conclusions
Standardisation of PRP preparations is urgently needed to best compare
systems. General opinion is that the majority of clinical studies do not have
the statistical power to give conclusive results. Human trials do not take
into account whether the platelets have been effectively concentrated,
whether the PPP is discarded or not, whether early activation occurred or
whether there were purification problems. Regarding skin rejuvenation,
larger scale studies and randomised controlled trials which would
decisively say which methods are most effective have not yet been
performed. However, clinical experience suggests that in general, PRP, for
skin rejuvenation and other aesthetic indications such as hair loss, can be
a useful and attractive treatment.
REFERENCES
Dr Terry Loong, aesthetic doctor, The Skin Energy Clinic Regen PRP system
Having used other PRP systems, I love the Regenlab system. It has a
red ATS (autologous thrombin serum) which allows thrombin to be
extracted from the blood, mixing it with the liquid PRP, activating the
coagulation cascade, creating a gel-like substance which provides
a matrix when injected, slowly releasing the growth factors. This
provides more controlled and targeted delivery. The gel-like matrix
acts as a natural alternative to filler, perfect for treatment under the
eyes, fine lines and wrinkles, and as skin boosters.
1. Martinez-Zapata M, Marti-Carvajal A, Sola I, et al., ‘Autologous
platelet-rich plasma for treating chronic wounds’ (Review), Cochrane
Libr (2012), (p. 10).
2. Kushida S, Kakudo N, Suzuki K, Kusumoto K., ‘Effects of plateletrich plasma on proliferation and myofibroblastic differentiation in
human dermal fibroblasts’, Ann Plast Surg., 71(2) (2013), pp. 219–24.
3. Eppley BL, Pietrzak WS, Blanton M., ‘Platelet-rich plasma: a review
of biology and applications in plastic surgery’, Plast Reconstr Surg.,
118(6) (2006), 147e–159e.
4. Marx R., ‘Platelet-rich plasma: evidence to support its use’, J Oral
Maxillofac Surg., 62 (2004), pp. 489-96, <http://scholar.google.com/sc
holar?hl=en&btnG=Search&q=intitle:Platelet-rich+plasma:+evidence+t
o+support+its+use.#0> [Accessed February 10, 2014]
5. Weibrich G, Hansen T, Kleis W, Buch R, Hitzler W, ‘Effect of
platelet concentration in platelet-rich plasma on peri-implant bone
regeneration’, Bone, 34(4) (2004), pp. 665–71.
6. McCarrel T, Minas T, Fortier L., ‘Optimization of leukocyte
concentration in platelet-rich plasma for the treatment of
tendinopathy’, J Bone Joint Surg Am, 94(19) (2012) p. 143 (1–8).
7. Kakudo N, Minakata T, Mitsui T, Kushida S, Notodihardjo F,
Kusumoto K., ‘Proliferation-promoting effect of platelet-rich plasma
on human adipose-derived stem cells and human dermal fibroblasts’,
Plast Reconstr Surg., 122(5) (2008), pp. 1352–60.
8. Fortier L, Barker J, Strauss E, Taralyn M, McCarrel D, Cole B., ‘The
Role of Growth Factors in Cartilage Repair’, Clin Orthop Relat Res.,
469(10) (2011), pp. 2706–2715.
9. Senzel L, Gnatenko D, Bahou W., ‘The Platelet Proteome’, Curr
Opin Haematol., 18(6), (2009), pp. 329–333.
10. Marx R, Carlson E, Eichstaedt R, Schimmele S, Strauss J, Georgeff
K., ‘Platelet-rich plasma: Growth factor enhancement for bone grafts’,
Oral Surgery, Oral Med Oral Pathol Oral Radiol Endod., 85 (1998), pp.
638–46.
11. Albanese A, Licata M, Campisi G., ‘Platelet-rich plasma (PRP)
in dental and oral surgery: from the wound healing to bone
regeneration’, Immun Ageing., 10:23 (2013)
12. Martinez-Gonzalez J, Cano-Sanchez J, Gonzalo-Lafuente J,
Campo-Trapero J, Esparza-Gomez G, Seoane J., ‘Do ambulatory-use
Platelet-Rich Plasma (PRP) concentrates present risks?’, Med Oral., 7(5)
(2002), pp. 375–90.
13. Martinez-Zapata M, Marti_Carvajal A, Sola I, et al., ‘Efficacy and
safety of the use of autologous plasma rich in platelets for tissue
regeneration: a systematic review’, Transfusion, 49(1) (2009), pp.
44–56.
14. Amgar G. Gestion, ‘du cerne creux avec les extraits plaquettaires
autologues’, Rev AFME, (2009) (Janvier), pp. 12–13.
15. Trink A, Sorbellini E, Bezzola P, et al., ‘A randomized, doubleblind, placebo- and active-controlled, half-head study to evaluate
the effects of platelet-rich plasma on alopecia areata’, Br J Dermatol.,
169(3) (2013), pp. 690-4.
16. Kutuk N, Bas B, Soylu E, et al., ‘Effect of platelet-rich plasma on
fibrocartilage, cartilage, and bone repair in temporomandibular joint’, J
Oral Maxillofac Surg., 72(2) (2014), pp. 277–84.
17. Jin R, Zhang L, Zhang Y., ‘Does platelet-rich plasma enhance the
survival of grafted fat? An update review’, Int J Clin Exp Med., 6(4)
(2013), pp. 252–258.
Dr Rita Rakus, aesthetic doctor, Dr Rita Rakus Clinic Angel PRP system
The Angel Lift is a highly effective treatment; it is a two-step procedure
that combines PRP with a fractional laser system. Targeting the signs of
ageing inside and out, The Angel Lift reduces fine lines, wrinkles and
blemishes on the skin surface as well as addressing the structure of the
layers beneath to produce visible natural results. With medical grade
credentials, the Angel PRP machine offers optimum performance,
ensuring it delivers the best possible results.”
Dr Sarah Tonks is an aesthetic
doctor and previous maxillofacial
surgery trainee with dual
qualifications in both medicine and
dentistry, who fell in love with the
results possible through minimally
invasive methods. Now based
at Beyond Medispa in Harvey
Nichols, she practises cosmetic injectables and
hormonal based therapies.
Mr Dennis Wolf, surgeon, The Private Clinic
I use the Tropocells kit as it has a few basic components; it is efficient
and reliably provides concentrated PRP (four-five times the usual
amount from 10ml venous blood). The gel plug separates the PRP from
the erythrocyte and granulocyte content, which is thought to have a
catabolic effect by releasing metalloproteinases. The filter sleeve prevents
any contamination. Depending on what areas the patient would like
treated I aspirate 10ml or 20ml venous blood. After centrifugation at
1500g for 10 minutes I can remove some PPP thereby increasing the
concentration of the platelets in the remaining plasma. My protocol
for facial rejuvenation consists of treating the peri-ocular region,
malar region, temple, peri-oral region and nasolabial folds. Peri-ocular
and temple region I treat very superficially. The malar region I treat
superficial and deep. The peri-oral region I treat superficially and the
nasolabial folds deep. For the hands and face I use a 2:1 ratio of fat to PRP.
Dr Adam Thorne, cosmetic dentist, Harley Street Dental Group
- BTI PRP system
We’ve been using PRP techniques at Harley Street Dental Studio for
some time now. We use it for faster wound healing, when placing
implants or to regenerate bone following tooth extraction, around
implants, in bony defects, bone graft placement or after extraction of
cysts. A subfamily of TGF is bone morphogenic protein (BMP), which
has been shown to induce the formation of new bone. When added
to the site with bone substitute particles it allows us to grow bone
more predictably and faster than before.
22
Aesthetics | March 2014
COME AND SEE
US AT STAND 79
A New Dimension in Non-Surgical Technology
A revolution in the non-surgical aesthetic skincare market...
Rotational Diamond Peel Microdermabrasion
is set to create a revolution in the
non-surgical Aesthetic skincare market. Following the success of
the award winning 3D-lipo which combines technologies for the
effective treatment of fat, cellulite and skin-tightening we are set
to launch a phenomenal new multi-functional device for the face.
Here are just some of the reasons why 3D-skintech will become
the brand of choice in 2013
• Complete treatment portfolio for anti-ageing,
pigmentation and acne
• 4 technologies ensure a prescriptive & total
approach to your clients needs
• Used in conjunction with medical peel and
cosmeceutical skin care line
• Unsurpassed results ensures maximum
client loyalty
• Highly profitable with a multitude
of services to offer
• Provides you with a competitive
edge in your area
• Free product starter pack
• Affordable finance packages
available
IT’S ALL YOU WILL EVER NEED…
For more information or a demonstration
Please call 01788 550 440
Utilising the latest technology available you can work in conjunction
with topical skincare to ensure that hydration and comfort are not
compromised whilst delivering excellent peeling results.
Radio Frequency
Tri-polar Radio Frequency is the most advanced technology
available for skin-tightening ensuring excellent results without the
discomfort associated with mono or bi – polar devices.
Mesotherapy
Non-invasive mesotherapy ensures that the active ingredients are
delivered where they are needed most without the need for needles.
LED
Full canopy LED ensures both rapid treatment time and excellent
results are achieved. Available wavelengths Red (640nm - 700nm),
Blue (425nm - 470nm), Yellow (590nm) and Green (520 - 564nm)
ensures effective treatment for anti-ageing, pigmentation, acne and
detoxification.
3D-skintech peels and clinical skincare
A compact range of medical grade peels and cosmeceutical skincare
products complete the Skintech’s unique offering and enables you
to both use as a “stand-alone” service or combine with equipment
protocols.
‘To compliment our core injectable business the 3D-skintech has added an array of
new result driven facial services to our clinic’s menu as well as the combination services
for our more curative patients. We recognized that this device offered the stand alone
quality of each technology in a unique machine that will ensure that we both deliver the
results but equally can make money from the start due its affordability. As a clinician
too many times in the past we have invested huge sums of money in a single concept
that has proven difficult to profit from. In my opinion this type of system represents the
future in our industry.’ Dr Martyn King – GP and Clinical director Cosmedic Skin Clinic
www.3d-skintech.com
www.3d-lipo.com
Clinical Practice
CPD Clinical Article
one point
aestheticsjournal.com
The External
Skin Barrier
Dr Mervyn Patterson discusses the structure, physiological
function and mechanisms for repair of the external skin barrier
The external skin barrier, the outermost layer of the skin, is comprised of flattened cells separated by thin layers of lipids. The integrity
of this barrier is critical to the health of the underlying skin. All skincare professionals who wish to deliver optimal skin health to their clients
need to be aware of the importance of the external skin barrier and how to maximise barrier repair mechanisms.
KEY COMPONENTS OF THE EXTERNAL SKIN BARRIER
The permeability barrier resides in the stratum corneum and consists of two components; the structural, cellular part and the lipid layer that
lies between these cells. A simple analogy is that of slates on a roof kept together and apart by a thin layer of glue, or in this case, lipid. The
slates are made of proteinaceous corneocytes filled with keratin. The glue between the slates is made of multiple layers and is predominantly
made of three lipids: cholesterol, ceramides and free fatty acids. A point of note is that half of the free fatty acid component must be linoleic
acid, an essential acid that cannot be synthesised by the body and must be ingested as an omega-6 fatty acid. When the three key lipids
exist in a specific equimolar relationship the barrier is at its optimum. Further research(1, 2) has demonstrated that repair of the barrier is induced
by several different, specific ratios of these lipids with very different degrees of repair resulting with each of the ratios. Topical applications of
skincare with the 3:1:1 ratio with either cholesterol or ceramide dominating was shown to be the most effective reparative ratio. These lipids
have a hydrophilic end that binds water and a hydrophobic end where they join to other lipids. They exist in a weight ratio of 50% ceramide,
30% cholesterol and 20% free fatty acids. This is the equivalent to an equimolar ratio of 1:1:1 in young healthy skin.
To date 11 different ceramides have been described in human skin. The production of these
Figure 1: The Epidermis
complex molecules is limited by one single enzyme, serine protein transferase. Other enzymes
are catabolic and contribute to the anti-inflammatory and hydration effects of ceramides. Sensitive
skin and those with eczema are characterised by a marked decrease in ceramide levels and the
catabolic enzymes are present in concentrations five times higher than in normal skin.(2, 3)
Cholesterol is essential for skin barrier function and is synthesised by the enzyme HMG CoAreductase. Very low cholesterol diets or prolonged high dose lipid-lowering drugs may damage
the skin barrier and underscores the importance of taking a good patient history when trying
to unravel the cause of a skin complaint. About 20-35% (by weight) of the stratum corneum is
composed of water lying between the lipid layers attached to the hydrophilic ends of the three
key lipids. The skin’s natural moisturising factor is a complex material that is a highly efficient
humectant. The balance of moisturising factor, the three key lipids and water affect pliability and
flexibility of the skin. The three lipids are reduced in dry skin and aged skin.(3) Moisturisation results
Figure 2: 28 day life of an
in increased water holding capacity or hydration. It does not necessarily improve the barrier
epidermal cell
because excessive moisturisation actually reduces barrier function. This factor explains why lipidsoluble corticosteroids applied to treat diseased skin penetrate the skin by up to fifteen times
14
more if the skin is excessively hydrated. This disruption of the stratum corneum and its barrier is
1
Days
due to hydration changes throughout the day or with bathing cycles. The epidermis must be in a
continuous state of metabolic and differentiation activity to obtain homeostasis.(4)
The skin barrier in addition to including corneocytes and their lipid layers also has two other
2
groups of molecules residing in the epidermis. Preformed biological response modifiers include
cytokines, growth factors and minerals and anti-inflammatory molecules that specifically bind to
14
pro-inflammatory factors to reduce, prevent or reverse the magnification of the seven inflammatory
Days
cascades. The purpose of the preformed biological response modifiers is that when injury occurs
barrier repair is immediately activated, as is acute inflammation, to rapidly kill microbes, neutralise
3
toxins, irritants and allergens and prevent their penetration.
1 Stratum corneum or External
Skin Barrier.
2 Epithelial cells migrate to the
surface, change shape, flatten,
loose their nucelus and turn into
the stratum corneum
3 Cells divide and produce the
stratum corneum
24
THE SKIN’S RESPONSE TO BARRIER DISRUPTION
During the first 30 minutes following insult, preformed packets of biological response modifiers
including cytokines such as tissue necrosis factor, interleukin-1, growth factors, histamine and
nuclear receptors are released along with barrier lipids from lamellar bodies, which are ready
prepared storage vesicles of lipids inside the cells. During the next 30 minutes synthesis of
cholesterol and free fatty acids are markedly increased to facilitate repair, then ceramide
synthesis increases during the next hour. Between two and six hours after injury DNA synthesis
and production of fresh lamellar bodies leads to further secretion of the three key lipids into
the extracellular space(5). The repair process after injury is dynamic. Basal cells at the base of
Aesthetics | March 2014
Clinical Practice
CPD Clinical Article
aestheticsjournal.com
the epithelium divide and the new cells migrate to the surface to be eventually shed. This maturation of the keratinocyte takes 28 days,
but slows to 35-40 days as we age. In addition to lipid synthesis disruption of the skin barrier by injury leads to reparative epidermal
proliferation as evidenced by increased DNA synthesis of basal cell keratinocytes.
ABNORMALITIES OF EPIDERMAL CELLS ARE SEEN IN MANY DISEASE STATES
The epidermal cell turnover is markedly increased in many chronic skin diseases, up to three times more in dermatitis and nine times greater
in psoriasis. Scaly diseases like ichthyosis vulgaris are due to abnormalities in the keratinocyte maturation process, which are due to abnormal
desquamation and have an additional abnormal barrier function.(1, 6) Compromised barrier function is seen in a significant proportion of humans
as determined by measuring transepidermal water loss. Upwards of 30% of females complain of sensitive skin with some estimates of
sensitivity rising to over 60% in diseases such as rosacea. This is often due to deficiency of total lipid content contributed to by their skincare
regimens. Up to 30% of children in the western world are atopic, a condition characterised by a compromised external skin barrier function.
Here the greatest reduction is in ceramide levels but with a reduction in all three key lipids as well as reduced levels of urea, filaggrin and
small protein-rich proteins. This genetic abnormality is linked to asthma, hay fever and food allergies with gastrointestinal symptoms.(2, 7)
SEVERAL ENVIRONMENTAL INSULTS COMPROMISE THE EXTERNAL SKIN BARRIER
•
•
•
•
UVA, UVB and X radiation
Humidity and temperature extremes
Microdermabrasion and chemical peels
Excessive hydration, especially hot water
•
•
•
•
Excessive use of humectants
Prolonged use of cold creams
Certain skincare ingredients
Physical and emotional stress
During the summer our skin is exposed to the sun for a longer period resulting in increased UV disruption.(8) Humidity and temperature
changes are known to compromise barrier function. In the winter, after two to four days in freezing or below freezing conditions, the low
ambient humidity results in dehydrated skin, scaling, itching or burning with water or moisture application and higher sensitivity to the
elements.(8, 4) Prolonged visits to polar regions where the protective troposphere is deficient allows for significant increased exposure
to UV damage. Microdermabrasion treatments and chemical peels may make the skin more vulnerable to sun damage, particularly if
exposure occurs before the external skin barrier has had time to repair. Sunscreen with a high
sun protection factor must be regularly applied, especially during times of increased sebum
Figure 3: External skin barrier
production because the sunscreen breaks down with sun exposure and is diluted as it mixes
with the acids in the skin barrier. Repeated or excessive hydration, particularly having hot
baths, usually disrupts the skin barrier. Despite moisturisers being regularly used by women,
the incidence of facial dermatitis has been steadily increasing over the past few decades. One
contributing factor is over hydration of the skin with excessive water and humectants, which
Lipids that m
actually decrease the protective function of the skin barrier by separating the spaces between
The external skin barrier is
barrier are in
the lipid layers. The converse to this is prolonged use of cold creams as cleansers. These
composed of the top 12 to 15 skin
cells and the lipids that lie between
products are devoid of water and dehydrate the skin to less than 10%, which causes abnormal
them. These keratinocytes and
corneocyte desquamation, producing visible skin scaling, decreased skin pliability and stratum
lipids provide protection to the
corneum fracturing.(4, 7) Harsh ingredients in skincare products, especially soaps and cleansers
underlying layers.
damage the stratum corneum by various methods. Sodium lauryl sulphate is still commonly
found in skincare products and actually destroys the lipid layers and corneocytes.(9, 10)
Figure 4: Electron
Other chemicals known to cause damage to the skin barrier include propylene glycol, retinoic
microscope image of the
acid, formaldehyde, urushiol, quaternium 15 and certain hydroxy-acids, including lactic acid.
stratum corneum and
Whilst intermittent exposure to these products causes acute inflammation, prolonged use
transitional layer
leads to activation of chronic inflammation which in turn produces upregulation of matrix
metalloproteinase enzymes. These go on to reabsorb and remodel collagen and elastin fibres
to produce micro scarring and wrinkling.(8, 11) A reduced quantity of the three key lipids in our diet
also contributes to a compromise in the quality of barrier function. Inadequate consumption of
2
anti-inflammatories and antioxidants impinge on the skin’s ability to mount a protective acute
1
inflammatory response. Also chronic use of lipid lowering agents, fish oil and Niacin, as well
as anti-inflammatories such as ibuprofen and aspirin, contribute to abnormal stratum corneum
3
and epidermal function. Radiation therapy carries a high risk of inducing itchy, difficult to treat
dermatitis due to barrier disruption, inhibition of lipid synthesis, slow epidermal proliferation and
reduced sebum production. Lipid variations resulting in barrier function abnormalities occur in
peri- and post-menopausal women due to the fall in oestrogen and relative rise of testosterone
which are known to compromise the permeability barrier. The production of all three key lipids
1 Stratum Corneum
and particularly cholesterol is reduced in this group. Medication that depletes water such as
2 Stratum Corneum cells separated by
diuretics and those that reduce sebum production, including isotretinoin, retinoids, niacin and
a thin layer of lipids
tetracyclines, all have an impact on barrier repair.
3 Transitional Layer
REPAIRING THE BARRIER, RESTORING THE DEFENSIVE SHIELD
Epithelial cells make a transition into the
flat, hardened stratum corneum cells
In young adults, after injury to the stratum corneum barrier, a rapid recovery phase occurs during
Aesthetics | March 2014
25
Clinical Practice
CPD Clinical Article
aestheticsjournal.com
the first 12 hours which produces 50-60% recovery, with full recovery taking up to
three days. In older people this may take up to a week or longer. Reaccumulating
skin lipids becomes the most critical factor in restoring barrier function. As
stated before, normal skin contains an equimolar ratio of cholesterol, ceramide
and free fatty acids of which 50% is the essential acid, linoleic acid. Work by
Dr Carl Thornfeldt and other researchers(11, 12) has shown that barrier recovery is
markedly accelerated by changing the proportion of the key lipids to a 3:1:1 ratio
with ceramide or cholesterol dominance. In one study this ratio produced a 75%
barrier recovery within four hours compared to only 35% with the equimolar ratio
1:1:1. Work has shown that formulas containing just ceramide or cholesterol or
fatty acids have either no significant barrier repair properties or adversely affect
barrier function. Certain non-physiological lipids such as petrolatum, glycerin,
lanolin, bees wax, and squalene provide some barrier repair. 100% petrolatum
is known to markedly improve barrier function by 43% in 45 minutes. The
other non-physiological lipids work by different mechanisms and also improve
barrier function, but at different time points and to various degrees. Thornfeldt
and others developed skincare technology that combined the best ratio of
the three key barrier repair lipids with low therapeutic concentrations of these
non-physiological lipids. The EpiB complex, which forms a key component of the
platform technology within Epionce skincare, has been shown to produce an
89.6% repair of the skin barrier with complete normalisation after two hours.(6)
For extrinsic ageing the ideal repair ratio of the physiological lipids is a 3:1:1 ratio
with cholesterol as dominant combined with petrolatum and glycerin between
3-15% concentrations of each. When used regularly, barrier-repairing moisturisers
not only help to produce and maintain remission of many inflammatory skin
diseases but they also help reverse and prevent the activation of extrinsic
ageing. An independent, split face, double blind, prospective controlled clinical
study using this barrier repair formulation showed a highly statistically significant
Figure 5: Healthy lipid ratio is
key to a healthy barrier
improvement in tactile roughness, clarity and
reduction in fine lines and wrinkles after 12 weeks of
use.(13)
Many of the very light moisturising products are
actually very destructive to the external skin barrier
because they are deficient in the total amount of
lipid needed and often negatively affect the normal
skin lipid ratio, thus damaging barrier integrity.
SUMMARY
• An intact skin barrier is the first line of defence
against harmful environmental insults
• The integrity of the stratum corneum regulates
DNA synthesis of the epidermis
• Many skin diseases and ageing are characterised
by external skin barrier abnormalities
• A disrupted external skin barrier is a primary driver
for unwanted chronic inflammation
• After exfoliating procedures, the barrier must be
rapidly regenerated, otherwise the benefits of the
procedure are reduced
• Rapid closure of the external skin barrier postprocedure is achieved with appropriately
formulated combinations of physiological and nonphysiological lipids
• Practitioners now have available barrier-repair
moisturisers proven in clinical studies to treat the
signs of ageing skin
Figure 6: Lipid layer made of three lipids,
ceramide, cholesterol and free fatty acids
fatty acid
(Stearic Acid)
Lipids that make up the external skin
Ageing, skin disease and poor skin repairbarrier are in a ratio of 1:1:1
lead to a deterioration of the skin barrier and
Lipids that make up the
the normal ratio of healthy lipids changes.
external skin barrier are
in a ratio of 1:1:1
Epionce is formulated to restore a healthy
lipid ratio and external skin barrier.
REFERENCES
cholesterol
Lipids that make up the external skin
barrier are in a ratio of 1:1:1
Lipids that make
up the external ski
As a co-owner of Woodford Medical,
Mervyn Patterson is a highly
barrier are inDr
a ratio
ofdoctor
1:1:1
experienced
aesthetic
providing
1) A.W. Johnson, ‘Cosmeceuticals: function and the skin barrier’, in Cosmeceuticals 2nd
ed, ed. by Z.D. Draelos (Philadelphia: Saunders-Elsevier, 2009), pp. 7-14.
2) G. Dell’Acqua, ‘Sensitive Skin and Skin Barrier’, Cosmetics & Toiletries, 123:12 (2008),
71-75.
3) J.A. Bouwstra, G. Pilgram and M. Ponec, ‘Structure of the Skin Barrier’, in Skin Barrier,
ed. by Peter M. Elias and Kenneth R. Feingold (New York: Taylor Francis, 2006), 65-96.
4) J.Q. DelRosso, ‘Moisturizers: Function and Clinical Applications’, in Cosmeceuticals
2nd ed, ed. by Z.D. Draelos, (Philadelphia: Saunders/Elsevier, 2009), pp. 97-103.
5) Kenneth R Feingold, ‘The role of epidermal lipids in cutaneous permeability barrier
homeostasis’, Journal of Lipid Research (2007), 48: 2531–2546.
6) Medical Barrier Cream Superior in Cutaneous Healing (2014) <http://
www.epionce.com/wp-content/uploads/2011/09/10_ClinicalStudy_
EpionceSuperiorinCutaneousHealing.pdf
7) Z.D. Draelos, ‘Noxious sensory perceptions in patients with mild to moderate
rosacea treated with azelaic acid 15% gel’, Cutis, 74(4) (2004), 257-60.
8) Peter M. Elias, ‘Defensive functions of the Stratum Corneum: Integrative Aspects’, in
Skin Barrier, ed. by Peter M. Elias and Kenneth R. Feingold (New York: Taylor Francis,
2006), pp. 5-14.
9) CIR publication (1983), “Final Report on the Safety Assessment of Sodium Lauryl
Sulfate and Ammonium Lauryl Sulfate”, International Journal of Toxicology 2 (7): 127–181.
26
ceramides
a wide range of non-surgical treatments.
Financial disclosures:
Medical director at Eden Aesthetics.
Distributors of Epionce / Agera skincare,
and Colorescience mineral makeup.
Dermagenesis microdermabrasion and Dermafrac
microneedling @drmervpatterson
10) Marrakchi S, Maibach HI (2006). “Sodium lauryl sulfate-induced irritation in the
human face: regional and age-related differences”. Skin Pharmacol Physiol 19 (3):
177–80.
11) Peter M. Elias and Kenneth R. Feingold, ‘Does the tail wag the dog?’, Archives of
Dermatology, 137 (2001), 1079-81.
12) C.R. Thornfeldt, M. MaoQing, Peter M. Elias et al, ‘Optimisation of physiological lipid
mixtures for barrier repair’, J Invest Dermatol, (1996), 1090-1101.
13) Renewal Facial Cream Reduces Signs of Photoaging (2014) <http://www.epionce.
com/wp-content/uploads/2011/09/2_ClinicalStudy_RenewalPhotoaging.pdf >
Aesthetics | March 2014
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Clinical Practice
Techniques
aestheticsjournal.com
8-point lift: achieving
the liquid face lift
Miss Jonquille Chantrey on the benefits of Allergan’s
new 8-point lift technique in achieving a comprehensive,
whole-face approach to facial rejuvenation
Miss Jonquille
Chantrey is a highlyexperienced surgeon
and well-respected
figure in cosmetic
medicine and
minimally invasive
cosmetic surgery.
She regularly presents at plastic surgery
conferences throughout the world
and has published scientific articles in
peer-reviewed journals, including The
Lancet. Miss Chantrey has her own
practice in Cheshire.
As an industry, we are continuing to move
away from ‘chasing the wrinkle’ and more
towards treatments and techniques that
incorporate a whole-face approach, with
increasing prominence given to flexible
and well-considered strategies.
Facial volume loss contributes significantly
to facial ageing, typically occurring in
the malar region, temples, infra-orbital
and mandibular areas, resulting in dark
shadows that give the face a tired and
drawn appearance. Over the past five
years we have primarily treated the midface, both supporting the peri-orbital
region and lifting the perioral region,
28
to treat the changes in the facial fat
compartments. In doing so, there have
been many techniques whereby large
boluses of products have been placed
in the anterior malar and zygomatic
areas. This can create inappropriate
projection and volume, resulting in an
unnatural-looking result, both in repose
and animation, when patients speak and
smile. Other side effects of large bolus
techniques may also include the formation
of biofilms.
For some time, many practitioners have
been considering and utilising techniques
in which we can use minimal amount of
product – with specific placements in
certain areas – in order to achieve the
maximum amount of lift for the patient with
a more natural outcome. This has now
been stratified into eight points: the key
lifting areas of the face.
The 8-point lift was
originally devised by
Dr Mauricio De Maio,
a plastic surgeon from
Brazil, and I was one of
the first physicians in the
UK to be trained by him on this signature
technique. Small adjustments are made
Aesthetics | March 2014
in eight areas of the face to achieve an
overall lifting effect, with the ethos being
to treat minimally and precisely, looking
beyond individual zones of concern to the
definitive causes of the signs of ageing,
which is often fat and bone resorption in
predictable parts of the face.
The technique utilises the Juvéderm
Vycross collection of non-permanent
HA dermal fillers. These hyaluronic acid
dermal fillers each work in specific ways
to volumise and give structure to the face:
Juvéderm Voluma is injected deeply,
lifting and restoring volume; Juvéderm
Volbella has a water-like consistency and
is suitable for the delicate peri-orbital
area, as well as the area around the lip;
Juvéderm Volift works to treat mediumdeep depressions.
My personal preference with my patients
is to use both needle and cannula for
a full-face treatment. The aim of the
8-point lift is to support the infra-orbital
areas, lift the mid-face, nasolabial fold,
oral commissure and help to improve the
jawline. It also helps to give more contour
and appropriate fullness through the malar,
parotid and buccal areas.
In terms of patient selection, the 8-point
approach has a lot of versatility. It is a
technique appropriate for the young
patient, perhaps in his or her 30s, who
might do a lot of physical training or who
has had large weight fluctuations due to
dieting, and has experienced significant
fat loss shifts to their superficial fat
compartments. Other indications may be
post-pregnancy facial changes or illness.
This technique addresses the variations
that can give the face a tired appearance,
despite a relatively young age of patient.
The technique is also appropriate for
patients 10 to 20 years older. These
patients will notice further signs of facial
ageing and descent within the face,
accompanied by a development of the
pre-jowl sulcus and an early loss of the
mandibular line.
I have successfully used the 8-point lift
technique to treat patients in their 70s
and 80s, who have advanced volumetric
changes and descent, with excellent
results showing a pleasing lift.
This approach is effective for both male
and female patients. Needless to say,
the proportions of a male face are very
different to the proportions of a female
face. As long as that is respected then the
8-point lift is absolutely appropriate for
both genders.
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Clinical Practice
Techniques
aestheticsjournal.com
The positions of the 8-point lift are as follows:
1
3
2
8
4
7
5
6
THE NO-GO AREAS
Images © Dr Mauricio De Maio
before
after
before
after
Patient images © Miss Jonquille Chantrey
• The first point is the junction between the cheek and the temple. It is a very specific
point and treated with a deep placement of Juvederm Voluma onto the zygomatic bone,
usually 0.1-0.2mL. This can help to lift the zygomatic area and restore it’s youthful curve,
whilst also correcting the lid-cheek junction.
• Point number two is a beautification point, positioned over the anterior aspect of the
zygomatic bone. Here I would use a further 0.1-0.2mL. This also helps to support the
outer aspect of the infra-orbital region and lift the mid face.
• Point number three is a point in the anterior malar area, within the cheek. The deep
malar fat is injected in this position, so that it acts as an anchor point to fix the face
superiorly. Placement of 0.3mL of Juvederm Voluma or Volift in this position helps to
support the tear trough, correct the palpebral-malar groove and can lift the nasolabial
fold.
• For point number four, I would switch to a lighter product such as Volift in order to
minimise any external vascular compression and inject a small amount of this into the
canine fossa. Between 0.2-0.3mL may be sufficient to lift the rest of the nasolabial fold.
• Point number five is the oral commissure. Here, I would also use 0.1mL Volift intradermally, which helps to give the oral commissure a more supported horizontal position.
• Point number six is the pre-jowl sulcus. This is the area that female patients in
particular can experience early mandibular recession and is also important for patients
who exhibit retrognathia. Treating this point delivers more support to the chin, and gives
better definition. This is a point where I use a cannula to simultaneously support the prejowl sulcus, marionette line and deeper element of the oral commisure. My product of
choice is commonly Voluma and 0.5mL can produce excellent contouring.
• Point number seven varies between a male and a female. In a male, this is the
definition of the mandibular angle, resulting in a square appearance to the jaw. In a
woman, it may be desirable to give gentle mandibular definition, but certainly not overly
project it, as this can masculinise a female face. The position where I tend to put point
number seven is higher than the mandibular angle, usually approximately 2cm above,
which gives a nice lift to the posterior aspect of the face. The important point to note
about this point is that it needs to be very superficial in its placement. If injected deep in
this area then risks could include a parotid cyst or facial nerve injury. Juvederm Voluma
or Volift can be used in this area; product volume varies from 0.05mL to 0.3mL for
enhanced definition.
• Finally, I like to think of point number eight as a superficial zone. This tends
to run from the pre-auricular area, across the parotid and then into the sub-malar and
buccal areas. By treating this zone, not only can volume deficit and hollowing be treated
appropriately, but a subtle lift of the buccal or jowl fat can be achieved. I always use
a cannula here, gently in the subdermal plane, above the parotid fascia. This helps to
minimise the risk of facial nerve, facial artery and parotid duct damage. Quantities used
for this zone may be approximately 0.3mL to 0.6mL. In patients that have significant solar
elastosis or weakness to the skin I would use Volift not Voluma. This area then requires
massage immediately post-treatment.
In points one to five I use a needle to administer the treatment, but it is important to note that you
can also achieve additional improvements by using cannulas in these points, by revisiting points
two and three. I return to these areas and treat them superficially with vectoring. I generally use a
many vectoring techniques in my cannula work and so I incorporate this into the 8-point lift.
I don’t use all eight points in every patient. In many patients, for
instance if they’re young or they have very good preservation of
their facial fat compartments, then I may only treat point one and
point two. Similarly, I may only use points one, two and three in
a patient whose face has a tired expression. With other patients
who might be financially limited we can use points one, two and
eight to give a lifting effect. This technique is about precise and
specific positioning and placing of the product, focusing on the
cause of the descent, rather than just treating the effects of it.
Communication is an essential part of the 8-Point Lift. Patients
30
must understand that if small initial quantities are used, then
they may require several appointments to achieve the desired
result. In the initial one-hour assessment, I consult the patient
to understand what they’re trying to achieve and also discuss
in detail the causes of the changes in their face. We then agree
a strategy as to how quickly or slowly they want to progress.
One of the advantages of this method is that the result is
buildable, depending upon the expectations of the patient.
In my experience, this approach results in a very high patient
satisfaction rate and predictable, beautiful outcomes.
Aesthetics | March 2014
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aestheticsjournal.com
Revanesse and Redexis
HA dermal fillers: the
practitioners’ choice
Boston Medical Group (BMG) Ltd. presents Prollenium
Medical Technologies, Canada and explains why
more clinicians are opting for their products
Established in 2007 with the goal of providing
exceptional aesthetic products within the UK and
Ireland, Boston Medical Group (BMG) distributes
mainly to aesthetic practices. BMG prides itself on
only selecting the most effective product ranges,
research-based with proven results and keeping
up-to-date with advances in the aesthetic world
with their top quality training programmes. BMG’s
extensive product range includes Revanesse
and Redexis dermal fillers, and Dermal Roller
SR - all manufactured by Prollenium Medical
Technologies. In addition to this, they also offer
SR Serum for skin rejuvenation and cellulite, HL
serum for hair loss, Viscoderm hyaluronic acid,
Phiderma cosmeceuticals and CNC equipment. The
Revanesse range is composed of six hyaluronic
acid (HA) dermal fillers, all of which suit a different
purpose whether it be for treating deep lines and
wrinkles, achieving fuller lips, volumetric filling or
improving hydration. The great thing about HAbased fillers such as Revanesse is that they are
biodegradable and non-animal based, therefore
safe for all skin types.
Both Revanesse and Redexis incorporate a
unique formula and patented Thixofix cross-linking
technology, which maximises the effectiveness of
the cross-linked HA chains in the gel and makes
the product safe and long-lasting. As a result, a
homogenous highly viscous gel with smaller, uniform
particles is created, allowing it to be easily injected
through a fine gauge needle without causing
degradation to the modified HA particles - setting it
apart from other HA-based fillers.
The manufacturer of the Revanesse range,
Prollenium Medical Technologies based in Ontario,
is the first and only manufacturer of dermal fillers
in Canada. The company undertake the whole
formulation process in-house including syringe-
filling, sterilisation, testing and packaging. Their on-site R&D department means
they are constantly researching new advances in aesthetics to improve their
range and stay ahead of their competitors. With integrity and trust at the heart of
what they do, Prollenium’s in-house nature lends transparency to the brand and
distributors can see exactly where the products come from – a welcome idea
following recent events in the industry such as the PIP scandal. This traceability
is one of the reasons many practitioners have opted to use the range. Malti
O’Mahony, medical director at popular London clinic Harley Street Treatments
Ltd., said, “The products are an ideal choice for me due to the safety and easy
traceability to the manufacturer in Canada.”
The Revanesse range is becoming increasingly popular with medical
practitioners across the UK and Ireland, receiving high acclaim due to its variety
and quality. Dentist Dr. I. Mian at Chinbrook Medical Ltd., said, “Revanesse
seems to tick all the boxes. The portfolio range can be used for different depths
and indications and you do not need to overcorrect. While the filler slowly
degrades over time, it does not result in complete loss of volume, and tends
to maintain its integrity whilst it degrades.” Others have noticed the numerous
benefits in comparison to other dermal fillers on the market. “I have incorporated
Revanesse into my every day practice as it offers advantages in ease of injection,
volume enhancement and smoothness of results,” said nurse practitioner Elena
Korshunova. “I have also found it to be very good for use in the lips, as it is soft,
does not cause more severe or prolonged swelling than other HA products
and once it is settled, the results look very natural, rather than the persistent
‘rubberiness’ seen with other longer-lasting HA fillers. Patient satisfaction is high.”
Malti O’Mahony agrees that the product range has produced high patient
satisfaction and little swelling. “The product is extremely well-tolerated by my
patients,” she said. “I am especially pleased with Revanesse Kiss due to its ease
of application, minimal swelling and longevity. The Revanesse range is extremely
well-tolerated and is now the most popular choice amongst my patients.”
Dr. Khan, medical director at the London-based Beauty Spot Ltd., added, “I have
recently been introduced to the Revanesse range, and I am very happy with the
results. I will continue to use this product range.”
Recent additions to BMG’s growing product range include the Lidocaine range,
Revanesse Contour for facial volumising and chemical peels – the perfect
solution for medical practitioners who want to purchase their products from
one reputable and well-tested source. Prollenium may be a relatively small
company compared to well-known industry brands, but with a strong research
and development department that is always at the cutting edge of aesthetic
advances, they are fast establishing themselves as a name to trust.
Want to learn more about any of the products from the Prollenium range?
BMG offers free product training in their purpose-built premises in London’s
Bayswater area. Visit the Boston Medical Group at stand 5 at this year’s
Aesthetics Conference and Exhibition (ACE) 2014 and see Revanesse Ultra,
Revanesse Ultra Lidocaine and Revanesse Contour in use at their ‘Facial
Volumising and Shaping’ workshop on Sunday March 9 at 2pm.
Boston Medical Group Ltd - Tel: +44 (0) 207 727 1110
info@boston-medical-group.co.uk - www.boston-medical-group.co.uk
Aesthetics | March 2014
31
Clinical Practice
Clinical Focus
aestheticsjournal.com
Why Emervel Lips?
Dr Beatriz Molina shares
her technique when using
Emervel to treat the lip and
perioral area
Lip treatments are a particular favourite of mine.
Treatments of this area can have a big impact,
and make a substantial difference to patient selfconfidence. My choice of product when treating
the lip and peri-oral area is Emervel Lips hyaluronic
acid (HA) dermal filler. The Emervel Range offers
an optimal balance between cross-linking and gel
calibration, creating four degrees of cross-linking
(resistance to deformation) and three degrees of
calibration (lifting capacity). This optimal balance
therefore provides (1) the broadest spectrum of
distinctive soft textures and (2) the optimal match
to the tissue type at each injection site. In a recent
FRESH study, 85.7–100% of patients injected with
products from the Emervel range for lips, upper
lip lines, nasolabial folds and marionette lines,
said they would like to be injected with the same
product again. Scores ranged from 85.7% for
Emervel Lips to 100% for Emervel Classic (upper
lip lines). The versatility of Emervel Lips allows
practitioners to treat vermillion border, body of the
lip and upper lip lines with only one syringe.
TECHNIQUES:
When treating the lip I divide treatments,
depending on which areas my patient and I have
agreed to treat. I look specifically at the following
factors: amount of volume loss or enhancement for
lip, symmetry and treating only vermillion border
and/or also perioral area. All of this will influence
treatment technique (layering, crosshatching, linear
threading) depth of injections, and tools (sharp
needle or blunt needle (cannula). For quick lip
volumising treatments, or just for lip definition, I use
needles. The needle is versatile, and creates great
definition within the vermillion border and volumes
the body of the lip well. Emervel Lips has 0.3ml
lidocaine and injects easily through a 30G needle
so comfort for the patient is optimised. However, if
I am treating the peri-oral area as a whole I prefer
using a 25G cannula, as I feel it is less traumatic for
patients and can treat a wider expanse. I believe
that when treating the lips it is essential to take
the whole perioral area into account and to assess
patients’ balance and asymmetry, not only face-on,
but also from in profile. Normally I begin with two
small injections of lidocaine in the chosen access
point, which will vary depending on the area of
treatment. I then use the 23G needle to puncture
the skin to allow easy penetration of my 25G
cannula. It can be challenging when a patient has a
32
Needle treatment using Emervel Lips:
Cannula treatment using Emervel Lips:
1
First 2 small
injections of
lidocaine 2%.
2
Second do your
access point with
a 23G needle.
Third I would
normally use a
25G 2” cannula
(you may also use
a 27G) and do a
fanning retrograde technique which
allows me to treat upper and lower
perioral lines as vermillion border and
commisures of the mouth from one
access point. You may even want to
treat nasolabial folds and marionette if
indicated from the same access point.
3
noticeable amount of volume loss
in mid-face, presenting heavy jowls
and deep naso-labials creating
deep mouth commissure lines, but
only wants a lip treatment with one
syringe of product. In these cases I
will limit my treatment to just the lip
and upper lip lines. The versatility
of Emervel Lips means that you can
provide an impactful treatment with
noticeable improvement. However,
I would always recommend a full
treatment to the mid-face first,
making the overall result much
more balanced.
Another challenge is uneven lips
and uneven smile. Always ensure
you take a range of patient photos
at rest, smile and profile. Uneven
smiles will normally require a
combination of botulinum toxin
(BontA) and filler. I prefer to treat
with BontA first two to four weeks
prior to balance the smile before
defining with Emervel Lips filler.
In summary, the key to a successful
treatment is:
• The initial assessment
• A technique that suits you
• Keeping facial features in
balance and in keeping with age
• Making small tweaks and
improvements to create a huge
difference
Assessing the face as a whole is the most effective approach and will always
deliver best results. You have one opportunity; if a patient is not impressed on
their first visit, it is likely that the initial assessment and consultation of needs
was incorrect.
Dr Beatriz Molina is a member of the British College
of Aesthetic Medicine (BCAM). She practised general
medicine in Somerset for 12 years, before opening
her first practice, the Medikas MediSpa Clinic. She
now practises full time as a cosmetic doctor whilst
also teaching beginners and advanced techniques in
botulinum toxin and dermal fillers.
FURTHER READING:
1) Cartier, H., et al., ‘Perioral rejuvenation with a range of customized hyaluronic acid fillers:
efficacy and safety over six months with a specific focus on the lips’, J Drugs Dermatol,
11(2012) (1 Suppl), 17-26
2) Kestemont, P., et al., ‘Sustained efficacy and high patient satisfaction after cheek
enhancement with a new hyaluronic acid dermal filler’, J Drugs Dermatol, 11(2012)(1 Suppl), 9-16
3) Rzany, B., et al., ‘Correction of tear troughs and periorbital lines with a range of
customized hyaluronic acid fillers’, J Drugs Dermatol, 11(2012) (1 Suppl), 27-34
4) Segura, S. et al., ‘A complete range of hyaluronic acid filler with distinctive physical
properties specifically designed for optimal tissue adaptations’ J Drugs Dermatol, 11 (2012)
(1 Suppl), 5-8
Aesthetics | March 2014
Distinctive Technology - Optimal Balance
TechnologyTM offers a variety of calibration
and cross-linking levels around a fixed HA
concentration of 20mg/ml for safety and
longevity
Long Lasting - 92.1% of participants
remained improved at month 6 vs. baseline1
High Patient Satisfaction - Across the range, 92%*
of patients would like to have Emervel again2
COME AND SEE
US AT STAND 58
Proven - Clinical studies demonstrate great
efficacy and patient comfort with Emervel1,2,3
Galderma (UK) Ltd, Meridien House, 69-71 Clarendon Road,
Watford, Hertfordshire WD17 1DS
Galderma Switchboard: 01923 208950 Email: info.uk@galderma.com
For more information visit www.galderma-alliance.co.uk
EME/021/1013
Date of prep: October 2013
References
1. Rzany B et al, Dermatol Surg 2012;38: 1153–1161
2. Cartier et al, J Drugs Dermatol. 2012; 11 (1)(Supp): s17-s26
(*Results taken from a mean value across all treatments performed in study)
3. Farhi D et al, J Drugs Dermatol 2013; 12: E88-E93
Clinical Practice
Techniques
aestheticsjournal.com
Dr Askari Townshend explains the technique
of using needles to deliver Sculptra
Using Sculptra
with needles
In last month’s issue, the benefits of using cannulae
by means of a new technique were discussed.
In this article, I explain the advantages and
mechanisms of the needle technique to deliver
Sculptra.
stay still to avoid traumatising surrounding
structures. Immediate post-injection
massage is also essential to ensure
good spread of the product and an even
aesthetic result.
PREPARATION
Sculptra is a powder that must be carefully
reconstituted with water (I use 7mls) at least 24 hours
before use though I strongly recommend no less
than three days. Injection of clumps of product risks
nodule formation and blockage of your needle. 2mls
of 2% lidocaine is added just before treatment, which
provides patient comfort during the treatment (some
practitioners also like to apply topical anaesthetic
beforehand). Ensure that you have a sterile field
for your equipment including a plastic reservoir for
chlorhexidine. Use it to clean the face thoroughly
before you start and before every injection.
TREATMENT AREAS
Sculptra should not be used in boney
areas with little fatty covering e.g.
forehead and nose. The lip vermillion, top
lip and modiolus (just under 1cm inferiolateral from the oral commissure) should
also be avoided. As with fillers, always
start with the most superior area and work
your way inferiorly as the volumisation up
high will change the requirements of the
areas lower down.
EQUIPMENT AND TECHNIQUE
Cannulae are useful for fanning under large areas
of skin minimising the number of needle punctures
and reducing the chance of bruising. However, for
those of you not familiar with cannulae, needles are
cheaper, easier to use and still achieve great results.
Many use brown 26G x 0.5inch Terumo needles
(Microlance seem to block more often) but you should
also consider the orange 25G x 1.5inch size (of either
brand). This much longer needle allows fanning
(similar to a cannula) in the sub-dermal plane.
Most use a 1ml luer lock syringe but I prefer to use a
2.5/3ml slip lock syringe. If you are pushing so hard
that the needle comes away, take this as a warning
that if you feel resistance to your injection, then
stop. Never inject against great resistance. Excellent
aspiration technique is important for all aesthetic facial
injections, regardless of the treatment, but is essential
with Sculptra as the volumes injected in depots are
larger. Ensure that the needle tip is not moved during
aspiration and that it maintains the same position
when injecting. Attention to detail in this will also be
important if your needle becomes blocked. When
pulling the plunger to and fro, the needle tip should
34
TEMPLE
Often, only two depot injections are
required of up to 1.5mls each. These
should be near perpendicular to the skin
and pass through both layers of fascia to
the periosteum.
Know your anatomy and avoid the
superficial temporal artery and its
branches as well as any visible superficial
veins.
1
2
3
1. Before
2. After first session
3. After month 7 from first injection
ZYGOMATIC ARCH
This can be treated in two ways – over the top of the arch with the 1.5inch needle
via a deep retrograde injection (as you might do with a heavy filler), or by a series
of deep injections just underneath it. A total of 2mls can be used here, which
provides volume from deep within, helping lift the skin of the lower face.
MID-CHEEK
My personal feeling is that the area most commonly needing volumisation is over
the infra-orbital foramen. Be respectful of the neurovascular bundle that exits
here though it is deep and has a fibrous covering. I use one finger to push up
fat from lower down to create a buffer and ensure that my needle doesn’t reach
the periosteum. If you are anxious about damaging the bundle, aim a little lateral.
I place boli of up to 1.5mls from medial to lateral without removing my needle
completely. Only change the direction of your needle once you have withdrawn
almost all of it.
Aesthetics | March 2014
aestheticsjournal.com
ALAR TRIANGLE
This single 45° injection, 5mm from the nasal alar pointing
medially, is sensitive but very straightforward. Pull the nose
anterially as you enter to move the angular artery out of the way
and deposit up to 1ml.
PAROTID AND BUCCAL AREAS
If hollow, filling this area can make the masseter less prominent
and improve the jawline and jowls. Beware those with masseter
hypertrophy and/or round faces: this is where the longer 1.5inch
needle is ideal. Stay above the parotid fascia and don’t stray
towards the superficial temporal artery. Fan the area and consider
using gentle aterograde injection. Hydrodissection is the idea; I’m
uncertain how much of a difference this makes but in my opinion
it won’t do any harm. You can easily use 2mls here.
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MARIONETTE AND CHIN
Marionette areas are treated with a vertical injection from the
underside of the chin keeping deep and parallel with the ramus
of the mandible. Like the mid-cheek, place more than one bolus,
only moving the angle of injection once you have withdrawn
the needle almost fully. The mental crease can be treated with a
deep retrograde injection.
SKIN TEXTURE IMPROVEMENT
As long as you keep to the rules set out above, you can fan
almost any area of skin that needs improvement such as thin,
crepey, sun-damaged skin or acne scarring. Ensure that you do
not leave any boli here; leave a thin lake of Sculptra across the
whole area and massage well.
AFTER CARE
Although you will have massaged after every injection, perform
a thorough massage at the end of the treatment. One big
difference with Sculptra treatment is that the patient must
massage the treated areas at home. The European consensus is
for five minutes twice a day for one week. There are benefits to
facial massage and so I ask my clients to massage until they see
me next, usually six weeks later. You cannot massage too much,
but you can certainly do it too little.
In summary, needles can be used to deliver Sculptra to various
treatment areas allowing for a diverse alternative to cannulae.
Whilst cannulae reduce the number of needle punctures and
chance of bruising, needles are cheaper, quicker and easier to
use with different lengths and styles available to target different
problem areas.
Dr Askari Townshend qualified as a
doctor in 2002 and was awarded MRCS
in 2006. Already with several years of
injectable experience, Dr Askari opened
his own clinic in 2008. Having been
approached by sk:n in 2010, he sold the
clinic and held the position of Director
of Medical Services there until 2013. His interests include
injectables, lasers, and peels. Dr Askari is an international
Sculptra trainer as well as lead UK Sculptra trainer for
Sinclair Pharma. In addition, he is the UK medical
consultant providing support for Sculptra practitioners.
• Skin Rejuvenation
• Acne (all grades)
• Pigmentation
• Psoriasis
• Rosacea
• Accelerated Healing
COME AND SEE
US AT STAND 22
Before & After Dermalux™ LED
Rosacea
Psoriasis
Acne
BEFORE
BEFORE
BEFORE
AFTER
8 Dermalux treatments
in 3 weeks
AFTER
8 Dermalux treatments
in 2 weeks
AFTER
9 Dermalux treatments
in 3 weeks
Aesthetic Technology Limited
Park View House, Worrall Street
Congleton, Cheshire CW12 1DT
t: 0845 689 1789 | e: info@dermaluxled.com
w: www.dermaluxled.com
Before and after images courtesy of; Rosacea – Blushers Clinic, Coventry;
Psoriasis – Miss Zahida Butt, The Cosmetic Clinic, Kings Lynn;
Acne – Dr Steve McGurk – Ilkley
ADVANCED
PROFESSIONAL
SKINCARE
For more information on SkinCeuticals contact
our dedicated team on 0870 850 4338.
www.skinceuticals.co.uk
Clinical Practice
Spotlight On
aestheticsjournal.com
Pigmentation
is the new
wrinkle
We discuss SkinCeuticals’ newest
addition to its skincare line,
Advanced Pigment Corrector
Today, over half of women aged between 35 and 59 cite
discolouration and uneven skin tone as a more significant
skin concern than loss of firmness. Dermatologist Dr Patricia
Ogilvie has gone so far as to say that “Pigmentation is the
new wrinkle.” While pigment problems can occur for hormonal
reasons, due to post-inflammatory hyper-pigmentation, and
because of environmental inflammation, UV exposure is
the primary cause. Many women experienced excessive
UV exposure in a time before high SPF creams were
widely available, or indeed, before there was any popular
understanding of the long-term risks of tanning. As they age,
these women are now seeing unwanted pigmentation appear
and are increasingly seeking out treatment from aesthetic
doctors and dermatologists for the problem. Advanced
Pigment Corrector is now offered as a new topical treatment.
THE SCIENCE OF SKIN TONE
Jim Krol, SkinCeuticals head of
Scientific Affairs, explains that the
concept behind Advanced Pigment
Corrector was to take a cocktail
approach to address pigmentation in all
layers of the skin. “No other treatment
does this,” he says. This meant it had
to interrupt melanin stimulation of the
melanocytes, block production of
melanin, and prevent transfer to keratinocytes, plus it would
help exfoliate existing dark marks from the skin surface. And
the aim was to achieve this with a topical cream that was
pleasant to use, would fit into a simple skincare routine and
would be non-irritating.
Research presented at the World Congress of Dermatology
in Seoul, Korea, found that photoaged fibroblasts produce
melanogenic growth factors that promote excess pigment
production, leading to both new and recurring pigmentation.
By strengthening fibroblasts, the expression of these growth
factors are downregulated, making skin more resistant to
pigmentation.
Skinceuticals’ Advanced Pigment Corrector contains 5%
yeast extract, which strengthens the dermal fibroblasts to
enhance skin resistance to newly forming pigment, and
contains ellagic acid to inhibit the production of melanin,
stimulating tyrosinase in the melanocytes at the basal layer. Ellagic
acid has been shown to be as effective as 4% hydroquinone at
reducing the appearance of dark spots and hyperpigmentation. It
also contains hydroxyphenoxy propionic acid, a non-toxic derivative
of hydroquinone, to reduce melanin transfer to skin cells in all the
layers of the skin. Hydroxyphenoxy propionic acid has been shown
to be as effective as 2% kojic acid at reducing discolouration. The
formula also includes 0.3% salicylic acid to enhance exfoliation of
dark spots at the skin surface and enhance penetration of the active
ingredients.
As they age, these women
are now seeing unwanted
pigmentation appear and are
increasingly seeking out treatment
from aesthetic doctors and
dermatologists for the problem
RESULTS
In a 12-week, multi-ethnic clinical trial, Advanced Pigment Corrector
was found to improve hyperpigmentation by an average of 15%,
dark spots by nearly 20%, and radiance by 20%.
Jim Krol says, “No patients failed to respond and there was up to
a 90% improvement in some cases. Indeed, the results matched
those of the gold standard treatment of 4% hydroquinone plus
0.025% tretinoin, with the treatment performing better on skin
tone clarity, radiance and evenness.” Cosmetic doctor Dr Tapan
Patel says, “Tretinoin, though invaluable
to dermatologists, can be too irritating for
some patients, and we do not recommend
it for daytime use. Advanced Pigment
Corrector can be used day and night.
Hydroquinone may also be problematic. It
can cause irritation, plus it can bleach skin
to a lighter colour than the natural skin tone,
which is impossible with the ingredients in
Advanced Pigment Corrector.” Krol adds, “We saw no side effects
in our studies. No subject discontinued the study because of
redness or peeling and we had 95% compliance in the study.” The
treatment can safely be combined with other skincare products
and medical treatments, such as laser and IPL. Study participants
used Advanced Pigment Corrector alone, with only Skinceuticals
Gentle Cleanser and SkinCeuticals Physical UV Defense SPF30,
which offered visible results, but these may be boosted further by
adding an anti-oxidant serum before applying Advanced Pigment
corrector by day, and, for severe discolouration, adding retinol
0.3% at night. As with all treatments for pigmentation, a broadspectrum sunscreen is essential to achieve and maintain results.
Krol says, “We launched Advanced Pigment Corrector in the US
in September where it was very successful. It has addressed a
huge unmet need for an effective product that is easy to use. The
new big trend in aesthetic dermatology is to offer home care with
in-office treatments. We believe this can help build patient loyalty
and compliance. When patients see the results and are invested in
them, they are more likely to stick with their treatment programme
and to try new treatments. When they see results, they want to
achieve more.”
Aesthetics | March 2014
37
Clinical Practice
Clinical Study
aestheticsjournal.com
Clinical Experience using
the 1440nm Wavelength with
SideLaze800 Delivery System
for Facial Contouring
Gordon H. Sasaki, MD, FACS
Professor, Loma Linda Medical University Center
Private Practice: Pasadena, California USA
Introduction
The purpose of this white paper is to report the early experience
with the 1440nm wavelength in combination with the SideLaze800
delivery system, including a side-firing fibre for facial contouring,
primarily to the lower third of the mid-face and neck.
The recent implementation of the 1440nm Neodymium YAG
wavelength laser (Cynosure, Inc., Westford, MA), provides tissue
rejuvenation in areas such as the face.1-3 The longer 1440nm
wavelength provides increased and localised photothermal and
photomechanical (microbubbling) effects on fatty tissue and
collagen fibres (water), achieving 20 times more absorption in
adipose tissue than the 1064nm/1320nm—and 40 times more
absorption than 924nm/980nm wavelengths.4
Laser Delivery System
The SideLaze800 delivery system allows for use of a 1440nm
wavelength through a fibre protruding 2mm from the tip of a 2mm
microcannula, delivering energy in a bidirectional manner. In this
report, the 1440nm wavelength was selected for laser lipolysis and
shallow heating of collagen fibres (water) within the dermis and
septae. An accelerometer (SmartSense), a motion-sensing device,
was attached to the laser handpiece. This prevents excessive
thermal deposition by regulating uniform energy delivery to the
treated tissues. To control tissue heating, two additional systems
were employed alongside SmartSense to monitor and regulate
realtime temperatures during bilayered treatments. First, the
Before
After
ThermaGuide system recorded subdermal temperature changes
with a temperature sensor located at the tip of the cannula. It was
set to an alarm temperature of 47°C, which reflected a superficial
skin temperature of between 40-42°C, optimal for collagen
denaturation. It also later delayed tissue tightening.1-3 When the
local temperature reading exceeded the limit, the laser system
would stop, resuming again when the temperature decreased
below 47°C, or when the laser fibre was moved to cooler
temperature areas. Second, an infrared thermal camera (FLIR
ThermCAM E45, Niceville, Florida) was used to obtain continuous
skin temperatures between 40-42°C and ensure a uniform, realtime delivery of heat via a depiction of a confluent orange-red
colouration within each treatment site.
38
Before
After
Clinical Protocol
Patients with isolated accumulation of fat to the lower third of the
face and neck and mild to moderate tissue laxity were selected for
laser lipolysis and tissue tightening1-3 with the 1440nm wavelength,
utilising the SideLaze800 delivery system. The procedure was
recommended in patients without strong and apparent vertical
platysmal bands. Patient exclusion criteria included pregnancy,
uncontrolled diabetes mellitus, collagen disorders, significant
cardiovascular diseases, bleeding disorders, smokers, and those
having previous surgical procedures to the current treatment
sites within a year. All subjects were consented for their office
procedures under local anaesthesia treatments. Subjective
aesthetic assessments included the Global Aesthetic Improvement
Scale and a patient satisfaction questionnaire at the third and
sixth month follow-up period. After pre-operative, standardised
digital photography, treatment sites were marked into one 5x5cm
square, lateral to each marionette line, and into three 5x5cm
squares across the entire neck. Subjects received oral premedication and skin preparation with povidineiodine (Betadine)
washes. Tumescent solution, consisting of 500mg lidocaine, 1mg
epinephrine, and 20ml 8.4% sodium bicarbonate per litre of normal
saline, was infiltrated into the deep and superficial subcutaneous
fat layers. Lasing began about 20 minutes later to allow for
diffusion of tumescent infiltrate and maximum vasoconstriction
through two incisions, ‹1cm postlobular and ‹1cm submental. Laser
energy was delivered within the deep subcutaneous fat in each
square. Then, liposuction with a 1.2mm cannula to the lower third
of the face or with a 3.2mm flat cannula to the neck removed the
liquefied fat and tissue debris under a vacuum pressure of 450500mm Hg. Thirdly, shallow subdermal treatment distributed laser
energy in each square, achieving the targeted skin temperature
of between 40-42°C. Temporary quarter inch penrose drains were
inserted into each post-lobule incision site and removed within 24
hours. Compression garments with sponge inserts were applied
for 7-10 days, after which a series of weekly external ultrasound
treatments were administered to reduce irregularities and swelling.
Results
Between September 2010 and May 2011, 12 consecutive patients
(two men, ten women; 41-74 years old, mean age 53.3) were
indicated for laser lipolysis and improvement in fat contour
and tissue tightening at jowl and neck regions.1-3. The mean
pretreatment weight was 78.8 kg (range 46.6-103.6 kg) with a
mean body mass index of 29.5 (range 20.5-36.9). At the third and
sixth-month evaluation period, there was no significant change in
the baseline weights and body mass indices. An average of 200ml
of tumescent solution (range 125-280) was infiltrated into the deep
and superficial subcutaneous layers within the lower third of the
face and the entire neck. This total volume was equal to about 3050ml within each 5x5cm square. Within the deep subcutaneous
fat in each square, the delivered energy ranged from 6-10 watts at
Aesthetics | March 2014
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Clinical Practice
Clinical Study
aestheticsjournal.com
25 Hz, averaging 695 joules per 5x5cm square (range 500-1044 joules per 5x5
cm square). The endpoints of treatment were determined when: (1) the average
number of joules was between 500-700 per square, (2) the ThermaGuide
temperature consistently measured around 47°C whereas skin temperatures
measured between 38-42°C, and (3) there was increased ease of passing
the firing laser fibre through the tissues. Depending on preoperative findings,
liposuction removed between 50-125ml aspirate, of which about 55% per volume
consisted of fat. Shallow subdermal heating distributed an average of 285 joules
per 5x5cm square (range 250-400 joules per 5x5cm square) at 1-5mm below the
dermis. The total average joules (deep and superficial) delivered per patient was
roughly 5565 joules, which translated to about 1030 joules per 5x5 cm square.
Because elevated skin temperatures returned to baseline levels within two to
five minutes after termination of shallow lasing, the skin was re-challenged with
additional lasing to temperatures between 38-42°C for possible increased tissue
tightening through tissue coagulation1-3, based on clinical findings. The quarter
inch penrose drains were removed within 24 hours to facilitate drainage of
residual fluids. The surgical time averaged about one hour (range 45-75 minutes),
with postoperative recovery less than an hour. Compression garments were worn
for another 10 days to prevent any incidence of seroma formation.
Conclusion
The incorporation of the 1440nm wavelength
delivered through a side-firing fibre, SideLaze800,
achieved effective laser lipolysis and tissue
tightening through coagulation for facial contouring
in 12 patients who presented fat accumulation in
the lower third of the face and neck. Most of these
patients exhibited moderate degrees of tissue laxity
and sagging. Photographic analyses and positive
responses from Global Aesthetic Improvement Scale
indicated that the 1440nm wavelength achieved high
thermal absorption within fat and collagen (water),
which led to laser-assisted lipolysis and collagen
denaturation, and progressive tissue tightening* by
three to six months. The combination of the 1440 nm
wavelength, SideLaze800 side-firing fibre, and the
thermal-control systems provided a safer and more
effective means for facial contouring. Further studies
are needed to validate these initial findings.
Outcomes And Side Effects
Patients were very satisfied with their results, especially regarding the definition
of their mandibular-neck outlines with reduction of the pre-jowls and submental
fullness. The incidence of bruising and swelling was low and resolved completely
within two weeks. No patients developed hematomas, sensory or motor nerve
injuries, striations, blisters or dyschromias after dual layers of treatment. Three
patients developed small fibrous nodules within the subcutaneous fat in the
neck, which resolved within six weeks with post-operative ultrasound treatments.
Post-operative discomfort was mild to moderate, with patients using analgesic
products such as extra-strength acetaminophen or lowest doses of hydrocodone/
acetaminophen. Most patients were able to resume their levels of pre-surgical
activities within two weeks. There were no unanticipated significant adverse
events. Patients experienced about an 80% improvement by three months,
with progressive tissue tightening* and contouring thereafter until six months.
Patients were asked to evaluate their overall satisfaction at three and six months
after treatment on a five-point scale (0, worse; 1, no change; 2, mild; 3, moderate;
4, excellent). The mean score at three months was 2.5 with improvements in
fat reduction and tissue laxity. The mean score at six months increased to 3.5
with continued progressive definition through tissue tightening. Ultrasound
imaging and measurements from one patient taken pre and three months
post SideLaze800 treatment, represented intensity change of the dermis with
enhanced collagen depositions from 1.40mm pre to 1.81mm three months posttreatment. This represents an increase in skin thickness of 29%. All patients said
they would recommend the procedure to others.
REFERENCES
Discussion
Using the side-firing 1440nm wavelength produces selective fat destruction and
collagen denaturation in septal and dermal structures for eventual tightening
through coagulation.5 A Monte Carlo simulation study6 with three different
wavelengths (1064nm, 1320nm, and 1440nm) demonstrated that the 1440nm
wavelength produced the highest fat and dermal tissue ablation efficiency, with
minimal localisation of heat over depth. A recent study5 on the acute and delayed
histological changes after 1440nm, 1320nm and 1064nm wavelength exposures in
the deep and superficial layers in human abdominal tissue, confirmed the Monte
Carlo simulation observations. The present clinical experience demonstrated
persistence of clinical benefits at six months in all patients by objective and
subjective analyses. Adverse events were limited to transient swelling and
bruising, the severity of which was mild and completely resolved by two to
three weeks. Treatment burns were not observed because the internal and skin
temperatures were monitored in real time.
40
Aesthetics | March 2014
1. Gordon H. Sasaki and Ana Tevez, ‘Laser-Assisted Liposuction
for Facial and Body Contouring and Tissue Tightening: a 2
Year Experience with 75 Consecutive Patients’, Seminars in
Cutaneous Medicine and Surgery, 28(4) (2009), 226-235.
2. Gordon H. Sasaki, ‘Quantification of Human Abdominal
Skin Tightening and After Component Treatments with
1064nm/1320nm Laser-Assisted Lipolysis: Clinical Implications’,
Aesthetic Surgery Journal/The American Society for Aesthetic
Plastic Surgery, 30(2) (2010), 239-245.
3. Gordon H. Sasaki, ‘The Significance of Shallow Thermal
Effects from 1064/1320nm Laser on Collagenous Fibrous
Septae and Reticular Dermis: Implications for Remodeling
and Skin Tightening’ (unpublished White Paper, Loma Linda
Medical University Center Private Practice, 2009)
4. Francis A. Duck, Physical Properties of Tissue (San Diego:
Academic Press, 1990), pp. 320 -328.
5. Gordon H. Sasaki, Ana Tevez and Marcella Gonzales,
‘Histological Changes after 1440nm, 1320nm and 1064nm
Wavelength Exposures in the Deep and Superficial Layers
of Human Abdominal Tissue: Acute and Delayed Findings’
(unpublished White Paper, Loma Linda Medical University
Center Private Practice, 2010)
6. J. I. Youn, ‘Ablation Efficiency Measurements for LaserAssisted Lipolysis Using Optical Coherence Tomography’
(unpublished White Paper, Lutronic Corporation, 2009)
Gordon H. Sasaki, MD, FACS
Professor, Loma Linda Medical University Center
Private Practice: Pasadena, California USA
Ana Tevez, Surgical RN
Pasadena, CA. USA
Connie Ha, LVN
Pasadena, CA. USA
Erica Lopez Ulloa, CST
Pasadena, CA. USA
Chelsea Knutson, CST
Pasadena, CA. USA
Margaret Gaston,
Computer Analyst
Pasadena, CA. USA
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Clinical Practice
Spotlight On
aestheticsjournal.com
Hyalual Daily
DeLux
Dr Iryna Stewart explains the mechanisms
and benefits of the new anti-ageing and postprocedural restorative care spray
Most cosmetic procedures are associated
with primary damage to the epidermis and
sometimes dermis, and this damage to the
integrity of the skin causes an inflammatory
response. Procedures in aesthetic
medicine most commonly associated with
epidermis damage include chemical peels,
microdermabrasion, laser resurfacing,
electrosurgical and laser excisions,
cryotherapy, electrical and laser hair removal
and injection techniques (redermalisation,
mesotherapy and biorevitalisation).
Hyalual Daily DeLux spray aids skin restoration
post-procedure by forming a membrane
on the skin surface. The spray contains a
combination of 0.014% hyaluronic acid (HA), 0.071% succinic acid (SA) and water,
and has no conservatives or preservatives. Both active ingredients are already
contained in body tissue and do not cause allergies or complications.
The HA in Hyalual retains epidermal moisture by forming a microfilm on the skin
surface, keeping moisture within the epithelium. This aids restoration after traumatic
procedures, where transepidermal moisture loss occurs. The resulting hydration of
the HA film increases the antioxidant and metabolic effects of SA. SA neutralises free
radicals, which are formed during skin traumatisation and attack cells. SA also has
an anti-bacterial and anti-inflammatory effect, providing cell mitochondria with more
energy to fight bacteria. This optimises cell metabolism and improves cell recovery.
Any anti-ageing or moisturising face cream will have no effect as soon as water
evaporates from the skin. The use of Hyalual Daily DeLux spray builds a membrane
on the dermis, which prevents water from evaporating and enables the effect of
face creams to be prolonged by extending their absorption time into the skin. It
can therefore be recommended to patients for daily rejuvenation. Other benefits
of Hyalual include no contraindications, no staining on clothes and no effect on
make up. Additionally the spray applicator provides a touch-free alternative for
your patients; the spray dries after one to three minutes and there is no need to
wipe, minimising the risk of infection. The product can be used post-procedure
with any major treatment, such as laser procedures, dermal and chemical peels,
Dermaroller, microneedling and botulinum toxin injections. Spray for three seconds
continuously one minute after treatment, then repeat one to three times, each time
after the evaporation of the water fraction and the formation of the HA microfilm.
The patient should then be advised to use the spray twice daily for up to a week
after the procedure, in the morning and evening. The hydrophilic ingredients
shorten recovery period and reduce appearance of erythema and oedema. It
can also be used on patients post-acne and with burns. The spray can be used
pre-procedure as a replacement for cling film when using Emla numbing cream or
Lidocaine. Ten minutes after application of the anaesthetic cream, spray Hyalual for
three seconds continuously in a parallel plane to provide uniform deposition and
absorption. Spray again after three minutes to improve the effect: the SA attracts
Emla into the layer of the epidermis. A clinical trial investigating the effectiveness
42
Aesthetics | March 2014
of the spray included 20 patients aged 26-52 years.1
After a redermalisation procedure, Daily DeLux
Hyalual spray was used at the final stage to reduce
intensity of pain, severity of oedema and erythema.
A control group of 20 patients aged 28-52 years did
not receive post-treatment. Results showed that 30
minutes after procedure and spray application, the
decrease in intensity of hyperaemia was 31%, intensity
of oedema reduced by 45% and severity of pain,
due to potentiation of anaesthetic cream, decreased
by 46%. Three days after application, there was no
pain or swelling recorded. Results of the control
before
before
after
Patient A
Patient in the
control group before
the procedure (T0)
and after 30 minutes
redermalisation
(T30)
after
Patient B
Patients were
sprayed with Daily
DeLux before the
procedure (T0) and
after 30 minutes
redermalisation
(T30)
group showed that there was a slower decline in the
severity of symptoms, and pain persisted after 30
minutes and after the procedure. The average score
of hyperaemia 30 minutes after procedure was 1.1,
oedema was 0.9 and pain was 0.9, compared to 0.5,
0.5 and 0.7 with use of the spray. On average, 80% of
treated patients reported low pain level, whilst only
55% of untreated patients reported low pain. Figures
A and B compare pre- and post-treatment photos
of patients in the control group (A) with patients
who used Daily Delux (B). Hyalual Daily DeLux is a
product only available for aesthetic specialists and
their patients. It reduces patient recovery time and
pain, by decreasing severity of inflammation and
contributing to potentiation of anaesthetic creams.
This helps to restore the surface of the lipid mantle,
accelerate healing and increase patient comfort,
which enhances their clinic experience and improves
efficiency and quality of treatment.
REFERENCES
1. E.A. Bardova, ‘Justification of applying the Daily DeLux
spray after invasive cosmetic procedures’ (unpublished
clinical trial, National Academy for Postgraduate Education,
Department of Dermatovenerology, Ukraine, 2013), p. 5.
Dr Iryna Stewart is
managing director of Rederm
and founder of IS clinics.
After graduating in 1998, she
worked for 15 years in NHS,
and has spent the last five
years dedicated to aesthetic
medicine. She specialises in skin rejuvenation
and restoration.
COME AND SEE
US AT STAND 6
Clinical Practice
Techniques
aestheticsjournal.com
A growing area in aesthetics is reshaping the nose without surgery.
Dr Sotirios Foutsizoglou discusses
Non-Surgical Nose Reshaping
Despite the fact that rhinoplasty is the most common facial operation in aesthetic
plastic surgery - among both men and women, and overall the third most
common - it is one of the most technically difficult surgical procedures and is
quite often associated with complications and poor aesthetic results. Over the
last few years non-surgical nose reshaping using dermal fillers seems to be
gaining popularity due to its safety profile, almost instant results and high patient
satisfaction for well selected individuals.
Patients seeking surgical or non-surgical nose reshaping often have dimensional
abnormalities such as the following.
• Excessive or inadequate nasal length
• Excessive or inadequate nasal tip projection
• Excessive or inadequate radix projection
• Congenital or acquired deformities (e.g. “saddle nose” or previous over reduction of the bony dorsum, the so-called “ski slope” appearance).
The excessive dimensions need a surgical rhinoplasty whereas patients with
inadequate nasal dimensions or minor deficits in the nasal skeleton would
potentially be very good candidates for dermal fillers. The use of silicone and
other permanent graft materials in the nose is generally not advocated. These
tend to be unreliable and the rate of extrusion and other complications is too
high to make such grafts a viable and safe option.
My experience with non-absorbable fillers such as Aquamid or Artecoll is limited
and therefore I cannot advise for or against these. Fat grafting by the Coleman
method can give good and predictable results when used to disguise visible
irregularities of the underlying cartilage and bone and enlarge the nasal tip with
virtually no complications or serious side effects. However autologous fat transfer
will inevitably prolong the procedure and make it more costly for the patient.
Injectable hyaluronic acid or CaHA fillers are by far the most commonly used
filler materials worldwide for non surgical nose reshaping. They are suitable for
Advantages and disadvantages of dermal fillers in nasal augmentation.
ADVANTAGES
• Ideal for those who do not want surgery for
whatever reason or may
have contraindications to general anaesthesia
• Minimally invasive
• Can be used in both congenital and acquired
nasal defects
• Potential for reversibility
• Satisfactory cosmetic enhancement
• Can be used in conjunction with rhinoplasty surgery
• Less expensive
• Safer
• Less complications
• Minimal downtime
• Quick treatment
• Almost instant results
• Only topical anaesthesia required
DISADVANTAGES
• Non permanent
• Limited range of application
• Skin necrosis or thinning
44
• Cannot correct nasal functional problems
• Cannot be used when nasal
reduction is required
Aesthetics | March 2014
augmentation of the dorsum, definition of the tip
and correction of minor defects such as retracted
columella, slight asymmetry, saddle nose or
pollybeak deformity. Fillers offer a safe alternative
to both primary and revision rhinoplasty when
there is a small area to be filled out. Although
great results can be achieved with dermal filllers,
they are not comparable with those obtained by
surgical rhinoplasties, and this is an important issue
to discuss with the prospective patient. In addition,
the patient should be made aware of the fact that
repeat injections are likely to be necessary to
maintain the result.
Nasal Aesthetics
The nose is the most prominent facial feature,
particularly, on a profile view. A three dimensional
assessment (caudal, profile, frontal view) of the
nasal osteo-cartilaginous skeleton is of paramount
importance. Optimal results can only be achieved
following a thorough evaluation of all the factors that
are associated with the nasal appearance.
For instance, missing frontal teeth causing inversion
of the lips and accentuation of the smoker’s lines
or a retracted chin will keep distracting from facial
balance even after a well corrected nasal dorsal
asymmetry.
Other facial features affecting nasal
appearance
▪ Nasal skin
You can achieve a better definition in a thin
skinned nose but a thick skin is more forgiving to
potential mistakes (e.g. poor injection technique,
overcorrection), lumps and bumps formed following
injection of a filler, etc.
▪ Subnasale
The point at which the nasal septum merges, in the
midsagittal plane, with the upper lip.
▪ Chin projection
When viewed in profile, an underprojected chin may
magnify the perceived size of the nose.
▪ Contour of lips and philtrum
Full lips and a well defined philtrum improve the
nasolabial angle.
▪ Malar contour
Enhancement of the malar/mid-face volume makes
the nose appear smaller.
Below are some measurements that can help the
inexperienced injector familiarize themselves with
the “ideal” nasal dimensions.
S
E
EATMEN
T
TR
20 MILLIO
STYLAN
RE
E
20
N
RLDW
WO
ID
Heritage – Over 16 year’s
experience in aesthetic
treatments
Superior Lifting – Firmness
that gives shape and definition 1
Lasting Effect – Clinical studies
demonstrate duration up
to 36 months with just two
maintenance treatments 2,3
COME AND SEE
US AT STAND 58
Galderma (UK) Ltd, Meridien House, 69-71 Clarendon Road,
Watford, Hertfordshire WD17 1DS
Galderma Switchboard: 01923 208950 Email: info.uk@galderma.com
For more information visit www.galderma-alliance.co.uk
RES/031/1113a
Date of prep: Feb 2014
References: 1 – Edsman K et al. Dermatol Surg 2012;38:1170-1179.
2 – Narins RS et al. Dermatol Surg 2008;34(Suppl 1)S2-8.
3 – Narins RS et al. Dermatol Surg 2011;37(5):644-650.
Clinical Practice
Techniques
aestheticsjournal.com
Nasal Anatomy
The supporting skeleton of the nose is composed of
bone and hyaline cartilage (Fig. 1). The bony part of
the nose consists of nasal bones, frontal processes
of maxillae and nasal part of the frontal bone and
its nasal spine. The cartilaginous part consists
of five main cartilages: two lateral cartilages, two
greater alar (or lower lateral) cartilages and a septal
cartilage. The bony part is covered with periosteum,
which is continous with the perichondrium over
the cartilaginous part. Please note that the angular
branch (A) of the facial artery (F) runs along the
nasolabial fold, branching off the superior labial
artery (SL). The alar branch is a terminal branch of
the angular artery, which is the main feeding blood
vessel for the nasal ala. The superior labial artery
and the dorsal branch (D) of the supratrochlear
artery (ST) communicate with the alar branch around
the nasal tip (Fig. 2). Fig. 3 shows the course of
the angular artery and vein across the side of the
nose as they approach the medial canthus. Bearing
this image in mind can help practitioners to avoid
injecting into these important blood vessels.
Fig. 1
Fig. 2
Injection technique
For correcting humps, augmenting the bridge or
defining the dorsum of the nose I prefer using either
Radiesse or HA filler such as Juvederm Ultra 4.
VOLUMA can also be used when greater volumes
are required such as in cases of westernisation of
a depressed bridge in an Asian nose (Fig 4). By
using a 27G x 0.5inch sterile hypodermic needle
(0.4x13mm) I usually start near the nasion where I
deposit, on average, anything between 0.2-0.5ml
over the bridge of the nose depending on the
degree of the augmentation I want to achieve. I
use the same size needle to inject both the nasal
dorsum and tip. Moving caudally, in a straight line
Before
After
Frontal View
• Symmetry
• Tip Defining Points
• Alar width
- Equals Intercanthal distance
- Half of Interpupillary distance
- 70% of Nasal length
• Nasal length
- 1/3 of the face
Profile View
• Dorsal Humps
• Nasal Length
• Naso-Frontal Angle (NFA)
• Naso-Facial Angle (NFcA)
• Nasolabial Angle (NLA)
Caudal View
• Equilateral Triangle
• Columella:Lobule = 2:1
• Ala (A):Lobule (L) = 1:1
• Columellar Show = 2 - 4mm
Fig. 3
TERMINOLOGY
Glabella is the smooth, slightly depressed area on
the frontal bone between the superciliary arches.
Nasion is the intersection of the frontonasal and
internasal sutures.
Nasal Root or Radix is a point on the midline
nasal dorsum at the level of the supratarsal folds.
If a supratarsal fold is not present, then the root of
the nose can be reliably measured in the midline
6mm above the inner canthus.
Tip is the midline point found at the level of the
dome-projecting points of the lower lateral
cartilages.
connecting the glabella to the supratip, and by using a linear threading technique
I deposit threads of about 0.1-0.2ml per injection until the desired dorsal definition
and augmentation has been achieved. Please note that by increasing the
height of the dorsum, the nasofacial angle will decrease. This will lead to an
apparent decrease in nasal tip projection. This is why I tend, almost always, to
refine the tip with every nose reshaping procedure. My favourite form of topical
anaesthesia for a non-surgical nose reshaping is application of cold packs
around the injection site which, in addition to instant pain relief, will also produce
vasoconstriction minimising any swelling or bleeding. In the case of dorsal
hump(s) I would apply the same technique as above with the only difference
being that I would inject only anteriorly and posteriorly to the hump(s) trying to
even out the height of the dorsum when looked at from the side.
Before
After
Fig. 4 Non-surgical nose augmentation
Nasal dorsal augmentation with Radiesse
46
Aesthetics | March 2014
Fig. 5 Linear threading
over nasal dorsum
Clinical Practice
Techniques
aestheticsjournal.com
Dermal fillers can also help in the case of a significant nasal asymmetry such
as deviated septum or nasal bone deformity. Fig 6 shows the example of a
42-year-old lady whom I treated quite recently. The patient has had two surgical
rhinoplasties following an assault 10 years ago. She was left with a deviated
septum, a C-shaped nasal dorsum and a bulbous tip. I injected 0.7ml of Juvederm
Grade 4 across the dorsum as described above and 0.3ml in order to redefine
the tip. That has resulted in the illusion of a straighter and better defined dorsum
and slightly more projected tip.
Fig. 6 Before and right After correction of nasal
asymmetry and tip projection
Sculpturing the nasal tip
The nasal tip, on lateral view, influences the refinement, inclination, length, and
width of the nose. Changing the nasal tip contour will change both the apparent
nasal length and dorsal height.
INDICATIONS FOR NASAL TIP REFINEMENT METHOD
Nasal tip volume reduction
Surgical
Interdomal distance reduction
Surgical
Cranial rotation
Surgical
Increasing tip projection Decreasing tip projection
Non-surgical / Surgical
Surgical
Sound knowledge of the blood supply to the tip will allow practitioners to inject
safely in this area. The superior labial artery supplies the nostril sill and the base
of the columella. The columellar artery of the superior labial artery, which is a
substantial branch, ascends in the columella just superficial to the medial crura
(Fig. 7). My experience in redefining the tip lies mainly with hyaluronic acid fillers
and therefore I cannot recommend or reject any alternative non-HA filler.
Dermal filler injections in the tip can be used instead of
• a spreader graft to restore the vault shape support
between the upper lateral cartilage and the septum
• a columellar graft in order to reinforce the medial crus
and increase the nasal tip projection
• a tip graft for tip projection and to correct the
proportion between the nostril and the nasal tip
thus avoiding any potential risks and complications
associated with nasal tip surgery and general
anaesthesia.
Fig. 7
Nasal tip technique
I insert my needle through the columella and caudal aspect of the septal
cartilage approximately 3-5mm below the tip defining points near the infratip
break in a superoanterior direction. Bearing in mind the columellar arteries
I inject boluses of 0.2-0.3ml between and over the domes as far as the
suspensory ligament of the tip. The dome is formed by the junction between
the middle and lateral crura of the greater alar cartilage - some rhinoplasty
surgeons also call it lower later cartilage. Ideally the projected tip of the nose
should have a triangular appearance with its superior apex lying approximately
2 mm above the dorsum and this is what we try to recreate by injecting fillers
in the dome area. This is a relatively safe area
to inject as there are no end arteries other than
anastomoses as shown in figure 7. Finally I apply
a lightweight aluminium external nasal splint for
24 hours which molds to any shape of nose and
can be trimmed easily to adjust size, but remains
rigid once applied (Fig. 9). The splint provides
protection for the nose against trauma as well
as preventing excessive soft tissue swelling
which may precipitate filler migration altering the
Fig. 9 Nasal splint
desired shape and size.
48
Aesthetics | March 2014
Fig. 8 The needle is inserted through the infratip lobule
Summary
Non-surgical nose reshaping has increasingly
become a very popular alternative to the traditional
surgical rhinoplasty due to its safety, quick results
and high patient satisfaction when used for
the appropriate indications. A thorough three
dimensional examination of the nose and application
of nasal aesthetics can guide you to a very
satisfactory outcome. Remember that documented
evaluation of all parameters that contribute to the
appearance of the nose such as the thickness of
the nasal skin must also be made. No matter how
well defined the underlying osteo-carilaginous nasal
skeleton may be, you may not be able to achieve
optimal definition of the dorsum or projection of the
tip in the thick skinned nose. In a future article I will
share my experience in using intradermal 10mg/1ml
steroid injections for the thick nasal skin. Finally,
you can always complement a non-surgical nose
enhancement by injecting a few units of BTX-A (i.e.
2 units per side) in the alaeque nasi for the bunny
lines, in the nasalis and levator alae nasi for the
flaring of nostrils, and in the depressor septi nasi for
the plunging tip.
REFERENCES
Foutsizoglou S and Leontsinis T. Augmentation
Rhinoplasty: A Unique technique using autograft rib
shavings enveloped in bovine pericardium for a more
natural and predictable result. Body Language Journal.
Issue 46; p. 60-62. 2011
Brown DL. Borschel GH. Michigan Manual of Plastic
Surgery. Lippincott Williams & Wilkins, 2004.
Dr Sotirios Foutsizoglou
is the founder and medical
director of SFMedica. He has
written for numerous UK
publications and presented
at national and international
conferences and expert
meetings. He is also the senior
lecturer in Facial Anatomy and trainer in nonsurgical procedures with KT Medical Aesthetics
Training Group.
LightSheer
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Lumenis (UK) Ltd
418 Centennial Park, Elstree
Borehamwood, Hertfordshire WD6 3TN
Telephone: 020 8736 4110
Lumenis
(UK) Ltd
e-mail: UKAesthetics@lumenis.com
418 Centennial Park, Elstree
Borehamwood,
Hertfordshire WD6 3TN
Lumenis (UK) Ltd
Telephone:
020 Park,
8736 Elstree
4110
418
Centennial
e-mail:
UKAesthetics@lumenis.com
Borehamwood,
Hertfordshire WD6 3TN
Telephone: 020 8736 4110
e-mail: UKAesthetics@lumenis.com
AEST H ET IC. L UMENIS. C O M
AEST H ET IC. L UMENIS. C O M
AEST H ET IC. L UMENIS. C O M
In Practice
Abstracts
aestheticsjournal.com
A summary of the latest
clinical studies
Title: Impact of vulvovaginal atrophy on sexual health and
quality of life at postmenopause.
Authors: Nappi RE, Palacios S.
Published: Climacteric, 2014 Feb
Keywords: Vulvovaginal, postmenopausal women, VVA
Abstract: Vulvovaginal atrophy (VVA) or atrophic vaginitis is a
medical challenge because it is under-reported by women, underrecognized by health-care providers and, therefore, under-treated.
More or less 50% of postmenopausal women experience vaginal
discomfort attributable to VVA. Very recent surveys suggest healthcare providers should be proactive in order to help their patients
to disclose the symptoms related to VVA and to seek adequate
treatment when vaginal discomfort is clinically relevant. Women
are poorly aware that VVA is a chronic condition with a significant
impact on sexual health and quality of life and that effective and safe
treatments may be available. Indeed, female sexual dysfunction and
genitourinary conditions are more prevalent in women with VVA.
That being so, it is very important to include VVA in the menopause
agenda, by encouraging an open conversation on the topic of
intimacy and performing a gynaecological pelvic examination, if
indicated. According to very recent guidelines for the appropriate
management of VVA in clinical practice, it is essential to overcome
the vaginal ‘taboo’ in order to optimize elderly women’s health care.
Title: Recent trend in the choice of fillers and injection
techniques in Asia: a questionnaire study based on expert opinion.
Authors: Lee SK, Kim HS.
Published: The Journal of Drugs in Dermatology, 2014 Jan
Keywords: Filler injection, Asia, questionnaire
Abstract: A panel of dermatologists, who are recognized as
filler experts and key speakers in Korea were asked to fill out an
in-depth questionnaire on fillers in 2012. The results of the 2012
questionnaire are presented and compared with the questionnaire
results of the exact same group of doctors in 2011. Those who
participated in the questionnaire study practiced fillers for an average
of 10.6 years with an average of 32.8 filler cases per week. Common
indications for filler injection were midface augmentation and nose
augmentation. Indications that most drastically increased between
2011 and 2012 were midface and forehead augmentation. For the
nasolabial folds, the most preferred choice of filler product, needle,
injection technique and injection depth was Radiesse, 27G short
needle, layering technique and the upper subcutaneous fat layer. For
filler rhinoplasty, the preferred choices were Radiesse, 27G short
needle,linear threading technique and the mid-deep fatty layer. For
dark circles, the favoured choices were Esthelis Basic, 30G short
needle, vertical technique and the SOOF (suborbicularis oculi fat)
layer. For forehead augmentation, the most favoured choices were
Juvederm Voluma, 23G cannula, linear threading technique and
fanning and the supraperiosteal layer.
Title: Bacterial biofilm formation and treatment in soft tissue fillers
Authors: Alhede M, Er O, Eickhardt S, Kragh K, Alhede
M, Christensen LD, Poulsen SS, Givskov M, Christensen LH,
Høiby N, Tvede M, Bjarnsholt T.
50
Published: Pathogens and Disease. 2014 Jan
Keywords: Biofilm, soft tissue fillers, bacteria
Abstract: Injection of soft tissue fillers plays an important
role in facial reconstruction and aesthetic treatments such as
cosmetic surgery for lip augmentation and wrinkle smoothening.
Adverse events are an increasing problem and recently it has
been suggested that bacteria are the cause of a vast fraction of
these. A novel mouse model was developed and hyaluronic acid
gel, calcium hydroxylapatite microspheres and polyacrylamide
hydrogel were evaluated for their potential for sustaining bacterial
infections and their possible treatments. The authors were able to
culture Pseudomonas aeruginosa, Staphylococcus epidermidis and
Probionibacterium acnes in all three gels. When contaminated gels
were left for 7 days in a mouse model, the authors found sustainment
of bacterial infection with the permanent gel, less with the semipermanent gel and no growth within the temporary gel. Evaluation
of treatment strategies showed that once the bacteria had settled
(into biofilms) within the gels, even successive treatments with
high concentrations of relevant antibiotics were not effective. The
data substantiates bacteria as a cause of adverse reactions reported
when using tissue fillers, and the sustainability of these infections
appears to depend on longevity of the gel. Most importantly, the
infections are resistant to antibiotics once established but can be
prevented using prophylactic antibiotics.
Muscle
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• Uses include: anti-injectables - Dermal fillers- Electrolysis,
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ACE
Special Focus
aestheticsjournal.com
Question Time is now free to all Aesthetics Conference
and Exhibition attendees.
Sponsored by
lite
Another reason to register FREE
for ACE 2014
Over 1532 medical aesthetic practitioners have
already registered to attend ACE 2014, taking place
at the Business Design Centre on March 8-9.
Now, in addition to an exhibition of over 100
premium aesthetic suppliers and access to a huge
programme of complimentary business workshops,
clinical demonstrations and masterclasses,
attendees will receive FREE entry to the evening
Question Time. Our thanks to Question Time
sponsors 3D-lipo and their 3D-lipolite programme
for making this possible.
What is Question Time?
Following a drinks networking reception, delegates will have the opportunity to
observe and participate with a panel of industry figures, and discuss important
topics affecting the medical aesthetic profession. Professional press will also
attend this important event.
Want to ask a question?
Audience members can submit their questions online now; so If you would like
to know what the implications of the Keogh report will be, how the CEN standard
will affect you, or you have another important question you would like to ask the
panel, submit your question today.
Visit www.ace2014.co.uk
The Question Time Panel
Peter Sissons - Chair
Dr Andrew Vallance-Owen
Formerly a news presenter for ITN
and BBC News, Mr Sissons was a
broadcast journalist for 45 years
before retiring from the BBC in 2009.
Dr Andrew Vallance-Owen is the
former medical director of Bupa
and a member of Sir Bruce Keogh’s
Cosmetic Interventions Review team.
Dr Leah Totton
Dr Mike Comins
After completing her Bachelor of
Medicine and Bachelor of Surgery,
Dr Totton went on to win the 9th
series of The Apprentice in July 2013.
Dr Comins is president and fellow
of the British College of Aesthetic
Medicine and head of the ACE
steering committee.
Dr Tracy Mountford
Sharon Bennett
Dr Mountford is the founder and medical
director of The Cosmetic Skin Clinic with
clinics in both Buckinghamshire and
London Harley Street.
Sharon is currently vice chair of the
British Association of Cosmetic Nurses
(BACN) and also the UK lead on the
BSI/CEN Committee.
Mr Dalvi Humzah
Dr Martyn King
Mr Humzah was a consultant plastic
surgeon in the NHS for 15 years and
has maintained a plastic surgery private
practice for over 10 years.
Dr Martyn King is the owner and
director of Cosmedic Skin Clinic
and medical director of Cosmedic
Pharmacy.
Book Now The Aesthetics Conference and Exhibition 2014 is just weeks
away but you can still register for your FREE place today. Call 01268 754 897 or
visit the website www.ace2014.co.uk
52
Aesthetics | March 2014
In Practice
HR
aestheticsjournal.com
Other parts of the handbook will not be contractual
and will consist of employment policies, which may
be subject to change in order to comply with legal
updates and general business changes.
Although it is never easy to predict the range
of issues you, as a business owner, will face, it
is almost a certainty that if you employ people,
you will be required to deal with absence
and questions about holiday entitlement and
allowances.
Managing
staff absence
Employment law specialist Vanessa Di Cuffa
explains the importance of setting out rules for
holiday and sick leave entitlement for employees
Managing employees and staff is arguably one of the hardest aspects of
running a business. And if you are a small business owner, you are unlikely
to have a dedicated resource to deal with employee issues. Certain rules are
essential in any business because they ensure compliance with the various laws
that we are all bound by, as well as providing clarity and certainty for managers
and employees on how to deal with routine scenarios that might occur. By
always following the same set of rules that have been clearly outlined to staff,
you provide consistency of approach, which will help to safeguard your business
against being sued.
The policies that are most vital are in relation to discipline and grievance
processes. The ACAS Code of Practice provides basic practical guidelines for
employers and employees to ensure policies on disciplinary and grievance in
the workplace are outlined effectively. Acting promptly and consistently with all
employees at the time of any issue is vital in maintaining relationships within the
business. Employers must be seen to carry out necessary investigations on any
issues that arise in order to establish the facts and make informed actions. It is
important to note that failing to comply with the Code does not, in itself, make
a person or organisation liable to proceedings. However, employment tribunals
do take the Code into consideration when assessing cases. Despite this, both
parties should always seek to resolve disciplinary and grievance issues within
the workplace by encouraging an open communication culture and following the
appropriate policies and guidance from an expert.
As your business grows, your bank of policies will most likely expand. Regular
policies I might recommend include: health and safety, company car use,
expenses, study leave, flexible working, maternity, paternity and adoption leave,
stress at work, equal opportunities, bullying and harassment and whistle blowing,
but this is by no means an exhaustive list.
Some businesses choose to place these rules or at least a summary of them in
a staff handbook, parts of which may be deemed to be contractual. Detail in the
handbook may expand on the rights set out in employment contracts.
54
Aesthetics | March 2014
Since there are a range of laws in the UK
which provide protection and rights for various
sections of society in relation to different types of
absences (pregnancy related absence, sickness
absence, holidays etc) it is crucial that you have
a process in place which enables your business
to maintain consistency in the management
of absence and also offers the opportunity
to establish the reasons for absence in each
individual case. Employers can request ‘fit notes’
from an employee’s doctor if they have been
continually off sick for seven days or more. On
the occasion where a fit note states an employee
may actually be fit for work, employers may need
to discuss wider occupational health issues
with the employee. Changes to working hours
or level of responsibility held by an employee
could be amended to encourage an employee
to return to work. These changes should be
discussed with the employee in detail to ensure
a suitable solution can be made. In the event that
an employee is unable to return to work or do
their job or any other job on account of illness, a
capability process may need to be implemented.
If an employee is unable to do the job they are
employed to do and/or there are no alternatives,
an employer may have to manage the employee
out of the business through a capability process.
Legal advice should be taken in respect of how
this could be done.
Pinpointing the reason for absence is critical
in determining the process that may follow.
For example, you need to ask if the absence
is related to sickness, a child being sick, an
emergency, bereavement, or is it not attributable
to anything and therefore unauthorised? The law
affords different levels of protection depending
on what the reason for absence is. Managing
the absence correctly is important to reduce the
risk to the business if an individual challenges
the process and threatens to sue. The rights
afforded to individuals who are deemed disabled,
in the legal sense of the word, are complex: the
management of a disabled employee requires
proper consideration and an element of flexibility
on the part of an employer, in order to assist and
help the employee to feel at ease to work.
When an employee books a holiday, a clear set
In Practice
HR
aestheticsjournal.com
of rules outlining the process from their employer means that
difficult conversations can sometimes be averted because the
matters are set out in a policy. Your business may have peak
periods and you would be entitled to set out in a policy whether
there are periods or days that holiday cannot be taken. It may
specify whether there is a limit on the time you take and a limit
on the number of people who can be off at one time.
Holiday entitlement and working bank and public holidays
always creates confusion and emotion. If your business works
bank holidays, this must be clear in the contract and policy.
If you want to shut your entire business down for a specific
period each year, for example, at Christmas or during a
particularly quiet period, then set it out in a policy. According
to Gov.uk, holiday entitlement for those who work a five-day
week is 28 days paid annual leave. However, self-employed
workers, which are common amongst the small business
community, aren’t entitled to annual leave at all. Whether
employees are full-time or part-time, and whether they have
irregular or flexible working hours will determine the level
of leave eligible to individuals, but it is important to ensure
all employees on the same contracts are offered the same
holiday entitlement in order to avoid employee unrest in the
workplace.
It really is not advisable to have the full range of ‘A-Z’ of
possible policies. You simply need what is relevant to your
business and the complexity of the policy will be dependent on
the nature of what you do and the type of people you employ.
Look on the ACAS website for guidance but generally it is
always best to consult a lawyer or HR professional.
Remember the more policies you have, the more you have to
keep up-to-date. Having a policy does not rule out the ability to
exercise discretion and make exceptions but in the key areas,
such as absence and holiday, it is always sensible for you
and your staff to have clear rules and to follow them. This will
reduce the risk of allegations against owners and managers of
discrimination based on sensitive and difficult issues. Sound,
professional advice can establish quickly what will and what
won’t be appropriate for your business, and experience and
exposure to the issues you may face will ensure that you get
the appropriate policies to suit your business.
Vanessa Di Cuffa Is an employment
partner specialising in employment law
and HR at the Birmingham office of law
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2) https://www.gov.uk/holiday-entitlement-rights
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In Practice
Digital Strategy
aestheticsjournal.com
5 Ways to boost your
online presence
John Castro explains how employing simple
online strategies can grow your business
The world has changed. The way consumers spend money, access information, build trust; the way they do just about everything has
changed. Why? The digital economy. The emergence and huge growth of social networks and mobile devices has allowed us to access
anything, anywhere, anytime we want it and all with our smart phones. Recent research even suggests that 2014 is the year we will see
50% of internet search originating from mobile devices. It is clear there is a wealth of information available, with new technologies and
social networks launching every day. However, using these platforms can be a confusing arena, especially for someone for whom this is a
new experience. Here, I’ve outlined five simple strategies to improve your online presence and thus boost your sales.
1. FIND TIME
You may already feel as though there aren’t enough hours in the day
to accomplish all that you need to, but if you’re not willing to dedicate
some time each week then you will struggle to boost your online
presence. Consistency is key. Set up a schedule and stick to it; two to
three hours a week will be sufficient. Putting this time aside regularly to
help increase enquires and appointments for your clinic is truly a must
for an effective digital strategy.
2. CONTENT IS KING, BUT CONTEXT IS GOD
Frequent content additions to your website such as blogging
and news letters are certainly the easiest way to engage visitors
and send out new information regularly. However, be sure to be
selective and relevant.. Your content should be something of interest
to your readers and potential patients, the last thing they will want is
just more junk email.
Quick tip: Write about more than one new treatment including ones
you don’t even provide. This may seem counter-intuitive but will
gain trust and ensures your readers that you genuinely care for their
wellbeing and that you are not only concerned with sales.
3. SOCIAL MEDIA
You may feel that you have heard this before but that’s because it
is of paramount importance to the success of your online presence
and thus potential sales. However, social media can be daunting.
Here are some tips to get you started
Be consistent. If you are going to build attention on social media
make sure you are regularly distributing content. But remember
quality information and content, no rubbish or you may find that
your audience dwindles.
Be patient. Social media is a marathon not a sprint. Your goal is
to build an audience by providing quality content and information
that captures attention so that when you post your services and
start to sell to them, they trust you and are more likely to book an
appointment.
Be personable. Do not be afraid to be you when posting and
sharing; do not follow the crowd. People buy people and you are
not going to attract everyone. Your ideal clients are those who you
genuinely engage with. It is those who become patients forever,
and it those who recommend you to others, thus expanding your
customer base.
Be organised. You should plan your social media activity in advance
each week. This will save you time and help you to keep your posts
56
regular. However, don’t forget the importance of being personal and
relevant. You should make sure you also post in response to current
affairs and reply to others’ comments.
4. UPDATE YOUR WEBSITE
If you had your website designed over three years ago, it is more
than likely already dated and not mobile responsive. The goal of
most websites is to get visitors to the content they seek as quickly
as possible. A simple, intuitive design is the best way to accomplish
that and fewer page elements are key to this. Keep focus on the
ultimate outcome, whether it’s a phone call, email enquiry, or sale.
Work with a web designer to clean up your site and make sure they
know and understand your intended client base. It is your design
and user interface that will help your home page generate more
enquires for you.
Quick tip: Replication is the easiest way to get results fast. This
does not mean copy, it means finding out what design techniques
others use to generate enquires and utilising these. Doing your
research and using a web agency that understands this is key.
5. GOOGLE, GET INVOLVED
I strongly encourage you to make use of Google’s free marketing
tools, such as Google Local and Google Plus (their social network).
Set yourself up a Google Plus profile and a Google Plus Business
Page and work it like you do other social networks. The more you
are active with Google products and platforms, the more Google
will value your website as an authority and therefore the higher you
are likely to rank in a search.
These five simple tips will help you to boost your online presence.
If you are consistent, patient and get on board with this evergrowing digital economy then you will soon see the returns in both
new enquiries and a loyal and engaged customer base.
USEFUL WEBSITES
http://www.google.co.uk/business/placesforbusiness
Aesthetics | March 2014
John Castro is the founder
and director of Websites For
Cosmetics, the only web agency
that solely and exclusively works
with the medical aesthetic and
cosmetic surgery industry.
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In Practice
Finance
aestheticsjournal.com
Maximising your
cash flow
Kurt Won explains the importance of close control
and understanding your business’ finances
The Common Myth: “If I’m a great practitioner, my
business is guaranteed to be a success,”
Being a fantastic practitioner certainly helps to
attract new patients and retain existing ones.
However, it does not guarantee the financial
sustainability of your business. The future of your
business depends on your ability as the business
owner to manage cash flow, and essentially
increase revenue and reduce expenses. Many
people shy away from taking responsibility for their
finances: they stick their head in the sand and wait
for their accountant to tell them the state of their
finances at month-end or quarter-end. Having a
bookkeeper and an accountant on your team is of
course vital, but it is even more important for you to
be comfortable looking at the numbers. Numbers
don’t lie and having a clear idea of the timing of
cash coming in and going out will help you make
better business decisions.
I’ve set out some simple but effective ways to help
you take better control of your cash flow:
1) Ask your bookkeeper or accountant to prepare
a weekly cash flow projection, which will use the
following formula:
Step 1: Note down your bank balance at the start of
the week (W)
Step 2: Calculate how much money is due to come
into your business that week (X)
Step 3: Work out what expenses (including payroll)
are due to be paid out of the account (Y)
Step 4: Calculate your projected bank balance using
this formula:
Beginning week bank balance + Projected revenues
– Projected Expenses = End of Week Cash Balance
W + X – Y = Z
Being aware of your projected end of week
balance will help you to make decisions quicker.
For example, deciding how many products or
consumables you can order from your supplier. If the
end of week balance was projected to be negative,
you have advanced warning of how many more
products or treatments you or your staff need to
sell to cover the deficit. If you have a contingency
fund, you will be aware of when to transfer money
into your current account. The worst position to be
in is being caught unaware of a potential negative
balance and being charged for returned direct debit
58
payments, or going into unauthorised overdraft limits. For example, one of my
clients discovered that a particular month-end was going to end in a large deficit,
so we focused their team on generating new sales and collecting outstanding
payments from their clients, which saved my client hundreds of pounds in bank
and overdraft charges.
2) Manage your accounts receivable and accounts payable
In your aesthetics business, there should not be a great deal of accounts
receivable (patients who owe you money) but patients may be paying for
treatments in instalments. Make a conscious effort to keep track of these clearly
and to chase your patients for those remaining payments.
Accounts payable is the money you owe to suppliers. If your supplier has kindly
given you terms on your invoice, e.g. ‘30 days to pay’, ensure you schedule
the date of the payment into your cash flow projection report so that you pay
it on time. Paying on time will help build trust and a good credit score with
your supplier, which will help if you need to negotiate for extended payment
terms. Successfully extending payment terms to 60 or 90 days will benefit your
business considerably. Failing to make payments on time could mean payment
terms or credit lines being revoked: avoid this at all costs.
3) Get into the habit of putting money away
It’s important to strategically re-invest money into the business. Have subaccounts where you can divert a percentage of your money coming in every
week or month. Your bank can easily create a long-term savings account if
you are thinking of investing in new equipment, premises or even staff. It’s also
advisable to create sub-accounts for tax and payroll. Speak to your accountant
about how much you can and should be putting away every week or month to
meet your future obligations. Your ultimate target as a good business owner
should be to get the business to a position which operates on 70-75% of the
money that comes into its bank account, so the remaining 25-30% goes into a
contingency or long-term investment account. Don’t worry if you can’t put 25% of
your money away straight away.
4) Prepare and review monthly management reports
At a minimum, ask your accountant or bookkeeper to prepare detailed, monthly
profit and loss statements for you to review with them or with a business advisor.
Don’t be afraid to ask them to explain what the numbers in your financial
statements and management reports mean. It helps to see each month’s
revenues and expenses in one spreadsheet, so that you can spot trends or
anomalies in how your money is being made and spent. The more frequently you
review your numbers, the quicker you can make decisions and adjustments in
your business and the more empowered you will feel as a business owner.
Kurt Won is the CEO and co-founder of SalesPartners
UK (www.salespartnersuk.com), a multi-award
winning business consultancy that has helped over
850 business owners and entrepreneurs in the past four
years to make and keep more money by driving sales,
increasing profitability and building championship
business teams. He has spoken at various aesthetic and
beauty conferences.
Aesthetics | March 2014
READY • AUTHENTIC • MY BUSINESS
Bocouture® 50 Abbreviated Prescribing Information Please refer to the Summary of Product
Characteristics (SmPC). Presentation 50 LD50 units of Botulinum toxin type A (150 kD), free from
complexing proteins as a powder for solution for injection. Indications Temporary improvement in
the appearance of moderate to severe vertical lines between the eyebrows seen at frown (glabellar
frown lines) in adults under 65 years of age when the severity of these lines has an important
psychological impact for the patient. Dosage and administration Unit doses recommended
for Bocouture are not interchangeable with those for other preparations of Botulinum toxin.
Reconstitute with 0.9% sodium chloride. Intramuscular injection (50 units/1.25 ml). Standard dosing
is 20 units; 0.1 ml (4 units): 2 injections in each corrugator muscle and 1x procerus muscle. May
be increased to up to 30 units. Not recommended for use in patients over 65 years or under 18
years. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis
oculi should be avoided. Contraindications Hypersensitivity to Botulinum neurotoxin type A or to
any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, LambertEaton syndrome). Presence of infection or inflammation at the proposed injection site. Special
warnings and precautions Should not be injected into a blood vessel. Not recommended for
patients with a history of dysphagia and aspiration. Adrenaline and other medical aids for treating
anaphylaxis should be available. Caution in patients receiving anticoagulant therapy or taking other
substances in anticoagulant doses. Caution in patients suffering from amyotrophic lateral sclerosis
or other diseases which result in peripheral neuromuscular dysfunction. Too frequent or too high
dosing of Botulinum toxin type A may increase the risk of antibodies forming. Should not be used
during pregnancy unless clearly necessary. Interactions Concomitant use with aminoglycosides
or spectinomycin requires special care. Peripheral muscle relaxants should be used with caution.
4-aminoquinolines may reduce the effect. Undesirable effects Usually observed within the first week
after treatment. Localised muscle weakness, blepharoptosis, localised pain, tenderness, itching,
swelling and/or haematoma can occur in conjunction with the injection. Temporary vasovagal
reactions associated with pre-injection anxiety, such as syncope, circulatory problems, nausea
or tinnitus, may occur. Frequency defined as follows: very common (≥ 1/10); common (≥ 1/100, <
1/10); uncommon (≥ 1/1000, < 1/100); rare (≥ 1/10,000, < 1/1000); very rare (< 1/10,000). Infections
and infestations; Uncommon: bronchitis, nasopharyngitis, influenza infection. Psychiatric disorders;
Uncommon: depression, insomnia Nervous system disorders; Common: headache. Uncommon: facial
paresis (brow ptosis),vasovagal syncope, paraesthesia, dizziness. Eye disorders; Uncommon: eyelid
oedema, eyelid ptosis, blurred vision, eye disorder, blepharitis, eye pain. Ear and Labyrinth disorders;
Uncommon: tinnitus. Gastrointestinal disorders; Uncommon: nausea, dry mouth. Skin and
subcutaneous tissue disorders; Uncommon: pruritus, skin nodule, photosensitivity, dry skin.
Musculoskeletal and connective tissue disorders; Common: muscle disorders (elevation of
eyebrow), sensation of heaviness; Uncommon: muscle twitching, muscle cramps. General
disorders and administration site conditions Uncommon: injection site reactions (bruising, pruritis),
tenderness, Influenza like illness, fatigue (tiredness). General; In rare cases, localised allergic
reactions; such as swelling, oedema, erythema, pruritus or rash, have been reported after treating
vertical lines between the eyebrows (glabellar frown lines) and other indications. Overdose May
result in pronounced neuromuscular paralysis distant from the injection site. Symptoms are not
immediately apparent post-injection. Bocouture® may only be used by physicians with suitable
qualifications and proven experience in the application of Botulinum toxin. Legal Category:
POM. List Price 50 U/vial £72.00 Product Licence Number: PL 29978/0002 Marketing Authorisation
Holder: Merz Pharmaceuticals GmbH, Eckenheimer Landstraße 100, 60318 Frankfurt/Main, Germany.
Date of revision of text: FEB 2012. Full prescribing information and further information is available
from Merz Pharma UK Ltd., 260 Centennial Park, Elstree Hill South, Elstree, Hertfordshire WD6 3SR.
Tel: +44 (0) 333 200 4143
Adverse events should be reported. Reporting forms and information can be found
at www.mhra.gov.uk/yellowcard Adverse events should also be reported to Merz Pharma UK Ltd
at the address above or by email to medical.information@merz.com or on +44 (0) 333 200 4143.
1. Frevert J. Content in BoNT in Vistabel, Azzalure and Bocouture. Drugs in R&D 2010-10(2), 67-73
2. Prager, W et al. Onset, longevity, and patient satisfaction with incobotulinumtoxinA for the
treatment of glabellar frown lines: a single-arm prospective clinical study. Clin. Interventions
in Aging 2013; 8: 449-456.
3. Sattler, G et al. Noninferiority of IncobotulinumtoxinA, free from complexing proteins, compared
with another botulinum toxin type A in the treatment of glabelllar frown lines. Dermatol Surg 2010;
36: 2146-2154.
4. Prager W, et al. Botulinum toxin type A treatment to the upper face: retrospective analysis of daily
practice. Clin. Cosmetic Invest Dermatol 2012; 4: 53-58.
5. Data on File: BOC-DOF-11-001_01
Bocouture® is a registered trademark of Merz Pharma GmbH & Co, KGaA.
1134/BOC/NOV/2013/LD Date of preparation: November 2013
In Practice
Patient Experience
aestheticsjournal.com
Gilly Dickons explains the importance of call-handling
in increasing patient retention in your clinic
Is your practice making
an exceptional first
impression?
In the highly competitive sector of aesthetics it is very important
that you regularly review the quality of your customer service,
especially your call handling. ideally you should take this
action every three months. The aesthetic client is making an
emotional and important decision in terms of having treatment,
as well as deciding where to go to receive it, and this requires
both a professional and personal initial response. If you have a
receptionist, whether part time or full time, it is essential that they
are thoroughly trained. After all, they are responsible for creating
the first impression that your patient will receive of your practice.
Equally, if you are an independent practitioner who handles your
own calls, the following will still apply. With great initial call handling
your practice will grow, enabling you to garner the right support.
I am convinced that hospitality is the one of the most important
aspects of your business, and suggest that you set time aside to
take a look at the various skills your front of house staff require, in
order to ensure you are optimising any new opportunities. If you
do not employ staff, these are skills you either need yourself, or
should look to acquire via outsourcing to a specialist service. The
consensus of opinion is that the current industry gold standard
of converting a new enquiry to appointment is 60%. With great
training and focus on the following areas this could be 75-85%,
which could make a big impact on your revenue.
Any front line member of staff will benefit from call handling
training; after all, they are in a sale’s role, albeit a soft one. The
person who answers your phone requires exceptional customer
service skills, in the same way that you need to be a skilled
treatment provider. As a starting point for a review of this aspect
of your business, whether for staff or to critique yourself, I would
recommend that you consider the following tips as a brief guide to
the essential skills your staff require:
· Tone of voice
Your staff must sound warm, inviting and interested. There is
nothing worse than rushing your caller, sounding distracted or
having an abrupt manner.
· Calls need to be picked up within a few rings
Not left to go to answer machine. When a first time caller gets
through to an answer machine they may be very reluctant to leave
a message. A caller who has waited for more than 10 rings may
become agitated and may question the service you are providing.
· Knowledge about the clinic
A thorough understanding of the clinic and what makes it special is
essential.
60
· Knowledge about you
Your employees must be able to credential you and let prospective
clients know why you are the person that they should choose to
administer their treatment.
· Knowledge about the procedures you offer
A general understanding of the treatments that you offer is
essential. Whilst you will give clients the technical information, your
staff must be confident in discussing the various treatments you
provide at a conversational level.
· Ability to ask the client questions
Asking questions enables the patient to open up, and when they
do your staff need to sound interested and engaged. Questions
should be gently probing and focused towards the reason for the
call. For example, ‘Have you been considering this treatment for a
while?’ This leads to the next point…
· Ability to listen
Listening is the key skill in building relationships. To use as a guide,
here are ten commandments of active listening:
1) Stop talking: you cannot listen if you are talking.
2) Concentrate: always be prepared to listen before the need
arises; stay focused.
3) Acknowledge and empathise: prove that you are listening and
interested by using encouraging noises and showing empathy
where appropriate.
4) Be objective: keep an open mind and do not make hasty
judgements of your clients. Everyone is different and everyone’s
reaction to a given situation is different. Never assume and always
treat each client as if they are your most important one.
5) Ask questions so that you can listen to answers: questions
demand answers and help to build understanding and
relationships.
6) Reflect, confirm, clarify, summarise: it is important to do this as
we cannot see the person we are talking to. We need to check our
understanding to maintain control of the call, for example, “So you
would like to book xyz – is that correct?”
7) Be patient: allow the patient his or her say and do not interrupt
them. Simply wait until they finish what they are saying. Listen to
understand, rather than to reply.
8) Take notes: get the key points of the conversation down so that
you can refer back to them.
9) Listen between the lines: listen for feelings and ideas behind the
words. Often it is the way something is said, not what is said, that is
important.
10) Stop talking: this is the first and the last commandment, as all
the others depend on this action.
Aesthetics | March 2014
In Practice
Patient Experience
aestheticsjournal.com
· Understanding key motivators/indicators
Clients always have a reason or a ‘trigger’ for their call. For
example, an event such as a wedding or a holiday. It’s important to
understand this as it helps to build a strong relationship right from
the outset.
· Overcoming objections
There will always be objections, most frequently regarding the cost
of a treatment. Equip your staff to handle these effectively right
from the start. Objections provide another highly effective way to
build the relationship, so see them as positive. Objections may
include price, appointment times, recovery time, how ‘painful’ the
treatment is perceived to be, lack of support from their partner etc.
· Need versus want
Patients often ask for one thing, even though they may require
something completely different. Asking questions and listening
carefully will highlight any inconsistency. For example, a new caller
often wants a ‘quick fix’ treatment, but what they really need is
the very best solution for the issue they are concerned about. It
is important to identify the need using gentle questions, and by
building a relationship on the phone.
making an initial enquiry or are simply shopping around. Ideally
you will have implemented the above and there will only be 1525% of enquiries who don’t book. Ensure that you have gathered
adequate information to enable you to send patients your next
newsletter and other relevant material as some of them will book at
a later date.
You may have identified at this stage that some of these points refer
to natural skills and abilities, such as tone of voice and warmth, whilst
others require training from you, such as product knowledge, for
example. If you are not in a position to employ staff you can look to
employ a remote enquiry management and appointment booking
service to take care of your phones for you. As you seek to grow
your practice, don’t overlook this area or take it for granted; the time
and investment you make in your call handling will make a huge
impact on your success. These essential front line skills will not only
impact your conversion of new enquiries into consultations, but will
also enhance your existing patient’s experience, contributing to
increased patient retention, which in turn will increase your revenue.
· Effective data capture
The minimum on any call needs to be a name and number, as well
as where the patient heard about you. Some patients are only
Gilly Dickons is the founder of Aesthetic
Response, a unique, expert enquiry
management service to the UK’s aesthetic
and cosmetic sector. AR’s team of patient
advisors manage calls and diaries on behalf
of a variety of practices, using exceptional
customer service skills to convert valuable
enquiries into consultations.
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In Practice
In Profile
aestheticsjournal.com
Owning your own
clinic is very different
to renting a room
Dr Terry Loong, owner of The Skin Energy Clinic and winner of Best
New Clinic at the Aesthetics Awards 2013, explains her route into the
industry and provides insight on setting up your own practice
After qualifying in 2002, working as an anatomy demonstrator, and undergoing
surgical training for four years, Dr Terry was inspired by her late mother to
change direction in 2007. “She suffered from terrible acne, psoriasis, eczema,
varicose veins and stretch marks,” says Dr Terry of her mother. “She inspired
me to help as many women as I could.” Dr Loong began aesthetic training
taking courses in botulinum toxin and fillers, then started out by treating patients
at a friend’s beauty salon in Kent, whilst working as an associate to a clinic in
Knightsbridge. “I was an ex-surgeon, so the eye-hand coordination and artistry
of aesthetics came naturally to me,” she says. In 2010, she started her own
business, at first just renting a room on Harley Street a few days a week. “I
was reluctant to open my own clinic, as I saw many doctors who owned clinics
working constantly with no work-life balance, which scared me,” she says.
She expanded her skill-base by studying nutrition, hormonal rebalancing and
functional medicine in the US in 2011, focussing on preventative and holistic
anti-ageing. Now with more experience and confidence, in 2012 she invested in
her first practice, The Skin Energy Clinic, based on South Molton Street. “Owning
your own clinic is very different to renting a room,” she says. “As well as being a
ADVICE ON SETTING UP YOUR OWN CLINIC
■ If you can, go into
partnership
You’ll find it easier to pay the
overheads and will have a better
work-life balance, rather than going
it alone and hiring a manager, who
will require a high salary.
■ Don’t get too emotionally
attached
Running your own clinic is not easy;
you will have good and bad days.
Remember that it’s just business,
don’t take things personally and
don’t make enemies.
■ Do present yourself publicly
Being a social butterfly by
networking and using social
media will help your business
grow - there’s nothing better than
word-of-mouth marketing. Take
opportunities to talk: I spoke at The
Anti-Ageing and Beauty Show last
year. It’s about meeting new clients,
retaining them, exceeding their
expectations and getting referrals.
62
■ Do be realistic
I was overly optimistic about having
100% capacity in my clinic at the
start – optimism will help you move
forward, but being unrealistic
can be stressful. If you halve the
expected capacity figure in your
business plan, you’ll exceed it,
which is much better than trying to
catch up.
■ Do retain your personality
My aesthetic mentor advised me to
build my clinic the way I want and
not to change who I am. You will
attract your own type of patients,
and there are enough patients
for every practitioner. My patients
tell me I’m like a friend; they feel
comfortable telling me things,
and I am honest with them when
I don’t know the answer. Doctors
are trained not to show weakness,
but patients love to know you still
have skin breakouts, you’re worried
about your wrinkles and that you’re
human.
Aesthetics | March 2014
good practitioner, you have to develop as an ethical
business person, and learn about finances, human
resources, sales, team building, marketing, patient
retention, practitioner motivation and administration.
The big learning curve was working with a range
of personalities in my team, whilst serving patients,”
she says. Dr Terry attended multiple workshops
on business, marketing and public speaking, and
even hired her fiancée, a business consultant,
as her business coach. She worked with online
marketing and video coaches, and when she found
her premises, commissioned an interior designer to
create a stylish interior. However, the set up wasn’t
a seamless process. “If I was to do it again, I would
spend less money on decorating the clinic and more
on PR and marketing to promote the business,” she
admits. Now, to keep in touch with patients, she
sends out weekly newsletters. “They’re inspirational,
educational and remind patients that you’re there for
them,” she says. “I don’t like pushing treatments. The
lack of consumer education in this industry concerns
me, so I want to put information in the public
domain.” The Skin Energy Clinic offers injectables,
PRP, chemical peels, microneedling, mesotherapy
and hormonal rebalancing. “PRP is my favourite
aesthetic treatment, because of the preventative
anti-ageing qualities,” she says. “It’s not just for
now, but for the future.” For her own future, Dr
Terry is partnering with a pharmacy. “This will make
dispensing a lot easier for my patients,” she says.
She also wants to create a training school, and focus
on her educational Dr Terry TV YouTube channel.
At the root of her plans is the aim of creating happy
patients and practitioners. “My biggest goal is to
create a clinical environment where patients love
coming to see us and feel looked after, but which
also promotes a positive work-life balance, so that
practitioners enjoy coming to work.” she says. “I’m
getting married at the end of this year and want to
start a family, so that’s really important to me.” But
crucially, she wants her patients to feel confident.
“The irony of aesthetics is that, if everybody was
confident in their appearance, the industry would
not make any money,” she says. “I want to take a
different approach: I want my patients to feel they
want, rather than need, aesthetic treatment.”
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In Practice
The Last Word
aestheticsjournal.com
With the long-awaited government response to the
Keogh report published this month, we asked members
of our editorial board to share their reactions
Government response
to the Keogh
report on cosmetic
interventions
Mr Adrian Richards
Plastic and cosmetic surgeon
“The government response to Keogh lacked firmness regarding regulations
and who can do what. As an industry I think we were hoping that dermal fillers
would be made prescription-only medicines. What the response said was that
individuals need to be trained before administering fillers – however it didn’t give
details on what kind of training, or who would be able to administer them. This
was disappointing. In the UK there are many different competing bodies within
this industry that naturally have different interests, so it’s understandable that it’s
difficult for the government to get consensus. Hopefully this response can be
marked as progress, in terms of assessing regulation and in the execution of an
implant registry, but it seems that real change will take a long time.”
Dr Nick Lowe
Consultant dermatologist and president of the BCDG
“I hope the details of the response today will be influential as far as this is
feasible. I am currently involved in proposing ideas to Health Education England
(HEE), the body which has been chosen by the government to work with
stakeholders to approve training for practitioners. I believe that an appropriate
body such as the British Association of Dermatologists working with the HEE and
with royal colleges would be ideally placed to organise training programmes
for practitioners. Today’s response was very much an overview of what’s been
discussed previously. Now it’s down to individual bodies to put this into effect. It’s
a move in the right direction, but I would have liked it to have regulatory teeth.”
Sharon Bennett
Vice chair of the BACN
“I welcome any review leading to tighter regulation in the aesthetic industry.
Following the government report there may be concern that it does not go far
enough to regulate an industry in need. Loopholes are in need of tightening
surrounding cosmetic injectables. The HEE will require support and guidance from
us all at this time and I am confident that their committee, made up of industry experts
including the BACN, will produce a framework of education and training with defined
minimum standards to ensure patient safety is met. Support from the professional
bodies will make a real difference to the practitioners who work in this area.”
Dr Sarah Tonks
Aesthetic doctor
“The recommendations specifically around non-surgical providers are shockingly
lax – what on earth is an appropriately trained person? Unless there are
prescriptive guidelines set out around who can inject what and where then
I don’t see how this can be in the patient’s best interests. I disagree with the
statement that we do not need our own register, because registration and
training as a unified body for all non-surgical providers doctors, dentists and
nurses is essential to ensure that we are all moving together, maintaining a
64
high standard of practice across the board. Each
practitioner must practice according to their abilities
but with knowledge of all the available treatment
options. At the moment we are all separate,
practicing alone and often with no professional
support. It’s time to take aesthetic medicine into the
medical professional arena and make it a serious
specialty with our own governing body.”
Amanda Cameron
Sales and marketing professional
“Whilst the government has gone some way to
protect consumers, I feel they have missed a great
opportunity to fully regulate the industry. They
appear to be encouraging double standards with
the qualified providers being held to account, whilst
unqualified individuals are still free to practice with
no accountability. I read the report several times
in the hope of finding some concrete actions but
they are sadly lacking. I am disappointed but not
surprised, as reports on our industry have been
produced before with recommendations developed
only to be ignored. It appears this one is no
exception and patient safety does not feature on the
government’s list of priorities.”
Dr Mike Comins
President and fellow of BCAM
“I was disappointed by the fact that there wasn’t
any immediate action on making dermal fillers
a prescription-only device. I think that this was a
missed opportunity and would have changed the
whole industry. I welcome most of the other points
raised, particularly the need for standardisation and
training in non-surgical aesthetics. I know that BCAM
are working with Heath Education England regarding
this. Whilst I support the idea that surgeons need
to be on the specialist register to perform cosmetic
surgery, I do feel that minor surgical procedures
such as fat reduction treatments and hair transplants,
which are performed under local anaesthetic and
which fall under the definition of aesthetic medicine,
need to be addressed. There’s still some confusion
around this area and I’m hoping BCAM can work
with the GMC to resolve this.”
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COME AND SEE
US AT STAND 59